• Five-year GP contract deal agreed
  • Plan to fund 20,000 non-GP staff as part of primary care networks, to work on seven new service models
  • State indemnity for GPs and practice staff

The number of non-GP care staff in general practice will grow by 20,000 under a new five-year contract deal, NHS England and the British Medical Association have said, probably outnumbering the GP workforce for the first time.

The deal, billed as “the biggest reform to GP services in 15 years”, sets out to substantially grow staff working across practices as part of primary care networks, as proposed in the NHS long-term plan earlier this month.

Some of the most notable changes include:

  • Funding growth agreed for the core GP contract for a period of five years for the first time;
  • State indemnity for GPs and practice staff for the first time, removing a large personal/practice cost;
  • The NHS will pay the majority of the cost of staff recruited over the five years – up to around 20,000 nationally – to work across practices as part of a “network contract” enhanced service. The networks will provide seven mandated services;
  • This separate “network” funding stream could flow to a host member GP practice, a federation, or an NHS trust, as chosen by the network practices;
  • A list of GPs with an annual personal income from NHS work of £150,000 or more being published online each year; 
  • A ban on practices advertising or hosting private services; and
  • New requirements and support to provide online and video consultations, as well as online booking and direct booking through NHS 111.

Staff

NHS England said there would be “20,000 more staff to help GP practices work together”.

It added: “The new recruits – pharmacists, physios, paramedics, physician associates and social prescribing support workers – will free up GPs to spend more time with patients who need them, most as well ensuring patients have access to a wide range of services at their local practice.”

The NHS will fund 70 per cent of the cost of most of the roles – with practices paying the rest – and fully fund one social prescribing worker per network in year one.

A 20,000 increase, if achieved, would represent a 16 per cent increase on current total practice staffing, and a 163 per cent increase in the current non-GP, non-nurse “direct patient care” workforce.

It has been very difficult to recruit and retain GPs in recent years, so the NHS and practices have looked elsewhere, with other staff groups growing as a result.

Currently, there are around 6,000 more GPs in general practice than nurses and other “direct patient care” staff combined. With GP numbers flatlining, both the BMA and NHS England acknowledged the deal was likely to mean non-GP care staff becoming the majority within five years.

Asked whether these staff could realistically be recruited, they said it was achievable given the clear five-year plan to do so and time to train them.

BMA GP committee chair Richard Vautrey said some practices already employed more other care staff than GPs, and said there were many benefits to multidisciplinary working, though the GP workforce would be increased as far as possible.

The deal was formally agreed at a meeting of NHS England’s board on Thursday - full details have been published here.

Dr Vautrey said: “We are pleased after months of discussions with NHS England, to have negotiated a package of reforms to the GP contract and beyond, that will begin addressing the unsustainable situation – whereby doctors are choosing to leave the profession while patients wait longer and longer for appointments – and laying the foundations for a general practice fit for the future.”

NHS England national director for strategy and innovation Ian Dodge, who led negotiations for NHS England, said: “Having a long-term plan has allowed us to come up with a five-year funding deal for primary care, for the first time in NHS history. And it is also a good deal for taxpayers, with money going directly into extra staff and services.”

NHSE acting medical director for primary care Nikki Kanani said the deal ”signals the start of a new era for general practice”.

Funding

The deal gives practices just under £1bn growth across the five years starting in April 2019, with a separate £1.8bn earmarked for primary care networks.

The BMA said in 2019-20 this amounted to “guaranteed investment of £405m through the practice contract and network contract… meaning every practice will be able to uplift staff pay by at least 2 per cent”.

The core practice funding growth for year one of 1.4 per cent was said to be similar to other recent years. In the subsequent four years planned core funding growth is: 2.3 per cent, 2.8, 2.5, and 2.7.

During the five years, a £300m performance-linked pot of network income will be created based on a “dashboard” of measures, including prescribing rates and emergency department attendance.

GP extended hours funding – currently worth £6 per head of population annually – has in some areas been used by clinical commissioning groups to contract external providers, but will by April 2021 become part of network funding in all areas; there will also be a new national review of GP access and how this sometimes controversial service should develop.

Pensions

The deal says NHS England and the BMA will jointly make a specific proposal to government to reform pensions to remove the incentive for GPs to retire early when they hit the current annual allowance cap.

Mr Dodge said: “We have asked for an equivalent partial pension scheme to the local government scheme where there’s a 50 per cent pension option, so you can continue to provide a 100 per cent time commitment [but] choose to reduce your contributions and your benefits accordingly.

”[That is] rather than the perversity of the current arrangements where people might try to reduce their time commitment to the NHS, which is the very last thing we want to see, partly because of their fear of being caught by the annual allowance cap.”

Forming primary care networks

As previously announced, all GP practices must be members of networks by the end of June, and they will receive an average of £14,000 income per practice in 2019-20 for participating.

NHS England believes around 80 per cent of practices are already signed up to networks, though some would now change. Mr Dodge said, while networks must cover a minimum of a 30,000 population, with little ability to be smaller,  NHS England would permit some to be larger than the 50,000 population ceiling where this could be justified, such as where a single super practice serves a larger population.

Networks will normally be formed of neighbouring practices, Mr Dodge said, but this is not mandatory, and will sometimes not be the case in urban areas. All areas of England must be covered, though, and CCGs will make sure this happens including – if any practice refused to sign up – asking others to cover their patch for network purposes.

NHS England and the BMA will provide a model governance agreement for networks.

Practices in a network will need to specify which organisation will receive their network funding. Dr Vautrey said while this would initially be a small amount which a single nominated practice might take on, as it became a substantial sum over time, it might more often be a federation company. Mr Dodge said in some cases GPs may also ask an NHS trust – particularly community health trusts – to host this.

Network services

Networks will provide, with member practices, a series of specified services as part of the contract, five beginning in 2020 and two in 2021.

The first five are: medicines reviews; enhanced care in care homes; anticipatory care – working with community health services; early diagnosis for cancer; and personalised care including social prescribing, care planning and personal budgets.

The final two are diagnosis and case finding for cardiovascular disease; and tackling inequalities.

They all reflect priorities in the NHS long-term plan. 

Updated to include agreement by NHS England, link to full details, and each year’s core funding uplift.