Oral evidence: Access to General Practice, HC 892

Oral evidence, 9 March 2017.

Witnesses

Professor Ian Cumming, Rosamond Roughton, Simon Stevens and Chris Wormald.

Chair

Good morning, everybody, and welcome to the Public Accounts Committee on Thursday 9 March 2017. We are here today to look at access to general practice. We looked at this last year and raised some concerns then; and some of those have been addressed a bit by NHS England. Today, we want to look at the variations in access around the country. There are very big concerns about the number of GPs—the ability to attract and retain staff in general practice—and clearly there are issues that we have talked about before in relation to the cost-effectiveness of plans for evening and weekend working. The variations are quite interesting. We were comparing our own constituencies—we will go into that shortly—and some GPs seem to be being paid for extended opening hours, but not providing them and closing sometimes during core hours. We want to probe the level of the relationship between NHS England and commissioners and GP practices, to assess how well you are assessing whether patients’ needs are being met by your proposals and by what practices are offering. It is quite a mixed picture out there, I think it’s fair to say. I want to introduce our panel. From my left to right, we have Rosamond Roughton, director of NHS commissioning at NHS England. I think we saw you a couple of years ago, Ms Roughton, so welcome back. We have Simon Stevens, chief executive of NHS England; Chris Wormald, permanent secretary at the Department of Health; and Professor Ian Cumming, chief executive of Health Education England, who is not such a frequent visitor to this Committee, but pretty important in terms of recruitment and training, which is obviously a real issue here. Before I go into all that, I want to touch on a couple of points in the Budget, Mr Stevens or Mr Wormald—whichever of you wants to pick this up. One is the money for triaging at A&E. We were a bit puzzled, because we think quite a lot of that is happening already, so could you just explain what is different and how quickly it will kick in?

Simon Stevens

Yes. We want to use the Chancellor’s Budget announcements, which we welcome, as a way of kick-starting a turnaround—

Chair

I think we take it as read you welcome them—they mean more money.

Simon Stevens

We welcome them as a way of kick-starting a turnaround in A&E performance, so that the NHS goes into next winter in a better position than we faced this past winter. In order to do that, we have to help at the front end of hospital A&E departments and at the back end in terms of delayed discharges for frail older patients.

Chair

And this money is for the front end, is it?

Simon Stevens

The Chancellor’s announcement is for both. Obviously, the £100 million capital is to help ensure that A&E departments can make the space available to put in place GP streaming on the model that has been successfully adopted in places like Luton and Dunstable hospital, one of our top performing A&E departments in the country, and have that in place by next Christmas. On the back end, with the extra £1 billion for adult social care, as the Chancellor said yesterday, it will be very important that councils use that to help reduce the number of blocked beds.

Chair

I was asking about the capital funding particularly. We do not want to get into the whole debate about the social care bit today. We heard the announcement; that one is well worn. On the A&E end of it, this is a bit of capital money; how many hospitals are going to get money to put a walk-in triage approach into their A&E?

Simon Stevens

We want all hospitals to have comprehensive front door streaming, with GPs, by next Christmas.

Chair

Have you costed what that will cost?

Simon Stevens

This is a contribution to that. Probably 50 to 100 hospitals need a bit of remedial work or extra capacity creation in order to get that in place.

Chair

So this money will be for 50 to 100 of the hospitals that need it. How much in total will it cost to deliver what you have outlined? What percentage of that was contributed in the Budget yesterday?

Simon Stevens

We are setting a requirement that all hospitals have GP streaming in place by this coming Christmas. Our assessment of the incremental capital required to do that is consistent with the funding we got from the Chancellor yesterday. Obviously, without glossing over it, this is only a part of the solution; there are a set of other things that need to change as well, and possibly the most important will be using the extra social care support to ensure that frail older people are able to leave hospital. If we can free up 2,000 to 3,000 hospital beds that at the moment are out of action, that is the equivalent of opening five new hospitals across England.

Chair

We are really asking about what that bit of money is going to do and how many hospitals it will affect. It meets not the whole cost but the additional costs.

Simon Stevens

It will certainly help. There will be revenue costs associated with this. Different hospital A&E departments have different physical layouts, but this will help.

Chair

So by Christmas, all hospitals will have this facility.

Simon Stevens

That’s right.

Chair

Okay. Let’s bring in the Comptroller and Auditor General briefly.

Sir Amyas Morse

I just want to check—is that for all hospitals, or all hospitals that have an A&E?

Simon Stevens

All hospitals that have an A&E. That is a key clarification.

Chair

All hospitals with an A&E. Mr Stevens was very clear on that. The other question was about the £300 million set aside for 44 STP areas to put in some capital funding. Do you have well worked up plans for that, or will it be a bidding round for STPs?

Simon Stevens

STPs have already developed their outline proposals, and in a number of cases those are quite well advanced. As the Chancellor explicitly said yesterday, this is a first instalment, with other propositions being considered in the autumn. This is £325 million over three years, so that will enable us to kick-start some of these but is not obviously the whole proposition.

Chair

So it is £325 million over three years. Is there any front-loading or back-loading to that, or is it evenly spread?

Simon Stevens

No, it is evenly distributed, which is reasonable given the time to get the—

Chair

So £100 million a year for the next three years.

Simon Stevens

There or thereabouts—slightly more than £100 million.

Anne Marie Morris

It seems to be limited to capital spend. For the transition and the STPs to work, clearly there is capital spend and there is workforce spend. I have made the point before about the need for double-running, which I know has not been accepted by you overall. Why the capital and not the revenue spend on workforce? Why do you think the Chancellor specifically focused on that capital piece? Will that not have implications for demand for workforce funding?

Simon Stevens

There are obviously revenue costs, but in fairness to the Chancellor, we did make the argument that if extra revenue were to be available, social care would have a strong case for it in 2017-18, and there was a need for further capital. In that sense, we have seen the first step of action on both those fronts.

Anne Marie Morris

So you are expecting the revenue piece to come out of the £2 billion—£1 billion in the next year?

Simon Stevens

No, that is social care. The revenue settlement for the NHS has not been altered by the Chancellor’s Budget yesterday.

Chair

It is the same pot of money paying for any revenue costs.

Chris Wormald

It is important to understand the process here. STPs were set the task by Simon and his partners of, “How do you live within your revenue settlement?” STPs came back with proposals, some of which involve capital elements that allow them to do so.

Chair

And this is what this is for.

Chris Wormald

And the Chancellor has, even within a very tight fiscal position, contributed money to meeting those plans for STPs. So this is the capital that allows—

Chair

A final question on this point before we move on to the main session. You say he has contributed money, but, Mr Stevens, have you yet analysed the total capital needs of STPs? Obviously some are more developed than others. Have you got a total bill for the capital costs of implementing STPs? How much is this contributing?

Simon Stevens

Well, this is a first instalment, as I think the Chancellor said. And, as the Budget statement said, in the autumn a further round of local proposals will be considered, subject to rigorous value for money tests. We will be bringing those forward for the Chancellor’s consideration.

Chair

So it sounds like a lot of money, and then you divide it by 44 and you think of the needs locally. Later I will touch on some of the property issues in my area—there are some issues there. We will move on. Our hashtag today is #generalpractice and I will ask Caroline Flint to kick off.

Caroline Flint

Good morning. Mr Wormald and Mr Stevens, do you agree that it is important to understand what is happening in GP practices in the core hours before extending them?

Simon Stevens

Both/and. I am not sure about before; I would say we need to do both.

Caroline Flint

Okay. Are you saying that you are not sure that you should know what is happening in core hours before we extend those hours?

Simon Stevens

No, I am saying we need to do both. We need to ensure that core hours are functioning effectively and we need to ensure that convenient appointments are available outside of those core hours.

Caroline Flint

So we need to ensure that core hours are functioning effectively. If we look at page 6 of the NAO Report, and paragraph 5 in particular, it says the contract “stipulates that ‘core hours’ are 8 am to 6.30 pm, Monday to Friday”, and that is “equivalent to 52.5 hours per week”. It then says, “Practices do not necessarily have to be open throughout these core hours, but they must provide essential services at times to meet the reasonable needs of their patients.” You will see it also says, “As at October 2015, some 46% of practices closed at some point during core hours. In particular, 18% closed at or before 3 pm on at least one weekday, despite three-quarters—76%—of these practices that closed receiving additional funding in 2015-16 to provide access outside of core hours.” Can you explain that to me, Mr Stevens?

Simon Stevens

Sure. So the reason we have the data is because for the first time NHS England has started collecting that through the e-declarations that began this year and, on the back of that, we are now taking action in two respects to deal with this. First of all, it turns out that about three quarters of the half-day closures are concentrated in about a quarter of the CCGs, so there is geographical targeting that we need to do with individual practices in those areas. The NAO Report talks about Waltham Forest. The same is true of Redbridge and parts of north-east London and other areas as well. We have collected the information and we are now following up with individual practices in those geographies. The second thing we are doing is that, from October, the GP contract is going to change as a result of the 2017-18 GP contract and practices will no longer be eligible for that enhanced service payment if, on a weekly basis, they have half-day closing.

Caroline Flint

On that basis, Mr Stevens, you are acknowledging that there was not sufficient data being gathered to understand what was going on in practices, which probably led to payments being paid when they should not have been.

Simon Stevens

Our view was that it was sensible to collect this data. Throughout the history of the National Health Service, it has not been done. We have now done it, and we are taking action.

Caroline Flint

Okay. But you are stopping these enhanced payments for extended services during core hours if those practices are not actually meeting their core hours obligation. That is what you just said.

Simon Stevens

That is right.

Chris Wormald

In some cases, there are perfectly sensible reasons why a practice is closed in core hours—

Caroline Flint

Can I come to that?

Chris Wormald

It is relevant to this question.

Caroline Flint

I am going to ask you a question about that—I will come to that.

Chris Wormald

I will answer it later, then.

Caroline Flint

Mr Wormald, what should patients expect from these practices during core hours?

Chris Wormald

As Simon has said, the history of this is that—the best description of the GP contract is that it has traditionally been a high trust contract, so we have usually left it to GPs to conclude what is in the best interests of their patients. Of course, there is a lot of strength to that system, and it has served us extremely well; people expect their GPs to be able to take decisions. What NHS England has now done, as I say, is collected data on opening for the first time, which allows a conversation on exactly that question.

Caroline Flint

Can I just stop you there, Mr Wormald? As you said, and as has already been mentioned by Mr Stevens, this data is being provided and we are able to better analyse what the opening hours are and the variabilities that are there, which I think is welcome. I have to say, I did a summary of the 12 MPs representing English constituencies on this Committee and I found quite a huge variation. For my colleague, Meg Hillier, the percentage of practices closing at some point during core hours was 72%, but it is 80% in my own area. Also, when it comes to the percentage of practices closing by 3pm on at least one weekday, in the Chair’s area it was 42% but in my own it was 15%. In Mr Pugh’s area, the percentage of practices closing at some point during core hours is 5%, with 0% closing by 3pm on at least one weekday. That is quite a lot of variation. Can I just draw your attention to paragraph 2.4 on page 17 of the NAO Report? Part of this is what patients need and also what the implications are of not being open for core hours. The evidence seems to be that, where practices are not meeting core hours, there is a higher rate of people therefore attending A&E. Do you accept that data?

Chris Wormald

Yes. As we have said, NHS England has collected this data for the first time, which allows the NAO to do the analysis it has done. I would like to add some extra points. When we survey patients—

Sir Amyas Morse

There is a point here on accuracy of evidence. As I understand it, you have been operating e-declarations since 2014. Is that not right?

Chris Wormald

Yes, but the numbers we are talking about here is the first run.

Rosamond Roughton

Yes.

Sir Amyas Morse

So when you are saying this is all new, is it? Is it your testimony that this is new?

Rosamond Roughton

This is something that NHS England has done for the first time; it was not done by primary care trusts or the Department of Health previously.

Sir Amyas Morse

Sorry, can you just tie up? You have been doing e-declarations since 2014, but you are presenting this as all new. Can you just tie that together for the Committee please?

Rosamond Roughton

It is new in that NHS England set up this process of an e-declaration in 2014-15; we didn’t have any data previously. We have increased the number of questions in that since 2014-15. We had started with a local process, and we have now followed that up with a national process to follow up and make sure that we have a consistent process so that, for every one of the 1,012 practices that are reporting closing before 3 o’clock, we are now chasing up exactly what are the alternative arrangements—

Chair

So you are seeing what you are paying for, and whether you are getting what you are paying for? Or what the taxpayer is paying for.

Rosamond Roughton

And we are seeing what they are doing in terms of meeting the reasonable needs of the population or failing to do so.

Chris Wormald

I will go back to the original question after this important clarification: when we poll patients in the annual patient survey, about 75% of patients are basically happy with their access to their GP, which is quite a high level for a public service. We know that.

Caroline Flint

We know those figures.

Chris Wormald

The point I was going to make a couple of questions ago is that there are valid reasons why an individual practice at a particular time may be closed.

Caroline Flint

Let me put it on the table that I appreciate that there are other things that will be happening in practices, such as training, paperwork and everything, but let me just be clear about this. Nobody is suggesting—I am certainly not suggesting—that a GP should literally have appointments with patients during core hours from 8am to 6.30 pm. I will come on to contact time with patients. What we are talking about here, and I think this is the definition that the NAO used, is that when we are talking about “closed”, we are talking about the practice literally being closed. You cannot go to the reception and you cannot necessarily get someone at the end of the phone—you get an answering machine telling you to go somewhere else. That is my understanding, in discussion with the NAO, of the definition of what we are talking about today and the way in which the NAO was looking at it for its Report.

Chair

Rosamond Roughton, do you agree that that is the definition the NAO uses?

Rosamond Roughton

The e-declaration asks about the core opening hours, so the data in the Report is absolutely correct about that. That is what we have been fed back. We are now going back to all those practices and saying, “Can your patients see a doctor if they have an urgent need? Can they pick up prescriptions?”

Caroline Flint

Let me stop you there. If the question is, “Can your patients see a doctor if there is an urgent need?” they will turn around and say that there is the out-of-hours service or something else. We are talking about the actual practice being physically closed to people even if they want to come in and book an appointment or collect a prescription. That is my understanding of the definition of what we are discussing today. Are you disagreeing with that?

Rosamond Roughton

We have gone back to follow up with every one of these practices, and some of them have said that they are open for somebody to pick up a prescription or drop off a specimen, but they have registered—

Chair

We need clarity. Jenny George from the NAO, can you please explain the measurement that the NAO used in clear, plain terms so that we can be absolutely clear?

Jenny George

The e-declaration descriptor, as I understand it, said that the reception was closed and therefore the building was closed at those times. It may be, as I think you are saying, that as you followed up with individual practices they said that in effect they had declared it wrong, but the data collected was that it was closed.

Caroline Flint

So let us all agree that at the time this data was collected it was made very clear, when the form was filled in, that “closed” meant “reception closed”. They may have changed some of their practices since this data was collected, but that was what was going on at the time it was collected. Can we agree on that?

Rosamond Roughton

That is what the practices reported to us when the data was collected.

Caroline Flint

That is helpful. Again, we are clear that we are talking not necessarily about appointments throughout this period but about practices physically being closed. Are you concerned, Mr Stevens, about the number of practices that are closing during core hours, the variation between practices and, in particular, that not being open during core hours leads to more patients referring to A&E, as the Report seems to suggest?

Simon Stevens

Yes, obviously—

Caroline Flint

Why are there these variations?

Simon Stevens

Precisely because we are tracking this and taking action in the two ways that I described. We do want to address it—while recognising that the clarification you provided is absolutely right. That is not to say that individual GPs should be running their surgeries throughout the day. There are many other pressures and commitments that GPs rightly have in terms of home visits, clinical letters, answering phone calls, discussing patients with hospital specialists and all the rest of it. This is not just about the operation of surgeries throughout the day but about making sure that GP practices are meeting the reasonable needs, as specified in the GMS contract.

Caroline Flint

Why do we not have data on the actual contact time of GPs—or other clinical staff such as nurses, for that matter—with patients?

Simon Stevens

As I am sure Ros will also mention, we are introducing for the first time a GP practice workload tool that is actually going to measure what is happening inside primary care. I would argue, and I think many GPs would argue, that one of the reasons why GP services have lost out, compared with other parts of the NHS, is that there has not been as much transparency about the extra work pressures that have been building in general practice for a decade as there has been about, say, the extra number of patients that hospitals are treating. That has contributed to the fact that the rate of growth in GP funding was half that of hospital funding in recent times until we took a clear decision to begin to reverse that, as we now are.

Caroline Flint

Ms Roughton, can you help me a bit more with how you go about tackling the differences between practices? In particular, can you give some insight into how local clinical commissioning groups are going to do that? One of the interesting bits of information from the Report was that there was a lack of confidence among both GPs and the inspectors that commissioning groups knew what was really going on in practices, even though they are led by GPs, and they were not equipped with the tools or authority to effect change.

Rosamond Roughton

The first thing goes back to what meeting the reasonable needs of the population means. That is the statement in the GP contract, and it is very broad. It is fair to say that local commissioners have not always had a consistent view about how to enforce and interpret it.

Caroline Flint

Can I stop you there? This is about the reasonable needs of the population. Can you explain to me what you feel that definition actually means?

Rosamond Roughton

I think that definition means that you should be able to phone your practice to book an appointment, pick up a prescription and drop off specimens. If results come into the practice that require urgent attention, there should be somebody there who is able to pick that up, if it is to do with warfarin monitoring or something, and contact the patient. Those are the sorts of thing that ought to be in place, and I think that in the body of GPs there is a reasonable sense of what that is.

Caroline Flint

There obviously isn’t, though, because there is quite a lot of variation in the core hours.

Rosamond Roughton

So I think we need to write that down. We agreed in the 2017-18 contract with the BMA that we will work with them and local medical committees to set out what that is. I think that is an important next step.

Caroline Flint

I think everything you just said is absolute common sense. I am finding it hard, given that this contract has been around for many years and “reasonable needs” have been part of it, to understand why, between the Department of Health, you, the BMA and others, they are not well understood. Again, we are talking not necessarily about seeing a doctor, but about just being able to come in and get your results.

Rosamond Roughton

That is why I think we need to absolutely write the definition down now and set it out so everybody can feel confident in applying those rules when talking to practices.

Caroline Flint

So it’s not written down at the moment.

Rosamond Roughton

No, it’s not written down at the moment.

Caroline Flint

It’s just essential needs, vague—

Rosamond Roughton

Yes. We know from the analysis of the location of the practices that report that they close before 3 o’clock that they are concentrated in very particular parts of the country. There doesn’t seem to be any obvious reason why some parts of the country have got this pattern of half-day closing and other parts do not. Over half the country has either none or maybe one practice with half-day closing. When we looked at the 1,012 practices, we think this is a cultural—

Caroline Flint

A historical set of circumstances.

Chris Wormald

It is always very difficult for us to answer questions about why something clearly sensible that we are doing now has not happened previously, which is the thrust of your questions. Until quite recently, the system relied on the professionalism of GPs to take all those decisions locally.

Caroline Flint

Have they not been taking them, then?

Chris Wormald

We look at what patients think of GP services. They have traditionally been very—

Caroline Flint

We can get on to engaging with the public about what they want. It is quite interesting that in all the discussion about needs and what patients want, there seems to be very little evidence of how you have gone out at a local level to ask the public what they actually want.

Chris Wormald

I am not disagreeing with the thrust of your questions—that is why we have been taking action. I am simply trying to explain why I think it may not have been done previously. It is because people have relied on these very popular services and have not specified what they want, in the way that NHS England is now doing. As I say, it is very difficult to explain why something we now think should happen hasn’t happened previously, but that is the best explanation I’ve seen.

Caroline Flint

I am just trying to get on the record clarity for us and the public about what this core contract means and what it doesn’t mean. So much is meant to be based on the reasonable needs of patients, and systems have been set up. A system is being set up that is going to cost money, but the definition of what those needs are has been pretty vague or not well understood. I think that is a fair enough thing to ask before we extend the hours, so that we understand what we are doing, why we are doing it, and what it is going to cost, so we get value for money. Going back to Ms Roughton—thank you for your answers, which were very helpful and clarifying—if commissioning groups are made up of local GPs, are they independent enough to challenge opening practices in their local areas?

Rosamond Roughton

Yes. We have worked hard over the last two years to be really clear about the management of conflicts of interest in delegating CCGs. We know that people in many parts of the country were taken aback when they saw the data. There is a lot of peer pressure here as well, with people thinking, “Why are some practices closing for a half day when we are not?” In some ways, we know that peer pressure is one of the ways in which change happens, but we will not just leave this to CCGs. We will ensure, in working with CCGs, that this happens. Where we have significant concentrations of practices closing early, we also need to support those practices to be able to address these needs. I know that a couple of areas of the country are struggling with the age profile of GPs. We are not frightened of taking contractual sanctions, if that is where we need to go, but in the first instance, we want to try to support practices in providing the great service that they want—

Caroline Flint

I know my colleague Mr Pugh wants to come back to this area a little later. You talked about tightening up the system, clarifying the definitions and so on. What other support are you providing to commissioners to support that in general practice, and how are GPs responding to that?

Rosamond Roughton

We have an extensive development programme now, since I last gave evidence to the Committee, to support those providers and commissioners in stabilising and changing general practice. We have a whole series of events, webinars and guidance to support providers of the service and the commissioners of the service in tackling these issues. We have done some very detailed work looking at how practices manage their work. We have clearly identified opportunities for practices to re-design their services within their funding envelope to provide a better service and reduce the workload, which is probably one of the key issues. Just this week, on Tuesday we had about 400 people, with two thirds from practices, looking at how they could learn from each other and build support to start making improvements.

Caroline Flint

Mr Stevens, it is very welcome that more information is being collected to have a better idea about what is happening and the variations. Is there a case for making the information more public and accessible to patients?

Simon Stevens

Yes, absolutely.

Caroline Flint

You have got the data, could you put it—

Chair

We discussed this last time.

Simon Stevens

I would go further than that; we want to have more information on the availability of GP appointments for routine conditions. We will start collecting those data during the course of this year, and then we want to publish those so that people can see what the different waiting times are. I think that will be good for patients and for GPs, because it will illustrate the opportunities that Ros has talked about. This is all in the context of a general practice system that is under great pressure, but into which we are putting investment. It is therefore reasonable to expect, on the back of that, improved access alongside the extra GPs, practice nurses, pharmacists and mental health therapists that we will put into general practice over the next several years.

Caroline Flint

Can I move on to the proposals for the extension of hours to 8 pm during the week and to weekends? Given our previous discussion about the core hours and the variations there, what do you expect from general practice in providing these additional hours? What should be happening during those additional hours?

Simon Stevens

We will get to a situation by next March where half the country is covered by GPs who are able to offer evening and weekend bookable appointments, and it will be the whole of the country by the following March, in 2019.

Caroline Flint

How many bookable appointments should be available in those additional hours? At the moment the core hours are to 6.30, so it is another hour and a half. How much of that extra hour and a half per day in weekdays should be appointments, for example?

Rosamond Roughton

We have specified to local commissioners that we are expecting at least an additional 30 minutes per 1,000 of population. That is about face-to-face appointments—

Caroline Flint

Roughly, a practice is what? They vary, but about 7,000?

Rosamond Roughton

Yes, 7,500 or 8,000, on average. How that is organised—in terms of do you put three GP clinics on a Friday night versus six on a Sunday, or is it one on a Friday night and six on a Saturday—is something that local commissioners will make a decision on. On the length of the appointment, one thing that we have found in the access schemes that we have done already is that by offering some additional extended-hours capacity, practices have been able to create longer appointments for some of their patients whom they are seeing during the week. So we are not specifying the number of appointments because we do not specify the length of time.

Caroline Flint

So we could get quite a lot of variation still.

Rosamond Roughton

Yes, but you will not get variation in the amount of additional capacity. You will get variation in, or you will be looking at things like group consultation. We have had schemes in which we have had group consultations, a really helpful device to improve compliance.

Caroline Flint

How are you and the CCGs assessing the evidence for the demand for these services in the evening and at weekends?

Rosamond Roughton

As Simon said, we have commissioned this GP workload tool, which every practice will be getting during the course of this year—

Caroline Flint

When will they be getting it? Do you have a more specific date?

Rosamond Roughton

From April this year.

Caroline Flint

Will they all be trained to use it? Will it be operational?

Rosamond Roughton

We will be following it up. The idea is that at the click of a button they can produce a monthly report which shows how their utilisation of their current appointments is going. So that provides a foundation to see what we are doing in the current system. In addition, with the current schemes, we have been doing patient surveys about where people want additional appointments. We are also getting feedback from patients about—

Caroline Flint

This is a big change. Paragraph 4 on page 6 of the NAO Report talks about cost. It suggests: “If the additional funding is only used to meet the minimum additional capacity required by the new commitment, this would equate to £230 per appointment hour per 1,000 registered patients. In core contract hours the cost is an estimated £154” equivalent. How are you assessing the need and the demand for this? It seems important to be able to justify quite a huge uplift in terms of the cost per appointment hour.

Simon Stevens

We say three things. First, we agree with the sentence construction that the NAO has used: it begins the sentence with the word “if”—

Caroline Flint

Oh. You’re not serious?

Simon Stevens

I am serious. This was a very constructive discussion that we had with the NAO during the course of the production of this excellent Report, and the point it makes is that “if” the additional funding is “only” being used to meet the minimum additional capacity, that would be £230 per appointment hour. The reason the “if” is there is that the funding is not only being used for that. Some of it is being used to lever in far wider changes, including the ability to operate as practices across a town, sharing access to medical records, so you can go to one practice in the evening and they can still see your own records from your own surgery. Those are one-time costs. The costs are coming down.

Caroline Flint

I appreciate that clarification. On the costing and the £230, of the additional amount over the £154 per appointment hour that it is at the moment, how much do you think will be going into the GP practice to pay for the “per appointment hour” rather than to some of the other things you described?

Simon Stevens

Ros can correct me on this, but I think that the first wave of schemes were in the zone of £11 or £12 a head—something like that—the roll-out is now taking place at half that, at £6 a head, and the in-year cost is going to be closer to £3 to £4 a head.

Chris Wormald

You would expect, as we do in all sections of the economy, to see some uplift for paying for out of hours rather than core hours. On the NAO’s figures it is about 50% uplift, which is about time and a half. As Simon says, you would expect it to pay for more than that, and to come down. On your question about evaluation, the policy has been rolled out quite slowly and iteratively. The first pilots were £50 million and there was an evaluation of that. We learnt quite a lot, particularly that things like weekend and Saturday morning appointments were considerably more popular than Sunday ones in that evaluation. We learnt a lot about the effects of how you advertise the services as on demand. That was then built into the wave 2 pilots, and then into the actual roll-out. The way this policy has been done has been to try it out on a small scale, learn from that and then build to the next stages, and we expect that to go on. We are not claiming we have got all the answers about how exactly this will work.[1]

Caroline Flint

Just remind me in case I have missed something, Mr Wormald. That is all very helpful: all the information that you have pulled together and the other information looking at what is currently happening and learning from concerns about how, under the core hours contract, enhanced payments were made when they were not open. Can that all be pulled together as a body of information that underpins the rationale for moving to extended hours?

Chris Wormald

Yes, with one proviso. The way this policy has been developed, which is one of its strengths, has been a continuous iteration. There will not be a point when we say, “Here is the definitive answer.” First, we want to iterate it, and secondly, we want some local flexibility.

Caroline Flint

The more information that is available would be really helpful to understand the processes and what therefore underpins the strategy, and of course the costings at the end of the day about any extended service.

Rosamond Roughton

I would add that we have got from the national GP patients survey really consistent results for many years now. If you are in work and aged between 18 and 50, you will have a worse experience of general practice. The older you are, the better your experience of general practice is. In terms of convenience of appointments, working age people find it much harder to get an appointment. That is what we get from the feedback in the local schemes.

Caroline Flint

I understand that. I have raised it myself. As a working person myself, perhaps if they were open from 8 am to 6.30 pm, and if there were appointments at 8 am or at 6 pm, that would certainly help me and a lot of other working people. But is it the case that appointments do not start until 9 and they finish by 5? I don’t know because we do not have any information on that pattern of appointments that are provided within the core hours. It is really important to understand not only what happens during the core hours beyond the reception.

Chair

Do you agree?

Chris Wormald

Yes. Some of the things Simon described will help with that.

Chair

But you agree with Ms Flint that we don’t really have the figures?

Caroline Flint

If we had appointments at 8 am, they might not need to stay open until late.

Chris Wormald

We do know quite a lot about what the public want. If we take the 25% of patients who were not satisfied with opening hours, 72% of those people think Saturday opening would help; 69% think evening; and 40% think Sunday. So we do know—

Chair

Those are national figures.

Caroline Flint

Mr Wormald, is it fair for me to say that you do not know, when you look across the 1,012 practices, how many of them offer actual contact time GP appointments before 9am or after 5.30 pm, within the core hours as things currently stand?

Rosamond Roughton

I would need to go back and check what our dataset that we have collected tells us about precisely what happens in those hours.

Caroline Flint

It is a fair point. It will not suit all working people, because some people work shifts and therefore weekend or 8 o’clock might not help, but if you do not know whether there are offers for working people before 9 am or after 5.30 pm, on what basis are we assuming that extending the hours will be value for money in terms of that suiting their needs? If we were more prescriptive about what should be provided during the core hours in terms of contact time, we might meet the need of some of those working people. Is that a fair comment?

Chris Wormald

No.

Caroline Flint

It seemed completely logical to me, but maybe not.

Chris Wormald

I will clarify my answer. I don’t completely agree.

Caroline Flint

So you do sort of agree?

Chris Wormald

The first thing to say is that we are of course implementing a manifesto commitment here, so we start from that as a baseline. We know, from patient surveys and our evaluations of wave 1 and wave 2, a lot more than we did previously about this. Would the kinds of information that you are describing help? Undoubtedly, yes. But I don’t think that that undermines the case for extended opening overall, although I think it is a perfectly valid point about—it has been worked into how Ros and others have been rolling this out—how you roll it out in particular places in order to meet—[2]

Caroline Flint

It is interesting that we really haven’t got much data about the application or the provision of appointments at those points that might help working people. But let’s move on—

Chris Wormald

I think that is a good point—

Caroline Flint

Let’s move on.

Simon Stevens

The patient survey—

Caroline Flint

No, I’m sorry.

Chair

We are going to move on.

Simon Stevens

It is practice-specific, so we do have that. It is practice-specific data on what the patients of that practice themselves say about the availability of appointments.

Caroline Flint

No, I’m sorry, Mr Stevens. What you haven’t got is data that we can talk about today that explains how many appointments are available before 9 o’clock and after 5.30 pm, which might be in the interests of working people. So let me move on. I am sorry, Mr Stevens. I asked a question.

Chair

We are not going to go back to the 2008 data collection.

Caroline Flint

We are trying to determine the basis of the strategy for the extended hours. There is some concern about how extending the hours sits with what is already available in terms of out-of-hours services. Can you tell me what assessment you have done of that and how you are going to avoid overlay and end up paying twice for services that are maybe not being used effectively? We have out-of-hours care and we have other things being developed, and that is a welcome strand of activity. It seems to me there is a danger that by extending the GP hours, those services will not be used—they are contracted to do that for a period, and therefore we are paying money and they will not be used—or that the GPs won’t be used because we are doing a marketing exercise as we speak to try to get people to use those other out-of-hours services. Who is doing the joined-up thinking about that?

Rosamond Roughton

This is definitely a risk and the NAO Report is right to pull that out. That is one of the main reasons why we ended up with the strategy being about devolving money at a local level to local commissioners to draw up plans, because they understand the range of services that this extended access needs to be connected with. It is also why—as we have set out—some of the flexibilities are there. What we have found from some of the pilot schemes is that in parts of the country with quite dispersed populations—take the East Riding of Yorkshire, for example—it would not be cost-effective to have the same concentration of extended access hubs as you might have in the middle of London. You might be better off using the GP out-of-hours service that is already there to provide bookable appointments on top of the urgent care service that they provide. What is really important for us at the moment is getting all the plans back from CCGs and scrutinising how they have made sure that there isn’t a duplication of cost and service.

Caroline Flint

Will you very clearly follow activity and take-up and match that against what you are paying for these services? First, we want to avoid overlapping, but we also want to clearly see, down the road, whether we are paying over the odds for a service that is now being underused, because other parts of the local health community are providing a very similar offer.

Rosamond Roughton

Yes. What we have done with the schemes already is get detailed reporting about the scale of appointments being offered and what the utilisation is on Saturdays and Sundays and evenings. That is why we want to get this tool in place from April available across the country—

Caroline Flint

Therefore, if in the local health community they have used the tool for assessing needs, and are able to look more clearly than before at who is accessing the service, the price against that, and whether a service is being underutilised because the patients’ needs are being provided elsewhere, how quickly could you move to change services so we weren’t paying them too much?

Rosamond Roughton

That would depend on how the contract has been set. We need to do some work on collecting the data not from the extended access provision, but from the GP out of hours. That is the area where we still have a data gap about the utilisation of GP out of hours across the country. Locally, in order to make sure you are using this money properly, you are going to need to understand both those things. It is no good just understanding one.

Chair

Are you planning to do a survey of out-of-hours access?

Rosamond Roughton

Not at national level, no, but that has been part of when we have gone to talk about the guidance we have issued to CCGs; that is, demonstrating and making sure we have got these connections right. That is one of the areas that we need to come back to.

Chair

To be clear, CCGs will be assessing how the out-of-hours service in their area is used, for example, whether someone has been to a GP in the day and then gone to the out-of-hours service, or are using the out-of-hours service instead of a GP.

Rosamond Roughton

We have not specified that precisely. We have asked them to tell us how they would be confident that they are not duplicating resource. One of the bits of data that they will need for that is about utilisation of GP out of hours. I couldn’t say to you here that we—

Chair

So it is national broad guidance but not the detail.

Caroline Flint

I have another question about the impact of extended service. It was interesting that the Report seems to suggest that, where currently practices offer extended hours, there is a danger that the continuity of care for patients is lost within that. What work have you been doing to bear down on that particular problem?

Rosamond Roughton

Again, working with some of the pilot schemes, we have been looking at how they have designed their flow so that, in essence, by providing additional capacity at these other times of day, whether they have been able to create longer appointments or group consultations for patients they might see on a routine basis or who are more complex patients. In some parts of the country they have been more successful at that. The GPs are saying, “This has helped us create space to have longer consultation times with those 100 patients who are on my personal worry list at the moment.” That is a really important element for the implementation, because we know the continuity of care for certain groups of patients at certain points of life is critical to the outcomes.

Caroline Flint

They want to see a named GP.

Rosamond Roughton

Yes, and the utilisation of resources in the system.

Caroline Flint

I understand that part of the negotiation about the extended hours is that a practice may not have to do this if another practice is offering it. They are obviously going to look at others. Earlier one of you mentioned patients’ notes. I understand that currently it is quite difficult if someone wants to go and see another GP in this situation for there to be sharing of patient notes. How is that going to change? Will that have to be in place before you allow that flexibility to happen?

Rosamond Roughton

This is really important to have in place. Otherwise, you end up getting people bouncing around the system because they see an unknown bit of the system and then they go back to their normal practice. When we have looked back over the past 20 years, that is one of the things that has meant we have not delivered better access. This is what we are doing. The schemes we have got already have devices that go on top of their systems to connect to another system with all the relevant information governance controls. That means that they can access that patient’s notes with their permission, even though they are not coming to their practice. We are trying to get a national solution. We are testing in Leeds and Cornwall a way to do that that would mean that, from September this year, there would be a much simpler national solution, instead of some of these workarounds.

Caroline Flint

Thanks very much, Ms Roughton, you have been very clear and helpful in your answers.

Chair

I want to follow up on that. Is that something you would consider rolling out to community pharmacies?

Rosamond Roughton

We have nearly completed investment for all community pharmacies to have access to the summary care record. I think the figures were that about 85% had taken up that investment.

Caroline Flint

My final question is about funding. Obviously, there has been a long discussion about making the funding formula fairer, Mr Wormald; and it has been going on since 2007, I understand. As of last year, my understanding is that, in terms of the new formula, that is being applied to, if you like, the areas—but the criterion for the new formula is not coming into being at practice level until 2018. Is not there a worry with that, in that the amount of money that is going to areas is meant to be based on a fairer funding formula, based on need of the community; but we are not going to be able to have that same methodology applied to practice level for another year and a half?

Simon Stevens

That is conflating two separate things. The area-based funding shares for primary care are based on relative need, whereas the payment formula for individual practices—the Carr-Hill formula—was essentially based on expected workload. So we have made dramatic strides in improving the equity of the allocation of primary care funding across the country, and it is probably fairer now than at any point since 1948. You can see from figure 9 the fact that for this coming year we will have ensured that no CCG is below 5% under its weighted cap, and from 2018-19 that will be true as well for the primary medical care component of CCG allocations. So in terms of ensuring that the people of Hackney or Doncaster or wherever it might be have got their fair share, not just for the NHS money in the round but also for the primary medical care component of that, I think it is dramatic progress. The second part of this is: what about the individual GP contract? As you may recall, this Carr-Hill thing was a source of great controversy and consternation and was almost enough to topple the new GP contract that came in in 2004, in the first place. I think everybody wants to tread with care when they are messing with things that actually would produce big swings in the resourcing for individual practices. As you will recall, we are moving to a fairer system around the minimum practice income guarantee, MPIG, but that has had to be phased in over seven years so as not to have that big dislocating effect at practice level, and the reviews we have been doing of the PMS funding, again phased, over four years—

Chair

Just explain PMS, please.

Simon Stevens

Personal medical services. Two different flavours of GP contract, the PMS reviews are phased in over four years, and so forth. We have committed in principle to phasing out the quality and outcomes framework bit of the GMS contract, which in my view and the view of many others now has run its course. So as part of the discussion about the replacement for the QOF element we have also got to take a look at what this Carr-Hill piece would be. I do not think we should throw all the cards in the air so it would be a big bang that would destabilise individual practices for 2018.

Caroline Flint

With, obviously, potentially quite a lot of variation in terms of GP practices moving towards extended opening hours, have you considered whether—obviously part of this is about patient choice as well, and we want more of that, I think, because it pushes up standards, hopefully—it might be more attractive for patients to want to be registered with those GP practices that are offering more of what you have identified as meeting their needs as working people, or for whatever reason? If there is a move and a desire for people to go to longer opening hours of these practices, will they be accepted, and, if they are accepted, how will that affect the planning for funding at a local level?

Simon Stevens

Part of GP income relates to the number of patients it is looking after under capitation. So, to the extent lists grow at a particular practice, because they are attracting more patients, obviously that gives them the resourcing to expand their services. But for a lot of these evenings and weekends, as Ros says, we are expecting that this will be done on a shared basis between practices in a town or a locality. So if you think about what is going to be happening in London, by March 2018 we expect to have 8-to-8 bookable access to GP appointments right across London. Obviously, that is not going to be every practice, but if you look at what is happening in south-west London right now, you will see they have figured this out. They have got the record-sharing, three or four practice hubs across those boroughs—

Caroline Flint

I know there’s a brave new world, where there will be shared information—

Simon Stevens

It’s happening—it’s already happening for 17 million people.

Caroline Flint

So, if I see a GP practice that is steaming ahead, providing a lot of different services based on need and providing me with options for when I have my appointments, if I choose to, can I go and say, “I like that place. I want to change and register with them”? First, will they accept me, and how will it be managed if people like me choose to do that? Secondly, will the funding move from my existing practice to support that practice?

Rosamond Roughton

Yes. We changed the regulations—I think it was last year—to make it possible for people to register with practices that might be near where they work, rather than where they live. Practices need to say that they are happy to do that, because you wouldn’t then be eligible for a home visit from that practice. So we have legally made that more possible. We assess the registrations at regular intervals during the year. As Simon said, the funding that goes to practices is determined by the number of people on the list. If a practice’s list grows astronomically during the year, it would see funding for it catching up during the year. The issue about whether a practice would accept you on the list is that practices can apply to have closed lists. So, they can say to commissioners, “We feel we are saturated. We can’t take on any more patients.” There is a policy about the circumstances in which we would accept a closed list from our point of view, and at what point would it mean, “Sorry, practices are obliged to take you on”? It is only if they have got a closed list that they couldn’t take you on.

John Pugh

May I move on to performance management of GPs? The performance managers par excellence are the clinical commissioning groups in this framework. You accept that there will be problems or issues connected with conflicts of interests there because you don’t normally get people being performance-managed by their colleagues and collaborators—if I can put it like that—do you?

Simon Stevens

We have very clear guidance on conflicts of interest—

John Pugh

I’m just saying that there could be a problem and therefore you have clear guidance. That’s all I wanted to say; it’s the preliminary point I wanted to make. It is fairly straightforward and discussed under the—

Simon Stevens

There is a trade-off here. We can either try to manage every town, village and hamlet from Leeds, or we have to recognise we need a more localised system.

John Pugh

Initially, Mr Stevens, I think that was the intention of the legislation. Then NHS England found it could not do that and therefore aggravated the potentiality for conflicts of interest. Would you also accept that, as a performance management system, if you have a look at it, you see there are an awful lot of carrots in this system and practically no sticks?

Rosamond Roughton

As Chris said, traditionally this has been a high-trust kind of contract—

John Pugh

That is another way of saying it, isn’t it, really?

Rosamond Roughton

So the process that our local teams have taken is looking at the range of data sources that exist, so that primary care—

John Pugh

I accept your assurance that it is a trust system. It is a system based on carrots and not on sticks. There is no equivalent to the fines you can impose when you performance-manage acute hospitals. I think they paid out £600 million in fines last year. Is that right?

Simon Stevens

We dropped fines from the standing contract for 2016-17, as you may recall. Let’s take a step back. If one accepts, as I do, that GPs are under very considerable pressure—no doubt we will come on to discuss the importance of retaining GPs and persuading people to come into general practice in the first place or to come back to it—

Chair

We will.

Simon Stevens

Then we’ve got to do two things. We’ve got to ensure value for money for taxpayers’ resources, but we’ve also got to recognise that this is a really tough job and the vast majority of GPs, according to their own patients, are doing a brilliant job.

Chris Wormald

You are clearly correct that we do not manage, and have not historically managed, the GP system in the way that we have managed other public services. However, if you put the point you made to the BMA—I was talking to them yesterday—they would not accept your starting proposition.

John Pugh

I wouldn’t expect them to. As a performance management system, I think you would accept—but possibly not in these candid terms—that it is a pretty rubbish system.

Simon Stevens

No, it is not a performance management system; it is a contractual system. That was the original deal in 1911 that Nye Bevan agreed to in 1946. We have a contract and we have to manage to those contracts.

John Pugh

If I could refer you back to page 23, there are two bits of evidence there that say that this is a performance system that is ripe for serious review. First, the GPs themselves, no matter how benign the system might be, are clearly not happy with its capacity to produce the changes that they think should happen. Page 23 states: “Two-thirds (66%) of CQC inspectors…thought that commissioners did not take effective action to deal with concerns about access at individual practices”. The CQC is saying it is not an effective management system.

Simon Stevens

Let us not over-interpret these rather skimpy data. The GP survey is n=124 out of 42,000 GPs. It is a sum total of 49 CQC inspectors responding to the first of the responses.

Chair

Sorry, we might get the NAO to clarify, but figure 7 says it is “Based on 839 responses from GPs”.

Simon Stevens

Yes, but the ones that are red—that is, the 15.1%—add up to a tiny fraction. It adds up to 124 GPs. So, 14.8% of 839 is 124 GPs out of 42,000.

John Pugh

Okay. Let me move on to something less contentious. When you put it to GPs that the performance management system is not perfect, they will say that none the less it is wholly beneficial for GPs to share data with one another. They can look at what colleagues do and ask themselves why they do not do better than some of their colleagues. You have developed a web tool, and I think NHS Digital is committed to transparency. Could you give me your understanding of how well that is working? In other words, are these sorts of soft incentives—looking at your colleagues and seeing how they’re doing—working any better than fines and stuff like that?

Rosamond Roughton

We have developed this primary care web tool, which I think has more than 20,000 users. It has more than 60 indicators of different measures that are either absolute health outcomes or proxies for good-quality care. Tracking it can give us a picture of how things are changing at a national level, and what we can see is that, on the whole, more practices are getting better than worse. I know, from talking to people at a local level—this is more anecdotal—is that there are places where this has been really useful and the practices have used it as a peer-to-peer tool. They can also look at it relative to practices that have the same kind of demographic population as them, so they can group themselves with similar practices to make sure they are comparing themselves to—

John Pugh

I am not saying that peer-to-peer doesn’t work; I am asking you how well you think it is working.

Simon Stevens

May I add a factual addendum? Let’s also understand that this is not just peer-to-peer. GPs are the one group of the clinical professions whose personal income is strongly tied towards performance against a set of clinical quality indicators—the quality and outcomes framework. Some £700 million of their practice income is tied to the world’s largest pay-for-performance incentive structure for any clinical professional, so they are much more exposed. There is a question as to whether that is any longer doing the heavy lifting we want of it. As I said earlier, I don’t think it is, but it is not the case that it is just some soft, peer-to-peer review process; they have £700 million of their income at stake, based on their clinical quality performance.

John Pugh

But the vast majority of them are maxing or nearly maxing out on their QOF measures one way or another.

Simon Stevens

They’ve done well.

John Pugh

You’ve raised the question of whether you need to sophisticate that, because you may actually be indirectly incentivising futile but none the less rewarded activity. People may go in to have their ankle looked at because it is strained, but find that their blood pressure is taken from some strange reason that they suspect is something to do with GP remuneration.

Simon Stevens

The move will be away from those kinds of approaches, towards a more professionally based quality improvement process, recognising that GPs are professionals and that this is probably a time-expired tick-box scheme.

John Pugh

How, therefore, will you be measuring the efficiency of a GP’s service? If they are not going to use QOF, which we accept is probably a time-expired scheme, are you going to use output measures? The Lancet showed that QOF improvements did not tally with mortality improvements.

Simon Stevens

Obviously Martin Roland and colleagues have done extensive work, not just in The Lancet, but in The New England Journal, the BMJ and elsewhere. Their advice is that we have now got as far as we are going to get with using QOF as a quality improvement tool.

Chair

QOF is over.

Simon Stevens

QOF is over, and that is a negotiation we will be having with the profession. We set a reimbursement rate that corresponds to an efficient delivery of primary care. An individual practice that then incurs higher costs to do so is obviously incentivised to bring its costs down.

John Pugh

May I just pick you up on your wording? Efficient delivery of primary care is not necessarily the same as what we have been talking about for most of this session, which is basically access. Obviously if primary care is working well, one of the benefits you would expect is that people would be much better at managing chronic diseases and would therefore need to access their GP less, or—as IPPR research showed—would see some other experienced professional, maybe not a GP. How are you going to catch that in the performance measures?

Simon Stevens

It goes back to a point Ros made earlier: we have about 300 million consultations a year in GP surgeries, and we have a differentiated group of reasons why patients are consulting their GP. It has tended to be seen as a one-size approach when looked at nationally, but we have to differentiate a person with multiple chronic conditions, who might require a more intense follow-up and for whom continuity of care will make a difference—there is good data on that—from the 85 million same-day urgent GP appointments that are happening each year, a lot of which are for things that just need sorting out there and then or one-off episodic improvement. The reason it is so important that the GP system functions well is not just the long-term conditions management, but the availability of same-day urgent care. If you think about 23 million A&E attendances versus 85 million same-day urgent GP appointments, it is obvious that if you under-resource or under-support the primary care urgent care system, that spills into other parts of the NHS. It is worth reminding ourselves of the fantastic efficiency that primary care represents—over 90% of patient contact is in primary care, and a year’s worth of GP care costs less than two A&E attendances.

John Pugh

I was trying to make the point that it is about how you measure the efficiency of GP care. It is not just how many people you divert, or not, to A&E; it is how few people actually turn up at the GP, because the first consultation has put them on a successful path of self-management.

Rosamond Roughton

May I add something? Maybe we are not doing it at national level, but that is part of what we are doing in our national general practice development programme. We are taking practices through a process that helps them to really look at and analyse the demand that they are seeing in their practices and, based on what we have learned from those pilots, find a better and more productive way of helping to manage GP workload, such as using other members of the workforce, as you mentioned, or the voluntary sector. Where we have done that work, it has been really fantastic for patients and practices. We are giving them a tool so they can measure it and so that, as Simon says, there is a really good incentive already built into the system for practices to be more productive. What we are trying to do is support them doing it for themselves, so that we build a bit more hope and confidence in general practice about being sustainable and long-term.

John Pugh

I suppose there is an issue about how well the CCG can lead that process locally, but we will move on. Just one last question, which may trespass over some territory that I think the Chair is likely to visit. In my patch, I have a very, very large medical centre opened under the LIFT programme, which is wholly underutilised. I also have the local CCG investing significant amounts of money in GP practices. The sensible thing for the health economy would be to persuade the GPs who have poor accommodation to go into the surplus accommodation that the NHS currently holds and pays for. Am I right in thinking that there is neither the leverage in the CCG nor the incentive to the GP to do that?

Rosamond Roughton

Cases like that involve a really difficult set of value-for-money considerations, because if they are GP-owned premises, buying out those GP-owned premises sometimes ends up being more expensive than the costs currently in the system.

John Pugh

The GPs are awfully keen on doing up their premises.

Rosamond Roughton

I don’t know what price they are expecting to get for them, but—

Simon Stevens

Also, in fairness—look, when the NHS was set up, we didn’t nationalise GPs and therefore GPs own many of their buildings and they have to invest in them to produce an environment where they can look after their patients. Is this changing as a result of a whole range of factors—the move towards larger practices, salaried staff as well as partners, upgrades in the scope of services such that you can’t now operate out of a semi-detached house, even though that is a lot of the real estate that people are in? We are in a much better position than we were in 10 years ago, but frankly we need to be in a dramatically different position in 10 years’ time from where we are now.

Chair

We will come to that later. Anne Marie Morris.

Anne Marie Morris

It is clear that if we are to ensure that there is access to GPs, we have to ensure that we have enough of them, they are doing what we need them to do and the other parts of primary care are functioning properly, so what you actually need is a workforce plan that is an umbrella plan and takes into account the GP bit, but that flexes, given what you do in-house with your MCPs, your physiotherapists, your mental health practitioners, your pharmacists and your practice nurses. Is there, within NHS England, a plan for looking at that workforce in a holistic way, because if you have not looked at that, you cannot work out what you need specifically from GPs?

Simon Stevens

There is, and it’s the GP forward view. We talk about needing an extra 5,000 doctors in general practice by 2020, but also supplementing that, as you know, with another 1,500 clinical pharmacists, another 3,000 mental health therapists embedded in general practice, practice nurses, physician associates and so on—at which point I think it is time for Ian to shine.

Professor Cumming

Thank you, Simon.

Anne Marie Morris

In which case, Professor Cumming, although I understand what Sir Simon has said, we have had three reports from the King’s Fund and the Nuffield Trust in the last two years, and we have had the Health Select Committee’s report on primary care. What Sir Simon seems to be saying is that we are going to have 5,000 of these and 5,000 of those, divided up, chop-chop-chop. That is not the same thing as saying, “What is the plan and how are we going to get these different specialists working together?” Also, how are we going to get the general man in the street to be willing to go and see some of those others, rather than feeling fobbed off? A lot of the King’s Fund and Nuffield Trust research shows that people want to go and see a GP—a doctor—not a nurse. Nurse practitioners are incredibly skilled individuals, but we have undersold them. So how are we looking at this plan driven by need, not just “Let’s have 5,000 here and 5,000 there”?

Professor Cumming

Absolutely. This is definitely about the team environment that we actually create and about ensuring that people see the person who is best able to address their needs at that particular time. We have talked about many of the professions. It is physician associates, pharmacists, paramedics, nurses in a range of guises, health visitors, community midwives, psychological therapists—there is a wide range of people who can help deliver these services.

Anne Marie Morris

I am aware of that, Professor Cumming. What I want to know is: when you are looking at your targets for recruitment, where is the need-driven push that will help us decide whether you have actually got that right, and how are you going to make sure that the incentives are in place? At the moment, if a GP wants to have a physiotherapist or if he wants to train a nurse, he has to take the money out of his budget, whereas if he wants a trainee GP, the Government pay.

Professor Cumming

I will let Simon and NHS England talk about the funding of people working in the practices, but from our perspective, we are seeking to train enough GPs to help meet the 5,000 additional doctors working in general practice component, but we are also training the additional workforce to meet the 5,000 others that Simon referred to. For example, yesterday, coincidentally, we published a report on the general practice nursing workforce and how we want to expand, revitalise, re-enthuse and redevelop that workforce across the whole country to make sure that we meet the additional 5,000 component there. So it is not just targeting doctors.

Anne Marie Morris

Understood, but you are still not giving me any basis upon which to then evaluate how many of these different groups I need. Secondly, from all that I have seen in these reports about communication across these different bodies—the colleges of X, Y and Z, including nurses, GPs and so on—they have not come together and looked at this holistically, to say, “This is together what we’re going to do and what we need.” The disparity in incentives means, in a sense, that you are defeating yourselves before you have started.

Rosamond Roughton

Perhaps I can say a little bit about what we are doing to try to stimulate use of the wider workforce in general practice and about patients. In terms of the incentives, one of the big things we are doing is offering co-funding to practices to recruit clinical pharmacists into general practice. In some parts of general practice, that has met with scepticism about whether it will be a useful addition to the team and whether the business case is there. But as we have been able to demonstrate the value in practice and give people hard evidence about how this is saving GP time and improving use of medicines, and how that is therefore helping with patient outcomes, we are winning over practices on this model.

Anne Marie Morris

Good, but that is one example. There are a number of different professions involved. What are you doing in the others and how are you joining up the dots? It’s no good doing this in a piecemeal way.

Rosamond Roughton

In terms of joining up the dots, general practice as a sector has been less connected to the NHS planning sector in terms of workforce. One of the things we have been doing with Health Education England is creating community training hubs so that general practice as a provider is part of a wider group, saying, “This is how many nurses we think we’re going to need in the future. This is where we can do some of the training together.” That is a step we have taken in the last 12 months.

Anne Marie Morris

Is that rolled out generally, or is it just a pilot?

Rosamond Roughton

We have hubs in every part of the country—I cannot recall if it has happened or if it is this year, but delivery is imminent in every part of the country. In terms of patients, there is work to do. We have found that in some of the sites where we have introduced this, they have almost started and then taken a step back and had a different conversation with the public. Once people experience it, they have a different view of whether it is something they would like, but if they haven’t experienced it, they tend to be more anxious, as anybody would be about it.

Anne Marie Morris

Which is understandable; that’s a human reaction.

Rosamond Roughton

I think we need to do more—it is not just about workforce; it is about technology as well.

Simon Stevens

I just want to put some numbers around this, because I think we might be talking ourselves into believing there is a problem where there isn’t one. We have about 300 million patient visits to GP practices each year. Of those, about 80 million-plus are already to nurses, therapists or others working in general practice. The 1990 GP contract gave co-funding for the first time—we could go back to 1966 actually, but let’s start with 1990.

Chair

Let’s not have a history lesson. We don’t have time for that.

Simon Stevens

The 1990 GP contract led to a big expansion in practice nursing. That has continued. The 2004 contract—which meant that the contract was with the practice, not the individual partner—made it easier to expand the skill mix. So actually, British general practice, compared with primary care doctors in many other countries, is more multidisciplinary already, and patients are clearly accepting of that. What we are doing now is using our national funding to support individual practices working together at the 30,000 to 50,000 population basis, which is why the clinical pharmacists won’t just be in each individual practice; they will be working across several practices. The 3,000 mental health therapists is not just a number plucked out of the air; it is very precisely designed to get the workforce needed to do the expansion in talking therapies that our mental health taskforce—

Anne Marie Morris

How did you get to the figure of 3,000?

Simon Stevens

We got to the 3,000 figure by saying that we need to expand the number of patients being looked after in primary care talking therapies from a 15% IAPT uptake rate to 25%. That corresponds to another 600,000 or so patient treatments a year. The workforce to do that constitutes these 3,000 mental health therapists.

Anne Marie Morris

How will you ensure that you incentivise practices? I hear about the hubs—I have one in my constituency. The constituents don’t know about it or think it is a complete waste of money, because they think it’s just a centre where admin put numbers into computers. There is something that is not yet working to get the consumer involved. While I understand, Mr Stevens, that we may be better than lots of other countries, there is still a problem, in that the consumer does not understand or value it and will still say, “I will not see a nurse.” That is what a very recent report from the Nuffield Trust came out and said. There is a still a problem, which in your honesty I think you should accept. Tell me a little bit more not just about how wonderful we are compared with everything else, but about what we are actually going to do about it, and how we are going to ensure that the cost incentive for the GPs for all these different pieces actually ensures they will buy into it, rather than just the ones that the Government will pay for centrally.

Simon Stevens

Unusually, I have a difference of view on this point. I think patients do understand when they need to see a doctor, what the practice nurse can do and, increasingly, what the pharmacist can do for their medication review. If you are having a blood pressure check or vaccinations and all the rest of it, of course that is a practice nursing role. I think over 20 years or so, people have really understood that.

Chair

I think the Report is quite clear; it is perhaps somewhere between the two of you. What Ms Morris is asking is how you are making sure that you will be able to measure use of them and recruit the right people, because of the disincentive that she has highlighted about the funding. It is cheaper for GP practices to employ people funded by the centre—

Simon Stevens

Hang on again. We are calibrating this quite carefully. For the clinical pharmacists, we are part-funding them. For the mental health therapists, we are deliberately fully funding them as part of our expansion of mental health services over the next several years. I must admit that one of the very few places in this Report where I think we had a difference of view was where the NAO suggested that somehow we were wrong to have a financial incentive for practices to take on GP trainees. Actually, at a time when we want to substantially expand the number of GPs in training, some positive financial incentives there make a lot of sense.

Chair

I am not sure the NAO had an opinion; I think it was more of a statement of fact that it is cheaper for you to take—

Simon Stevens

Okay, as long as it is not a criticism, because we want to expand the GP trainees.

Chair

Let’s not go back down that squirrel hole.

Rosamond Roughton

I think we can see in the way that general practice has developed over the last 10 years that, as a proportion of the income they get, they are spending more and more on other staff. We can see that that ratio is changing, so it is in their interests, if it works for their patients, for them to be employing staff that do not cost as much as a doctor. There is a very direct incentive there.

Anne Marie Morris

I hear what you say and what Mr Stevens said. I just refer you to the Nuffield Trust’s report and the primary care report that came out last year from the Select Committee, which do not agree with you.

Chair

That is the Health Committee.

Anne Marie Morris

Yes. Let us move on. It seems to me that one of the things you are looking to do is put in place new structures to, if you like, ensure integration, which we all applaud. The MSPs are very well conceived—I do not have a problem with that—but one of my challenges, to go back to the debate we had earlier about need, is that those are predicated on footfall, so you can only have that consolidation and these different specialists coming together in these hubs within a population area that will give enough demand for the service. I have a rural constituency, and there is no way we could have an MSP. In a sense, that leaves us high and dry. If you applied the current structural arrangements as they are now, you would see a number of our district hospitals closing because we do not get the footfall. You would have a challenge because our GP surgeries, due to the challenge you talked about earlier, couldn’t manage. We cannot go further than the MSPs. I have a real sense that while the intention is right, you have got a one-size-fits-all approach, and you have not looked at the diverse needs across the country in rural, deprived and urban areas.

Simon Stevens

We completely recognise what you say. The model for the branch surgery—the practice in a village serving rural areas—is going to have to be different from the model in Hackney, but the horses for courses approach is implicit in the way that general practice will continue to evolve, just as it has been one of the great strengths of British general practice hitherto. It is adaptable and it is diverse.

Anne Marie Morris

Diversity is absolutely right, but the challenge is that these are small practices in rural areas. There is no pot of money to help them innovate and move forward. Often, they do not even have broadband. There is a real challenge. While I applaud the desire for flexibility, I cannot see any help in all the noise I hear for that particular rural challenge.

Rosamond Roughton

I think what I would point those practices to is, first, that we have asked CCGs to set aside about £171 million to support practices in their areas over the next two years. That is about improving access, supporting at-scale working and securing sustainability. Secondly, every practice in the country has got the chance to take up our development offer. We have already got about 600 practices signed up to doing productive work. We have got about half of CCGs across the country going into practices. That is where you can get things that I think help smaller practices, because working at scale might offer them the opportunity to get things like payroll, HR and career development functions without losing that village community sense. They can still be small practices, but they are able to get some of the at-scale provisions where that makes a difference to them.

Anne Marie Morris

At one level you are right. The challenge is that some places are particularly rural. In Devon we have more roads than Denmark, and therefore we have to look at different ways of working—the way we use hours, access, telephones, etc. I don’t see the GPs getting support for that innovation. Mr Stevens, you referred to the GP five-year plan—I have read it and it is good. When we looked at the STP issue last time we all met, it was clear that the GPs were not as involved in the STP process as they should be, and that not enough attention was paid to the GP five-year plan. I have a concern that, for all you have both said, we are still not really engaging the GPs, given the diversity of need across the country, in this new journey forward. Do you agree?

Simon Stevens

I accept that you are concerned.

Anne Marie Morris

Do I have reason to be concerned?

Simon Stevens

Are you talking specifically about Devon?

Anne Marie Morris

Rural areas.

Chair

Sparsely populated areas.

Simon Stevens

There were particular issues in the south-west, which we are collectively having to approach. As it happens, in Devon there is a good process now that is bringing together the GPs and the CCGs. Some controversial decisions are under discussion and are progressing there, but there is no reason why GPs across Devon ought not to be able to engage with the process that Angela Pedder as the STP leader is convening on behalf of you all.

Anne Marie Morris

Indeed. Mr Stevens, Angela is an exemplar, but she has also got her hands tied behind her back. She can tell them only indirectly, rather than directly. What we ought to do now is move on, focus specifically on GPs and look at how on earth we are going to find these 5,000. It is predicated on the ones we have got staying. As we look at the statistics now, as evidenced in the Report, we have got the same number leaving as staying.

Chair

The same number joining as leaving.

Anne Marie Morris

Thank you, Chair. We also have a challenge increasing our part-timers. We have also got more locums. We have got people more attracted by a salaried option. Realistically, what are we going to do to ensure we get these GPs? At the moment, the current scheme, while expected to increase—to get to 97% isn’t bad—is still not where we need it to be.

Professor Cumming

You are absolutely right that this is about flows in and flows out. It is not just about training the new workforce. It is also about the number of hours an individual chooses to work in delivering patient care, which has gone down over the years as people choose to work fewer hours. We have been successful in recruiting an increased number of people into GP training. This year we had 3,019, which is the highest ever number of doctors choosing to train in general practice, and is about 10% up on the year before. Our target is 3,250, which we are aiming to hit for this year’s intake. Round one has just closed, in terms of applications for GP training this year. That is 4.7% up on the same time last year, so we are seeing continued progression in the number of people wanting to train as GPs. In part, I think that is in recognition of some of the work that is going on elsewhere, in terms of seeing the additional funding coming through. Going back to your earlier question, other professionals support and work with the GPs in that team environment.

Anne Marie Morris

That’s all lovely. I don’t disagree with what you are saying and I am pleased it is more attractive, but I have talked to an awful lot of GPs and the Royal College, and there is still a sense that GPs are the last choice if you are an ambitious doctor. Something about that has to change. What used to be the attraction was the lifestyle. What are you going to do about the part-timers and couples to help them work in a sensible way? During training, are you going to advise them about what they might train in so they can work together? What are you going to do? You have to realise and accept that you can’t change it; there will be more part-timers and people who will stay in for only 10 years. What are you going to do to change your offer and the attractiveness to get them to stay?

Professor Cumming

We need to embrace that rather than see it as a bad thing. Professor Val Wass from Keele University did a report for us, looking at what happens at medical school and what the perception is of general practice by new doctors as they are coming out of medical school and why some are put off. You are right that in some parts of the country—in some places—there is a perception that being a GP is not as good a career choice as going to train to be a cardiologist or a neurosurgeon. To my mind, that is fundamentally flawed. It is a different role, but it is just as challenging and just as rewarding. Being a specialist across the whole of general practice is a very challenging career. What we do know is that there is a direct correlation between how much time medical students spend in the community when they are learning and how likely they are to choose general practice as a career further on.

Anne Marie Morris

That is absolutely right. One of the things we clearly need is more training in different parts of the country and GPs circulating around. Are you doing anything about that?

Professor Cumming

One thing we have done over the last two years is offer a financial enhancement to people wishing to train as GPs to go into training slots that have not had a GP train in them in the last three years.

Anne Marie Morris

Can I stop you there? It is a good initiative, but in rural areas we have found that that is not the point. It is not about the money; it is about lifestyle. They will not come and work in rural areas. What else are you doing to help these people attract the resource they need?

Professor Cumming

If I may disagree slightly with that, on that initiative this last year 105 out of 122 slots in predominantly rural areas that have either never had a GP training in them or not had a GP training in them in the last three years have been filled. So we are finding that some financial incentive at the start of training, which in some cases is allowing people to pay for a deposit on a house—of course that has the added benefit of meaning that they are more likely to stay there once they have trained—is beneficial.

Anne Marie Morris

That is good. What about couples—how are you going to help them? Otherwise, you are going to lose one or other or both out of the system.

Professor Cumming

We have been working with the BMA, looking particularly in training at what happens if a couple want to train together and one of them gets a place in Newcastle and one gets a place in Exeter. The concept of being more flexible in terms of how we can allow people to move to be able to train together is something that we are about to agree with the BMA as the next step for the next recruitment round.

Anne Marie Morris

When you say “about”, when is that?

Professor Cumming

In the next few weeks. We will be publishing it in the next two weeks.

Anne Marie Morris

That is good news. What about the use of resource overseas? Maybe this is a question for Mr Wormald. As I understand it, there was an attempt to try to ensure that GPs coming in from overseas were a priority to get them in, and that was rejected. Are we going to change that policy?

Chris Wormald

We recruit quite a lot from overseas. Health Education England leads that. Do you want to say a bit more, Ian?

Professor Cumming

We lead the recruitment into training. One of the things we have been looking at quite closely is the potential impact of Brexit on international applications or EEA applications for our training programme. This year—bear in mind that the applications for training opened after the referendum—was exactly the same as last year. So we have seen 18% of applications—this is not just for general practice; this is all specialties—being from EEA nationals this year and it was 18% last year. So seemingly the attractiveness of postgraduate training in this country, which is widely considered to be among the very best in the world, has not been impacted by Brexit so far.

Anne Marie Morris

Okay. That is good. What about the people who are fully trained and we want to bring in as fully trained? They are not coming here for training. As I understand it, they do not have any priority in the visa system, with their ability to work.

Rosamond Roughton

Part of the other end around GPs—Ian has talked about training—is attracting people back into practice. We are doing three things. One is about international recruitment of doctors already working in general practice in other places. We started piloting that in Lincolnshire, looking at a rural area, and in that, we are not coming up against those difficulties. We have got a plan to roll that out for other parts of the country over the next two years.

Anne Marie Morris

But they are not a priority sector, are they? Because the way the system works is that in some areas the UK says, “We need these people” and they are a priority.

Rosamond Roughton

It is not a shortage occupation, no. General practice is not on the shortage occupation list.

Anne Marie Morris

Do you not think it should be? I believe there had been an application to put it on that list, which was rejected.

Rosamond Roughton

Yes, I understand that was rejected.

Anne Marie Morris

In your view, should that be changed if we are to have any hope of meeting the numbers of GPs that we need in our system?

Rosamond Roughton

At the moment we are not finding that it is the inhibiting factor, but obviously we collectively put that application in and it was turned down.

Chair

We have got a shortage of people. On that and more widely on Brexit, Mr Wormald, in the discussions with Government are you shouting loudly that we may need to keep people coming in from the European Union to be doctors given that we have already got 18% applying for training places?

Chris Wormald

Yes. What we look at is the overall supply of doctors. Actually, when you look at the GP—

Chair

I am asking specifically about what conversations you are having across Whitehall to put the case for European nationals to continue to be able to work to the NHS. There is going to be a new regime—we do not know what it is yet—for people who are currently here and those who may want to come. Have you but in a bid or a viewpoint?

Chris Wormald

You will be unsurprised by my answer, but I am not going to discuss the exact conversations we are having.