All change now, what next for the NHS and dispensing practices

Dr David Jenner, GP Cullompton Devon and Board Member DDA

All Change Now and What Next for the NHS and

Dispensing PracticesDr David Jenner

GP Cullompton Devon and Board Member Dispensing Doctors Association

Probity Statement

These are the views of Dr Jenner to stimulate thought and debate but do not necessarily represent the views of the DDA

Dr Jenner also works for NEW Devon CCG but these views should not be associated with that organisation in any way

Today

• Review of Five Year Forward view

• The new deal for General Practice

• Whither the GP workforce?

• The role of pharmacists in the system

• What Does This All Mean for Dispensing Practices

The Five Year Forward View

Published October 2014 by NHSE

Supported by Monitor,Trust Development Authority,CQC,Public Health England

Calls for extra 8 billion in funding over next five years (Tories did promise to fund but no firm timelines for investment)

Requires ongoing efficiency savings of 3% p.a.

The 8 billion keeps us standing still not 8-8,7/7

Five Year Forward View

• Talks passionately about prevention as a key priority

“The NHS will therefore now back hard-hitting national action on obesity,

smoking, alcohol and other major health risks. We will help develop and

support new workplace incentives to promote employee health and cut

sickness-related unemployment. And we will advocate for stronger public

health-related powers for local government and elected mayors.”

But...Vision or Illusion!!

• Already Public Health Budgets for Local Authorities look to be cut by 200 million

• 2.8 billion earmarked for Local councils to be reduced by 7%

• DH say “The NHS budget will remain protected but difficult decisions

need to be made right across Government to reduce the deficit.”

Executive Summary

The foundation of NHS care will remain list-based primary care.Given the

pressures they are under, we need a ‘new deal’ for GPs. Over the next

five years the NHS will invest more in primary care, while stabilising

core funding for general practice nationally over the next two years.

GP-led Clinical Commissioning Groups will have the option of more

control over the wider NHS budget, enabling a shift in investment from

acute to primary and community services. The number of GPs in training

needs to be increased as fast as possible with new options to encourage

retention.

Vision or Illusion?

• Several non recurrent funding initiatives:

• Prime Minister’s Challenge fund -access

• Pharmacist in practice scheme 15m

• Premises infrastructure scheme 4 years funding

• No new recurrent funding streams for GPs

• PMS and MPIG reviews removing funds from some and giving to others

Vision or Illusion

• Promise of a new capitation formula but no sign of this yet and will this be level up or “level out” like PMS? (and will it favour inner cities)

• General Practice share of NHS budget fallen from 10% to 8%

• As hospitals on pay as you go contracts and GP on fixed ones -CCGs often have little to spend on primary care

• BUT.. some CCGs have received significant growth and could invest, though others in deficit

General Practice FundingVision or Illusion

• Stabilising funding will not be enough

• It does need the investment but that is not promised now, but “over next five years”

• GPs in training falling behind target -20% training places still unfilled

• Many practices closing as a result of MPIG or PMS reviews

• 1% pay limit for Public Sector but new minimum wage legislation will inflate expenses

The General Practice Funding Dilemna

• GPs need more income to employ more staff,nurses,doctors,pharmacists and cover rising expenses (CQC,equipment, indemnity costs)

• DDRB meant to track expenses and recommend income rise to GPs but often ignored by politicians

• Minimum wage increase (£6.50-£9.00 by 2020) is a 54 % rise and will affect many NHS staff

• Minimum wage rise will then drive pay for higher paid workers too (dispensers/HCAs/nurses)

Five Year Forward View Vision or Illusion

• How much of the 8 billion will be used to pay the increase in minimum wage? and it’s impact on differentials on staff on slightly higher pay?

• Will Government recognise DDRB recommendations on the impact of this?

• Will “invest more in General Practice” mean more in real terms or inflation adjusted?

Hot Press

• Jeremy Hunt has promised to write to each practice by the end of the year (? 31/12/15 or 31/03/16) with an investment plan for resources

• David Cameron announced a new voluntary contract from 2017 to cover 7 day opening and new models of care but no QOF

• A day later J.Hunt said practices would still need to record clinical data from QOF?

• BMA say its all news to them!

Five Year Forward View-New Models of Care

England is too diverse for a ‘one size fits all’ care model to apply

everywhere. But nor is the answer simply to let ‘a thousand flowers

bloom’. Different local health communities will instead be supported by the

NHS’ national leadership to choose from amongst a small number of

radical new care delivery options, and then given the resources and

support to implement them where that makes sense.

MCPs

• One new option will permit groups of GPs to combine with nurses, other

community health services, hospital specialists and perhaps mental health

and social care to create integrated out-of-hospital care- the Multispecialty

Community Provider.

• Early versions of these models are emerging in different parts of the

country, but they generally do not yet employ hospital consultants, have

admitting rights to hospital beds, run community hospitals or take

delegated control of the NHS budget.

New care model

Multispecialty Community Providers (MCPs)

• Smaller independent GP practices will continue in their current form

where patients and GPs want that. However, as the Royal College of

General Practitioners has pointed out, in many areas primary care is

entering the next stage of its evolution.

• As GP practices are increasingly employing salaried and sessional doctors,

and as women now comprise half of GPs, the traditional model has been

evolving.

PACS

A further new option will be the integrated hospital and primary care

provider - Primary and Acute Care Systems - combining for the first time

general practice and hospital services, similar to the Accountable Care

Organisations now developing in other countries too.

PACS

A range of contracting and organisational forms are now being used to

better integrate care, including lead/prime providers and joint ventures.We

will now permit a new variant of integrated care in some parts of England

by allowing single organisations to provide NHS list-based GP and

hospital services, together with mental health and community care

services.The leadership to bring about these ‘vertically’ integrated Primary

and Acute Care Systems (PACS) may be generated from different places

in different local health economies.

PACS

• At their most radical, PACS would take accountability for the whole health needs of a registered

list of patients, under a delegated capitated budget - similar to the Accountable Care

Organisations that are emerging in Spain, the United States, Singapore, and a number of other

countries.

• PACS models are complex. They take time and technical expertise to implement. As with any

model there are also potential unintended side effects that need to be managed. We will work

with a small number of areas to test these approaches with the aim of developing prototypes

that work, before promoting the most promising models for adoption by the wider NHS.

So Over Time..

• MCPs employ consultants

• PACS employ GPs

• Both integrate other community health professionals (nurses,pharmacists)

• This looks like diagonal (both vertical and horizontal integration)

• Similar to other models e.g. Alzira in Spain

So Does This All Mean

Move to population based capitated ,(i.e cash limited) contracts

Let by CCGs or their descendants

Budgets lasting for several years

End points of horizontal (MCPS)and vertical integration (PACS) look very similar -

Different starting points to the same end

No single dictated model -local flexibility

Vanguards

• Have been announced for several of the FYFV models of care

• MCPs/PACs/urgent care networks/small hospitals/nursing home care

• Again non recurrent funding to explore the possibilities

• Largely awarded to those who are already innovators

• Too early to see any results yet

FYFV Vision or Illusion? new Models of Care

• New real models of change appearing

• Super practices in Birmingham

• MCP model in Whitstable

• Vertical integration in Durham/Yeovil/Hampshire

• But can the money be made to work?

• Remember 60% provider trusts in deficit

• These are the ones to watch but ? transferrable

Can the New Models of Care Deliver?

Many similar models in other countries failed financially in first few years

What is Plan B if they fail?

BE SURE TO LIMIT YOUR LIABILITY

The “New Deal for GPs -Deal or No Deal”

Announced by Jeremy Hunt June 2015

He Said

• “successive governments have undervalued, under invested and undermined the

vital role (general practice) has to play."

• "we need effective, strong and expanding general practice more than ever before

in the history of the NHS".

• “If we are to have a new deal I will need your co-operation and support – both in

improving the quality and continuity of care for vulnerable patients and

delivering better access, 7 days a week, for everyone.”

He Announced

• An increase in training place for GPs

• A new returner scheme to encourage GPs back

• Something to help GPs near retirement in practice (no details)

• 1 million for struggling practices

• He re-announced the premises infrastructure fund £1 billion over 4 years

• The pharmacists in practice scheme -more later

His Words “Your Side of the Bargain”

• So plenty of commitments from me. But now perhaps the more tricky part: your

side of the bargain.

• I am prepared to commit money to this plan – more GPs, more community

nurses, more money for infrastructure, help to reduce burnout. The vision for out

of hospital care set out in the ‘Five Year Forward View’ requires more investment

in primary care so this is the biggest opportunity for new investment in General

Practice in a generation.

• But in return I will need your help to deliver a profound change the quality of

care we offer patients.

But GPs side of the Deal

• Seven day access to primary care (no details)

• A new deal on assessing the quality of care provided

• And ....

• “Everybody needs to know where the buck stops for their care – and most people

would like that to be their family doctor”

Deal or No Deal

• No new recurrent money

• Some money (non recurrent) to employ pharmacists and for 7 day access and premises

• Increase training places they cannot even fill now

• And in return

• Seven day access ,much better quality and GPs take the buck!

• Poisoned chalice of Holy Grail -choose wisely!

Oh and This too!

“We need to empower general practice to deliver an even bigger role in public health. The NHS England ‘Five Year Forward View’ talks about prevention not cure - and if we are going to change lifestyle choices to improve health outcomes family doctors have a critical role to play.”

My comment -indeed,-especially now money for Local Authorities is being cut by 20 million !!

My Interpretation

• It’s all about the economy “stupid”

• Treasury won’t release more money yet for NHS

• They need to save more from welfare and pensions first

• So the FYFV funding looks more towards 2020 but watch autumn comprehensive spending review

• Few think the NHS can make the FYFV efficiency savings of 8 billion –NHS trusts £900,000 in debt

Pharmacists in Practice

• Announced July 2015

• 15million (note taken from premises infrastructure fund!!)

• Again non recurrent -sliding scale investment

• Aim for 250 pharmacists in wave one

• “Model” is one senior pharmacist supporting five others

• Directed at under-doctored areas

Pharmacists in Practice

• “co-funded” with GPs

• NHSE will pay 60% costs year one

• 40% year two

• 20% year three

• nothing thereafter

So Deal or No Deal?

• Genuinely helpful where shortage of GPs

• But can the pharmacists step up to the mark?

• At end of period can they replace GP workload?

• Will they be able to prescribe and manage long term conditions? how much will indemnity cost?

• What are potential risks for GPs if it does not work?-redundancy costs etc

Compare to GP Trainee Scheme

• GP trainee salary paid and expenses reimbursed in full

• Practice paid for training the trainee

• Extensive support for training for trainer and trainee

The Role for 19000 Excess Pharmacists

September 2013

Key Findings

CFWI Modelling Shows

• That current numbers of GP trainees are inadequate and likely to lead to a major demand- supply side imbalance by 2020 under a wide range of scenarios

• So from Jeremy Hunt

• “That’s why we are growing the workforce further with a new class of medic (physicians assistants) so busy doctors have more time to spend with patients!”

CFWI Key Findings

• There is considerable geographical variation in the distribution of GPs

• Simply increasing the number of GPs will not necessarily lead to a more equal distribution

• The GP role has become broader and more complex

• General Practice activity and workload has increased substantially for GPs and other practice staff

WorkforceA Clear and Present Danger

Workforce massive issue

50% practice nurses over 55

Currently c.26% medical graduates become GPs

Health Education England are meant to produce 50% as GPs by 2018 (already behind on this)

Only 75% training places filled

Deputy medical director NHS England Dr Mike Bewick “we are almost burying our head in the sand”

So Are Pharmacists the New GPs?

• Quite probably so in part, -and if they can-

• Diagnose,prescribe and manage LTCs

• They will be really useful members of practices

• But this is not how they leave university trained to do.

• So who pays to train them? (key issue for practices)

• Why not a master’s degree?

So In Summary

• The FYFV is a “view” not a strategy

• It does not mention dispensing practices

• There is no new recurrent funding for General Practice

• There are real workforce challenges for GPs and all forms of nurses in the NHS

• There is an oversupply of pharmacists but to meet the above challenges they will need further training further after qualification

Dispensing Practices

• Appear to occupy a strategic and policy void!

• Much loved and most are in Tory constituencies

• Effectively integrate services as FYFV proposes

• But will dispensing become robotic and remote with local supply through practices?

• And perhaps in time they will employ pharmacists (as will most practices) but doing what? -probably not dispensing

Dispensing Practices

• New models of care can threaten dispensing rights

• They are time,individual and location specific

• Companies cannot hold dispensing Dr contracts

• Mergers can be effected but SEEK EXPERT LEGAL AND ACCOUNTANCY ADVICE -you can lose dispensing rights if not careful

• You can work “at scale” without losing the core contract

Core GMS/PMS Contracts

• GMS is a permanent contract and cannot be terminated unless the terms are breached or resigned by practice

• PMS can be terminated on 6 months notice but legal right of return to GMS

• APMS can hold dispensing contracts but are time limited

• Will new contract offered give such guarantees? or a right of return to GMS?

• Think twice before giving these up!

Core GMS/PMS Contracts

• New contract not yet discussed with BMA

• Will new investments only be offered through new contract?

• Will GMS/PMS be ossified to make it less and less attractive

• Can GMS/PMS be reformed to stimulate new models of care -ideal if it could be

• We will have to wait and see but lobby the BMA!

Working At Scale

• You can keep the core contracts and form a company above those to perform extended work

• Specialist PMS allows this

• Joint ventures with Hospital Trusts also possible

• The overarching body could employ the staff who are then deployed though the practices

• But limit your liability and protect your partnership SEEK EXPERT LEGAL ADVICE

The Future is Very Uncertain

• Now Tories have a (slim) majority will they change policy on NHS? and how it is funded?

• But the future for General Practice as a concept looks sound if we can find the workforce

• Dispensing practices especially in rural areas cannot easily “scale up” -dispensing rights at risk BUT IT CAN BE DONE WITH CARE

• AND maybe all practices in time will employ pharmacists or...

• Pharmacies employ GPs?

I think in fact the future is bright for all new “visions” have effective primary

and community care at their heart

• But they may be organised differently from now

• And some aspects of this, especially urgent care will need to be more consistently available 7/7

• But local outposts of “joined up care” for those with long term conditions will be key

• And what better than General Practice to deliver this part

And At The End of The Five Year View

It could be a tale of two Jeremys

Hunt or Corbyn for PM maybe?