REVEALED: ALL NEW GP CONTRACTS WILL BE THROWN OPEN TO PRIVATE PROVIDERS
From the FMS Global News Desk of Jeanne Hambleton 18 August 2014 PULSE By Alex Matthews-King
EXCLUSIVE All new GP contracts will be opened up to bids from the private sector by NHS England in a move that GP leaders have warned marks the ‘death-knell’ of traditional life-long general practice.
As a tide of practices face closure, managers have told Pulse that because of competition law they will not be replaced with GMS or PMS contracts, but with time-limited APMS contracts instead.
The move has taken GP leaders by surprise, with the GPC seeking urgent legal advice about the move. Some have warned it will lead to the privatisation of the NHS with surgeries replaced with ‘short-term, profit making ventures’.
APMS contracts were introduced in 2004 to open up primary care to ‘new providers’ and were famously used to procure the Labour government’s ill-fated ‘Darzi’ centres across the country.
In October last year, Pulse revealed that NHS England’s London area team was planning to procure a ‘significant’ number of APMS contracts this year.
And managers say this policy has been adopted nationally, to ensure that NHS England complies with competition regulations.
An NHS England spokesperson said: ‘Under the GMS regulations there is scope to enter into a temporary contract but this is at clear odds with procurement law and the 2013 regulations so best practice would dictate that this should not be used when APMS effectively does the same job and does not come with the same risks attached.
‘GMS can still be entered into upon reversion from PMS and the new form of PMS contract may be entered into by way of renegotiation (ie variation) but in respect of procurements, yes they should all be on APMS.’
Pulse has previously revealed an increasing trend towards APMS contracts. In February, NHS competion watchdog Monitor launched a probe on how to attract new general practice providers to regions with poor care, despite warnings from the GPC not to put ‘competition ahead of continuity’.
GP leaders are warning that, with practices under increasing workload and financial pressure, strict tender requirements could exclude smaller practices from primary care and drive the invasion of private providers.
And they are advising practices to seek alternatives to contract termination, for example by merging, when partners reach retirement in order to avoid losing ‘invaluable’ GMS and PMS contracts.
GPC chair Dr Chaand Nagpaul said he was surprised to hear about the national policy that would ‘spell the death knell of the whole ethos of long-term, continuity of care in the way general practice operates’.
He said the GPC was seeking urgent legal advice on whether NHS England was correct in asserting that APMS contracts were the only way to satisfy international procurement law.
He added: ‘It is extremely unfortunate, and highly ill-advised that area teams should be undermining secure, long-term sustained provision of general practice through APMS contracts. There is nothing to stop an area team choosing to use a PMS or GMS as a contract, on the grounds that it offers a local population the best mechanism for the provision of general practice services.’
Dr Tony Grewal, medical director at Londonwide LMCs said they were worried about the moves in the capital that would replace family doctors with ‘short-term, profit making ventures that went against the ethos of primary care’.
He added: ‘APMS is only for five years, potentially renewable, which means that you cannot invest time, you cannot invest in the long term. It is designed for people to go in, to make a profit, and to go out again. Which is not, in my opinion, what general practice is about.’
‘What it means is, over a reasonably short period of time, given the rate at which practices are closing at the moment, you are going to have significant proportions of general practice services in London, being run by the commercials or big conglomerates.’
And Dr David Jenner, GP contract lead at the NHS Alliance and a GP in Cullompton, Devon, warned that the move would mean that independent GPs would struggle to compete with larger healthcare corporations.
He said: ‘Often minimum requirements of IT, quality, financial backing, in practice can make it difficult for small providers to effectively compete.
‘It can be a very inefficient way of procuring a service of limited value. There is also the danger of providers bidding low to win the contract and then being unable to meet the terms of it.’
BMA Council member and Lewisham GP Dr Louise Irvine told Pulse: ‘I am worried about that becoming the new model of care, we have already seen new models of private companies bidding for these APMS contracts, some of them have been successful and it is hard for ordinary practices to bid against them.’
She added: ‘It is very much part of a trend, it is part of this big push to privatise, to commercialise and bring in private, for profit companies to run more and more, not just primary care, but community and secondary hospital care.’
MONITOR LAUNCHES PROBE INTO ATTRACTING NEW PROVIDERS TO RUN GP PRACTICES
From the FMS Global News Desk of Jeanne Hambleton Posted 6 February 2014 PULSE By Sofia Lind
The NHS competition watchdog is to investigate how to make it easier for alternative ‘high quality’ providers to set up GP practices in areas of low quality care, reveals a report today.
The report from the competition and integration regulator Monitor says that it requires a ‘better understanding’ of what barriers there are currently that prevent practices from expanding and new providers entering the market.
The conclusions come despite the BMA’s submission to the review warning against putting competition ahead of continuity, while RCGP warned against any move to extend the use of ‘loss-leading’ APMS contracts.
The wide-ranging report identifies several priority areas for more research, after its ‘call for evidence’ on how it should act as a regulator of general practice.
Monitor will also map out supply and demand for GP services and embark on a mission to ensure that CCGs understand competition regulations and do not allow them to hinder local integration plans.
The regulator said it received 140 responses to the call for evidence, many of which came from patients, and has concluded its work should focus on efforts to reduce health inequalities, support self-care, move care out of acute settings, and provide coordinated care for older patients and those with long-term conditions.
As part of this drive, it said it wants to help existing high quality practices to expand, especially in areas with ‘currently low levels of access and/or quality’.
The document says: ‘What we have heard suggests that, as sector regulator, there is scope for Monitor to support these efforts in three principal ways.
‘First, by undertaking further research to gain a better understanding of variations in access to and quality of GP services and the factors which limit patients’ ability to make choices about their care.
‘Second, by doing further research to gain a better understanding of the factors that limit commissioners’ ability to enable high quality providers of GP services to invest in expanding their services, or for high quality potential providers to begin offering GP services, especially in areas with currently low levels of access and/or quality.’
Monitor’s senior policy adviser Paul Dinkin, who led the review, said that they would be looking at how to ensure that new providers were attracted to areas that were under-doctored.
He said: ‘One of the concerns that some commissioners have is if you did allow that to happen in a non-targeted way you… could end up with a situation where you have got GPs being attracted away from areas that are already under-doctored, or have fewer doctors per patient, into more attractive areas.’
But GPC deputy chair Dr Richard Vautrey warned: ‘There is no problem with expanding services if you have an expanding resource to be able to do that, but if you do that by taking away resource from other providers then you destabilise them and you end up with a worse situation that we have at the moment.’
He added: ‘[Expansion of existing GP practices] comes down to resources and a sense of stability that has been absent for the last 10 years. Practices will only make long-term investments if they are confident their investments are secure.’
GP LEADERS HIT BACK OVER CLAIMS PATIENTS NEED BETTER CHOICE OF GP PRACTICE
From the FMS Global News Desk of Jeanne HambletonPosted 4 September 2013 PULSE By Sofua Lind
Exclusive GP leaders have hit back over a move to gather evidence on whether competition among practices is operating in the ‘best interests of patients’, claiming instead that more investment is needed to ensure patients have greater choice of services.
Pulse has learnt that both the BMA and the RCGP have submitted statements to Monitor emphasising that patients are generally satisified with their GP, and warning against any move to extend the use of ‘loss-leading’ APMS contracts.
They also both said that any extension of the pilots that abolished practice boundaries in some cities would destabilise practices and warned that the bureaucracy of Any Qualified Provider was reducing – rather than extending – choice.
The response was to a ‘exploratory exercise’ by the NHS competition and integration watchdog gathering evidence on whether patients are able to switch practices easily, whether they are open at convenient times and the rules for setting up/expanding a general practice.
The call for evidence cames after Monitor’s ‘Fair Playing Field’ review was unable to examine issues pertaining to general practice in detail.
The BMA said that although patient choice was important, patients valued continuity from GPs. It said: ‘Large numbers of existing providers in general practice would very much like to provide more extended services for their patients and take over some of the work provided in secondary care.
‘However, they are often unable to do this due to a lack of funding both for provision of care and investment in premises.’
It also argued that the bureaucracy and the uncertain income from providing services under AQP was also another factor reducing the choice of services that GPs could provide.
It said: ‘These contracts offer no guaranteed income, but pay providers retrospectively for services delivered. This clearly disadvantages smaller practices who may be less willing to risk investment of time and resources in qualifying as an AQP provider.’
The RCGP in its response said that increasing choice in general practice was a ‘meaningless’ exercise whilst there are still too few GPs.
The RCGP response said: ‘The primary challenge faced by general practice is workforce capacity. The Centre for Workforce Intelligence has concluded that “the existing GP workforce has insufficient capacity to meet current and expected patient needs”.
‘In order for choice and competition to be meaningful it is necessary to have excess supply in the market; this is clearly not the case for many areas of general practice.’
It went on to warn against ‘loss-leading’ by allowing companies to set up short term APMS-contracted practices in which there may not be sustained investment for the long term.
It’s submission, signed by honorary secretary Dr Amanda Howe, said: ‘We would strongly caution against the assumption that the challenges faced by general practice are caused by a lack of competition, or that the best lever to reduce perceived variability in access and/or quality would be an increase in competition.’
The RCGP further warned that GP practices would be destabilised by a removal of practice boundaries because it would be more difficult to plan to meet demand, which could especially be to the detriment of the most vulnerable patients.
Dr Howe said: ‘It is likely that a number of rural practices would become unsustainable, as they would face losing significant numbers of their patients – typically younger, healthier commuters – and would be left caring for a greater proportion of patients lacking mobility and/or with complex, long-term conditions.
‘This imbalance would rarely be viable in the long term and would thus ultimately reduce choice in rural communities, to the detriment of the most ill and vulnerable.’
It comes as Londonwide LMCs urged Monitor to consider a shift of resources and incentives away from hospitals towards better primary care.
In a statement, the LMC said: ‘The solution to much of the challenge to the NHS in supporting general practice in London clearly lies in redirecting investment both towards practices’ workforce, infrastructure and technology needs.’
It added: ‘CCGs need to work out what LESs are needed to support non-emergency issues including decent community, social and mental health services with a shift of resources and incentives away from hospitals towards better primary care.’
INVESTIGATION: WHY HAS RECRUITING GPS BECOME SO HARD?
From the FMS Global News Desk of Jeanne Hambleton PULSE Posted 27 February 2013 By Jamie Kaffash
With the GP vacancy rate quadrupling in two years, practices are facing a recruitment crisis just as they prepare to take on more work, finds Jaimie Kaffash
Four years ago it would have seemed ludicrous to predict a shortage of GPs to fill partnerships and salaried posts.
Deaneries were warning GPs to expect unemployment after training, with reports of 50–80 applicants for every full-time role in some areas. Pulse even launched a ‘One Voice’ campaign calling for contractual changes and incentives to make it easier for practices to take on extra partners.
But fast-forward to 2013 and the profession is facing a very different jobs market. Many GPs are now complaining of a ‘dramatic’ reduction in the quality and number of candidates for vacant partnerships and of rising locum costs.
As practices struggle to cope with rising expenses, below-inflation funding awards and a huge shift in workload from hospitals into primary care, they are finding it harder to recruit GPs to share the load.
A Pulse snapshot survey of 220 practices, covering around 950 full-time positions, reveals the full extent of the problem.
The results show an average vacancy rate for all full-time-equivalent GP posts in the practice of 7.9% in January 2013 – almost double the 4.2% figure found in a similar Pulse survey in January 2012, which itself was twice the official figure of 2.1% at the start of 2011.
There is no doubt that, for practices looking to take on GPs, the quadrupling of the vacancy rate in just two years is causing real problems.
Dr Peter Swinyard, chair of the Family Doctor Association and a GP in Swindon, says: ‘It is immensely hard to recruit. This is the experience of a lot of the doctors I have talked to. We are on our second firm of headhunters now, at significant expense, to fill our vacancy.’
Dr Anne Crampton, a GP partner in Crowthorne, Berkshire, says there were 30 applicants when her practice advertised a partner post three years ago, but only five for a similar post this year. She says: ‘I do not know why general practice seems to be so unpopular. This difficulty in recruiting came as a complete surprise.’
‘We are on our second firm of headhunters now, at significant expense, to fill our vacancy’ – Dr Peter Swinyard
Dr Malcolm Kendrick, a member of the GPC’s sessional executive committee and a salaried GP in Cheshire, says there has been an ‘absolute’ turnaround from the situation five years ago.
‘It is becoming more difficult to recruit partners. There is definitely less appetite for partner roles.’
Recruitment is not such an issue in Scotland, Dr Kendrick adds, but rural practices in Wales are struggling to take on partners.
GPC deputy chair Dr Richard Vautrey says the problem has been a big concern at the BMA contract roadshows: ‘Wherever we have been, GPs have been telling us there is a recruitment and retention crisis. It is starting to happen now.’
The recruitment crisis comes at a particularly difficult time for practices, with CCGs taking over commissioning responsibilities and the new GP contract hiking up practice workload from April.
The GPC argued in response to the Government’s contract imposition that ‘practices have reached a point of workload saturation’, while LMCs have reported a ‘shocking’ rise in requests for pastoral care – partly as a result of excessive workload.
The difficulties practices are having in filling vacancies are also having a financial impact. In the Pulse survey, practices reported an average increase in locum costs of 9.5% over the past 12 months, on top of the further 9% increase seen in 2011.
So why are so few GPs applying for jobs? Official figures from the NHS Information Centre show there was a slight fall in the number of GP partners in 2011 – 27,218 – compared to 2001, when there were 27,938. By contrast, the number of consultants rose sharply from 27,782 in 2001 to 39,088 in 2011.
However, the total number of practising GPs has increased by an average of 2.3% annually since 2001, from 31,835 to 39,780. In other words, fewer GPs are taking the route into partnership, instead remaining salaried or locums. However, unlike in 2009, when competition for partnership vacancies was fierce, this now seems to be through choice.
GP vacancy rates quadruple in two years. Practice locum costs rise 9.5% in a year. Contract changes will cause workforce crisis, claims BMA. Dr Richard van Mellaerts: ‘Recruiting people has become an arms race’
A shift towards portfolio careers and a steadily rising number of women choosing to work part time are both having an impact, GPs say.
Dr Crampton says: ‘Nobody wants to work full time. Initially, we wanted a nine-session partner.
‘What most GPs seem to want to do now is part-time general practice and part-time GPSI work – clinical assistants, out-of-hours work, that type of thing.’
Dr Kendrick agrees partnerships are widely seen as unattractive: ‘There is a lot of uncertainty about the contract imposition, falling income and people seeing partners working ridiculous hours.
‘GPs doing other roles are now saying: “This does not look like such an attractive option”.’
At the other end of the scale, GPs are increasingly considering early retirement as the demands of the job pile up. Exactly half of the respondents to Pulse’s survey said they were thinking of retiring early. Many cited workload as a key reason for considering early retirement.
Dr Swinyard says: ‘We are seeing more and more principals saying: “Sod this, I am going early”. Some take roles working as locums for the last few years of their practice lives. It is a shame to lose the wisdom of senior people – you cannot replace that.’
Looking to the future
The Department of Health has recognised that more GPs are needed for the NHS to function, with former health secretary Andrew Lansley last year setting out a plan to boost the number of GP trainees by 20% by 2015 in England so that GP registrars would make up 50% of the specialty training places (up from 41%).
But this drive is floundering. Figures from the GP National Recruitment Office (GPNRO) last summer showed there were 2,693 GP training places accepted in England in 2012, which actually represented a net decrease of three compared with the previous year.
‘There is a significant imbalance in the workforce at junior level that has and continues to produce too many “-ologists” and too few generalists, especially GPs’ – Dr Barry Lewis
This compares with a rise of almost 700 in hospital training places in England, with 4,725 places accepted, up from 4,034 in 2011. The proportion of GP trainees fell from 40% in 2011 to 36% in 2012.
A DH spokesman says: ‘The DH and Health Education England are currently working with key stakeholders to support the increase of training numbers in general practice.
‘A national GP taskforce has been established to support this work and make recommendations for increasing training posts to 3,250 each year.’
An unattractive proposition
According to the Committee of General Practice Education Directors, the struggle to recruit new GPs is down to an excess of hospital training places, rather than a dearth of GP ones.
Chair Dr Barry Lewis, a GP in Rochdale, says: ‘We have expanded training steadily and have an expansion target for the next three years – there is no shortage of training places. We have empty slots in programmes, except in London and the South East.
‘There are not enough applicants because an excess of hospital specialty posts is still in the system.”
Research published last month showed that only 28% of medical graduates cite general practice as their first-choice career, compared with 71% who opt for secondary-care specialties.
Study leader Professor Michael Goldacre, a professor of public health at the University of Oxford, says there is ‘some cause for concern’ about this relative lack of interest in general practice from newly qualified doctors.
He says: ‘A much smaller percentage express a preference for a career in general practice than the NHS actually needs.’
Rising medical school fees and the proposed four-year training for GPs, which could begin as soon as 2014, are also likely to have an effect on the numbers entering the profession.
The reluctance of many medical graduates to opt for general practice is not new. However, the Government is doing a poor job of encouraging people into the profession, says Dr Vautrey.
‘There is a feeling there are better opportunities for them in hospital or abroad,’ he says.
Dr Swinyard – still looking to fill his practice’s outstanding vacancy – says more must be done to encourage the next generation into the profession.
‘General practice as a whole is looking less attractive as a long-term career option,’ he says. ‘I still think this is the best job in the world, but it is becoming bloody hard to do it.’