I found this great comment from a GP about the GP Forward View. Unfortunately, I can no longer identify the source of the quote, even though I copied it at the time. I paraphrase some of it.
“This package will save General Practice and the NHS and must be fully backed. The government has kept its word. There was no top down reorganization of the NHS, no rowing back on the 2004 contract, and HEE will comfortably deliver the 5000 extra qualified GPs they have promised. The evidence for 7 day routine and emergency care as delivered by that great man Prof Keogh is overwhelming and clear cut. The government and NHS England can be trusted to deliver 7 day NHS with existing staff numbers and no extra funding because of the brilliant management skills that they have. With time junior doctors will realize that their pay will not go down and their hours will not be cut under the watchful eye of CQC and our dear friends such as Prof. Fields. The RCGP has been instrumental in supporting grassroots GPs by always championing patients and calling for Physician Assistants, Mental Health workers, Pharmacists etc. By shoring up demand and bringing in anyone except GPs we are sure that the survival of the profession will be achieved. So stop being so cynical.”
So, trying not to be cynical….
The GP Forward View has to be seen as a step forward. It tries to respond to key issues raised by general practice. It takes a broader view than just the GP. It spends time on IT. It takes tentative steps towards the issue of indemnity. It helps with issues of premises. And it provides significant funding.
Unfortunately, a look at the bigger picture throws much of this in doubt.
Privatisation
Simon Stevens has returned to UK from a huge, corrupt US health organisation and might be expected to boost privatisation in the UK. Maybe that is why he was brought back. In some ways, though, his actions in post has been to find as many ways as possible to avoid the chaos of the Tory redisorganisation of the Health and Social Care Act. STPs, working more closely with local authorities, the 5 Year Forward View, all pull the NHS away from competition and marketisation.
The legal procurement infrastructure, now boosted by new laws from the EU, makes it very difficult to avoid tendering. So, all these new structures: new models, STPs, devolution and some of the recommendations in the GP Forward View will inevitably lead to more entries for the private sector into clinical care and commissioning.
Funding
The RCGP suggest the provenance of the money will be a mix from the Transformation Fund, a 10% uplift in CCG spending, New Sustainability and Transformation Fund, the Better Care Fund.
There is much to be concerned about here.
Londonwide Local Medical Committees say that £2.4bn would take us BELOW 2010 levels of funding for primary care. Surgeries need money now. CCGs will find a 10% levy very difficult to manage, even if it is for our own tribe. There is no new money, so from whom is the money being stolen? Some, I understand, from pharmacy and some presumably from social care via the Better Care Fund.
The £1bn promised for mental health is already under threat so why should this be any safer?
Are these the right things to spend money on?
Margaret McCartney challenges many of the assumptions in the GP Forward View. Sadly, like much of the NHS’s plans, many of the recommendations are evidence-free and have more than a whiff of magical thinking about them. The £22bn savings, for instance, which are already well below expectations, as are most CCG predicted saving plans. In the case of GP Forward View, these include Skype consultations (good for patients, but saving little time if any for primary care), weekend working (evidence for reducing demand?).
How about scrapping the Health and Social Care Act which rips GPs away from patient care?
Too little too late for the workforce
We are bleeding right now. Surgeries are shutting. The NHS workforce is inadequate and planning is chaotic. Social care cuts are leaving patients in dire straits. GP recruitment is under strain everywhere (except my surgery actually, where we are now, for the first time in years, up to full strength!). Sadly, the GP Forward View does not give the support needed right now. It avoids the issue of indemnity which would have made a rapid difference. NHS England and the RCGP have supported the creation of 5000 new GPs by 2020. Again – this is never going to happen, says LMCs.
Not cross-sector enough
Linking with pharmacists is good. Different additional workers may be useful, though their effectiveness is largely unproven.
But we need a grander vision for primary care to include those sectors that have perhaps as much impact on health as we do: housing, for instance. The housing sector has developed radical approaches to health issues and we should be working more closely. We need incentives and support to make that possible.
We need a contract that explores whether the small business model of general practice is really fit for purpose, whether in Federations or not.
There is little about working with the communities we serve. This remains a major blind spot for the NHS, despite attempts by some Vanguards to explore evidence-based options such as community development. This can improve health protection, support individual behaviour change, help statutory organisations be more responsive, help tackle health inequalities – and may save money, too. The GP Forward View missed an opportunity.
Has Stevens done enough to stave off GP industrial action?
We’ll see. An overview of the NHS this week shows catastrophic governmental chaos: the Ombudsman report, staffing report, social care cuts, a brutal and possibly corrupt approach to evidence, practices and Trusts under impossible strain. We may be brewing up another Mid-Staffs tragedy.
GPs should protest formally and take industrial action – not only for our sakes, but for the sake of the NHS. We need to show that this offer from the government is too little, too late. That we do not trust this offer which is on the backs of other sectors in the NHS. That the government’s austerity is destroying the lives of citizens and the NHS. That we understand how the junior doctors have been mistreated and we stand by them.
This is not cynicism – this is a call to action.
This was first published in GP magazine