The 'GP Forward View' avoids some awkward realities of reform

Today’s national strategy for general practice had to fulfil two separate purposes. First, it had to serve as a rescue plan for the sinking ship of traditional general practice; and second, it needed to be a map, enabling the NHS to chart a faster route to modernised primary care. 

It is clear from both the document itself and the media coverage that the first of these roles has dominated. They emphasise promises of more money (which are to be treated with appropriate suspicion) and more staff, while “care redesign” and new models of care are relegated to the final chapter.

There was plenty of temptation to take this tack. General practice is indeed under massive pressure. This is making it harder to access, while increasing numbers of good practices are closing, causing real problems for other services. National leaders are clearly convinced this is not just special pleading.

On top of this, the widely trusted and respected GP workforce is angry, and the British Medical Association’s GP committee holds the threat of spreading the medical industrial insurrection.

With the Brexit threat informing all political judgment calls this spring, and question marks over the tenure of both the health secretary and prime minister, there is scant chance of political support for any bold new reform proposals.

Of course the twin agendas of rescue mission and modernisation are not always in conflict. Unblocking investment in expanded premises should help struggling practices, as well as acting as a lever to bring them together to offer more. Efforts to spread digitisation will be expanded under the banner of reducing workload.

Bringing together many such themes, with a concerted effort to help general practice, makes for a persuasive vision.

Reforming primary care requires winning GPs’ hearts and minds, and the General Practice Forward View carefully avoids including material which might stoke the profession’s substantial anger and suspicion. It has won back the confidence and support of some leading GPs, which had ebbed away since the 2014 Five Year Forward View.

However, in doing so, a number of uncomfortable realities of the modernisation agenda – which are hard to sell to the profession but are nonetheless important – have been left absent from the document published today.

Here are some of the most pressing issues left unaddressed:

1. Growth funding – which may turn out to be less than it seems – will have to be split between increases in core GP funding and incentivising practices to move to new models, for example on the new voluntary “MCP (multispecialty community provider) contract”.
2. The potential for spreading quality care by expanding large, strong providers around the country, something which Birmingham’s Modality super-partnership is exploring, is not discussed.
3. The document hypes up the scaling back of GP inspections next year – which was always likely after the first round of practice inspections was completed. But it does not mention the prospect of better data soon being used to identify practices and GPs with quality and safety problems.
4. Nor does it mention the urgent need to get more information flowing from primary care, with no clear way forward for Care.data.
5. Federations have spread quickly in recent years but there is massive variation in how much they are doing to provide better primary care, and how much momentum they have. There is no clear plan to drive this or bring more consistency.
6. Primary care leaders in many areas are grappling with how to persuade colleagues to buy into joint working, either through much strengthened federations or – often better – merging. Some are making headway slowly, but there is a very long way to go, and little hard detail here to help.
7. There is a problem in some inner city areas of moving on recalcitrant GPs, whose practices are not needed but which provide their partners with a secure lifetime income. Again, the GPFV does not address this issue.
8. Despite new commitments in the document, capital for premises development is still very tight. Rationalisation and reconfiguration of secondary care estate still need to be kick-started so buildings can be repurposed for primary care.
9. Although proposals are promised soon on the “MCP [multispecialty community provider] contract”, the long-held aim of combining core general practice with responsibility for wider services in a single contract has not yet been cracked.
10. With only a handful of independent GP groups appearing capable of taking on substantially expanded responsibility and risk, in many areas it is likely to be existing NHS organisations which become the lynchpins of the future for primary care. The document is virtually silent on this, too.