Background and context

Following a stalemate in negotiations between the BMA’s GPC (General Practitioners Committee) in England and NHS England, the changes laid out in a letter from NHS England published on 1 March and which come into effect from 1 April 2022, have not been agreed or endorsed by the BMA.

NHSEI (NHS England and NHS Improvement) has chosen to remain aligned to the plan agreed in 2019, before the global pandemic. Despite repeated requests from GPC England, NHSEI has refused to discuss matters brought by GPC England to support practices with proposals outside of the five year framework. However, we note that NHSEI have introduced new proposals that are not part of the five year framework.

As a team, GPC England negotiators worked in good faith, engaged in many conversations with a variety of stakeholders ranging from NHSEI, DHSC (Department of Health and Social Care) and the Secretary of State for Health and Social Care. We sought improvements on the tabled NHSEI proposals and put forward suggestions outside the 5 year framework for agreement. This included resources to manage general practice pressures, a long-term-conditions recovery fund, reform of childhood immunisations IOS (Item of Service) and QOF (Quality and Outcomes Framework), a tapered approach to QOF to support recovery, the provision of long COVID occupational health and a new contract for general practice. However, these discussions were not seen as negotiations by NHSEI.

NHSEI seem willing to understand the current day pressures being faced by GPs and their teams, but there was seemingly no willingness to act decisively to support the profession so that it can continue to deliver care to those who most desperately need it.

As a result, no agreement has been reached. These contract changes do not go far enough to support access, safe working or backlog pressures in the context of a raging pandemic that has impacted all matters of life across the world.

The five-year framework concludes at the end of March 2024. The default position is that the existing GMS contract (and its add-ons) at that time will automatically roll forward unless it is changed.
Set out below is guidance on the new changes to support practices in their decision making and next steps.

Core contract changes and requirements

• Online patient registration – removal of wet signatures and the need for hard copies. Many practices and regions already offer this. NHSEI intends to introduce a new format and will be working on the design principles and is seeking to replace what is already in widespread use.
• (NHSEI has clarified that the development of the GP registration service, currently subject to pilot, has and will continue to be informed by extensive engagement with general practice and patients. The registration service will be made available for general practice to adopt on a voluntary basis. The enabling changes contained in the GP contract apply equally to this service as to any alternative locally developed online solutions that general practice may wish to put in place).
• Online appointment booking – removal of 25% minimum, to be replaced with all directly bookable appointments that do not require triage; this is a new contractual requirement which goes beyond the five-year framework. This change will allow practices to determine what is most appropriate to make available for online booking; an example of this is flu vaccination or COVID vaccination appointments.
• Deceased patient records will no longer need to be printed and sent to PCSE (Primary Care Support England); practices will now legally be required to process access requests.

(NHSEI has clarified that while practices will no longer be required to always print and send copies of the electronic record of deceased patients to PCSE, they will still be entitled to use PCSE to store the physical Lloyd George records of deceased patients. PCSE will continue to deliver transit labels and collect physical Lloyd George records.

Upon receipt of an Access to Health Records Act (AHRA) request the GP practice should, if required, request a copy of the physical record previously sent to PCSE. PCSE will scan the physical record and send a scanned copy of the record back to the GP, allowing the GP to respond to the AHRA with the entire record.)

Limited changes to some vaccinations and immunisations:

• HPV – transition from Gardasil 4 to Gardasil 9 during 2022/23. Additionally, the JCVI (Joint Committee on Vaccination and Immunisation) has advised a move from a three-dose schedule to a two-dose schedule (with doses given at least six months apart), for both those aged 15 and over, and for the national HPV MSM vaccination programme.
• MMR – cessation of the 10 and 11-year-old catch-up programme along with practice participation in a national MMR campaign as per the current contractual requirement for practices to take part in one catch up campaign per year.
• MenACWY Freshers programme – come to an end on 31 March 2022.

Funding

‘Investment and Evolution: A 5 year Framework for GP contract reform’ sets out the expected funding arrangements. The financial arrangements were further amended in 2020 to take into account 100% reimbursement of ARRS (Additional Roles Reimbursement Scheme).

In December 2021, NHSEI published a letter setting out temporary GP contract changes to support the COVID-19 vaccination programme, including QOF and IIF (Investment and Impact Fund) indicators.

• As per the five year deal, global sum will increase by 3% from £96.78 to £99.70 per weighted patients.
• The OOH (Out of Hours) adjustment remains at 4.75%, increasing the value from £4.59 to £4.73.
• There will be a continuation of funding in Global Sum (£20 million) for one additional year (2022/23) to reflect workload for practices from SARs (Subject Access Requests). The original 5-year deal had assumed that this funding would cease beyond 2021/22 subject to a variety of conditions which would have been met, that have subsequently not been met.
• While no amendments are being made to the content of QOF, due to changes in the average number of patients per practice, the value of a QOF point will increase by 3.2% from £201.16 to £207.56.
• ARRS funding has been uplifted from £746m to £1.027bn, as planned in the update to the five year deal.
• The extension of the £43m for leadership and management, in addition to the existing £44m planned for PCN clinical directors as part of the five year deal, brings the total Clinical Director funding pot for 2022/23 to £87m.
• IIF has been uplifted from £150m to £260m to reflect the planned uplift of £75m, plus an additional £35m agreed for specific purposes (see IIF section below). The value of an IIF point will remain at £200.
• As described in the five year framework and subsequent updates, the two funding streams currently for PCN DES (Primary Care Network Direct Enhanced Service) extended hours (£1.44 per patient) and CCG-commissioned enhanced access (£6 per patient) will be combined under the Network Contract DES to fund a single, nationally consistent access offer with updated requirements, to be delivered by PCNs. See enhanced access section for details.

Health and Social Care (National Insurance) Levy

GPC England sought agreement to cover the employer contributions for the uplift in National Insurance for the proposed 1.25% health and social care levy. The Government has refused to provide this funding, despite the intention to cover the employer cost for all other public services, including secondary care employers.

Pay uplift

The five year framework agreed funding to provide pay uplifts in line with predicted inflation (as at April 2019). This year the funding provides for a 2.1% pay uplift for all GPs, practice staff and practice expenses. GPC England had sought additional funding given the economic changes (due in large part to the impact of the pandemic), but NHSEI has refused this.

The DDRB will recommend a pay award for other doctors, including Salaried GPs, in May 2022. DHSC’s evidence to the DDRB (Review Body on Doctors' and Dentists' Remuneration) suggests they would support an uplift of 2%.

We acknowledge that the impact of inflation will have a material financial impact on practices who will need to consider whether it is financially viable for them to provide uplifts to staff more in keeping with current day financial pressures.

QOF

The five year framework acknowledged in 2019 that QOF provides vital core income to cover practice staff pay and expenses.

While NHSEI is not making any changes to QOF for 2022/23 beyond changing the topics for the QI (Quality Improvement) domain citing stability, they will be fully reinstating QOF and all its requirements from April. This does not seem to take into account the significant impact of the pandemic on all long term conditions.

Despite GPC England’s requests for additional support for Childhood immunisations, in view of data from around the country on achievement, NHSEI has declined to address this as part of the 22/23 contracting round. We believe changes should be made to these indicators to enable practices to deliver more for their patients without being financially penalised. NHSEI refuses to make changes to these indicators in-year, despite this being done in the past.

We have also highlighted the acute challenges practices will face in light of impact to IOS payments for many practices; this too has not been considered as part of the 22-23 contracting round.

The proposed QI modules for 2022/23 focus on optimising access to general practice and prescription drug dependency.

Optimising access to general practice

The proposed overarching objectives of the module are:

• a. Understanding of demand and capacity within the practice (and PCN) and using a QI approach to optimise capacity;
• b. Undertake team development of the wider practice team to look at ways to better match demand to capacity and optimise use of capacity. This may include reviewing areas such as care navigation and triage pathways within the Practice/PCN, staff rotas and demand patterns, use of digital tools, use of ARRS roles and wider primary care services e.g. CPCS (Community Pharmacist Consultation Service) and other similar schemes;
• c. Working with your practice patients to understand views around access issues, including: ease of contacting the practice to obtain advice, an appointment, communications etc and to co-produce an access improvement plan;
• d. Consider access beyond the practice by reviewing links/pathways with parts of the system beyond the practice and PCN.

Prescription Drug Dependency

The proposed overarching objective of the module is to lead to improvements in relation to the following aspects of prescribing safety:

• a. Use of non-pharmacological alternatives rather than initiation of dependence forming medications in - line with best evidence and guidance;
• b. Structured medication reviews of patients taking 120mg oral morphine equivalent (OME) or more for chronic pain;
• c. Structured medication reviews where there is polypharmacy of dependence forming medications.

Enhanced service on obesity and weight management

Although GPCE wholeheartedly supports the need to tackle obesity robustly, we did not previously agree the weight management enhanced service introduced in 2021. This service has had 97% signup from practices.

NHSEI has decided to extend this service to 2022/23 with the same £11.50 per referral payment, but there will be a requirement for the explicit agreement of the patient for referral.

Previously £20M was allocated to this, however the expected number of referrals and engagement with the service, means that this funding has not been utilised. This year, it has been reduced to £11.5M, there was no willingness to consider increasing the IOS for referrals.

As this is an enhanced service, it remains optional for practices.

Friends and Family Test

The requirement to submit Friends and Family Test (FFT) data was suspended across the NHS in March 2020 and was reintroduced into the GP Contract from 1st April 2022. However, practices will only be required to submit data from Q2 in 22/23 onwards and commissioners will be made aware of this.

GP practices will also be required to implement the new FFT guidance, which includes the following changes to the policy:

• a new more appropriate mandatory question
• the practices’ increased ability to design how and when they hear from patients
• a reduced focus on the numerical data
• the increased local focus on the free text comments from patients
• the role of the PPG in making this more about listening and less about collecting data

Access the new FFT guidance

The key requirements for GP practices will be:

• make the FFT available for people who want to use it to give feedback (they can use whatever method suits them, including cards on the reception desk, SMS text messages, web page etc)
• use the standard FFT question (Overall, how was your experience of our service?)
• include at least one free text question (practices can decide themselves what free text questions to ask)
• submit monthly data to NHSE using CQRS

Network contract DES

NHSEI is planning to implement changes to the PCN DES; while some of the principles were agreed in the five year framework, many of the details have not been agreed by GPC England.

Should practices decide that they cannot accommodate the below changes, that their patients would be better supported outside of the PCN DES, that the practice would operate more effectively and safely outside of the PCN DES or any other reason, they are able to opt-out.

We are awaiting confirmation of the opt-out period, but expect this to be 1 to 30 April 2022.

See below for further information about the impact of opting-out of the PCN DES.

PCN Enhanced Access

The planned transfer of current CCG-commissioned extended access services was delayed as a result of the COVID-19 pandemic and delivery will now start from October 2022, with preparatory work from April 2022. An outline of the new Access service is provided below:

• Extended hours and enhanced access combined into one pot with one set of requirements.
• PCNs will be expected to provide a range of general practice services during enhanced access network standard hours (6.30pm-8pm weekday evenings and 9am-5pm on Saturdays), including vaccinations.
• There is no additional requirement to deliver services on Sundays, however, PCNs will be able to provide a proportion of enhanced access outside of these hours, for example early morning or on a Sunday, where this is in line with patient need locally and it is agreed with the commissioner.
• PCNs will be required to provide 60 minutes per week per 1,000 patients, weighted using CCG (Clinical Commissioning Groups) primary medical care weighted populations.
• Funding will be £7.46 per weighted patient.
• Due to different financial arrangements combining, moving from unweighted to weighted, and the difference in contracting mechanism, the funding distribution and service expectations will change for all.
• Subcontracting the service remains an option.
• PCNs must ensure GP cover during the Network Standard Hours, providing in person face-to-face consultations, remote consultations, leadership, clinical oversight and supervision of the MDT.
• The expectation is for routine services to be provided; this is not a replacement for OOH, urgent and emergency care.
• PCNs must make available to NHS111 any unused on the day slots during the Network Standard Hours from 6.30pm on weekday evenings and between 9am-5pm on Saturdays, unless it is agreed with the commissioner that the timing for when these unused slots are made available is outside of these hours.

PCN Workforce

NHSEI propose to implement the planned increase to the limit on Mental Health Practitioner reimbursement from one Whole Time Equivalent (WTE) to two WTE per PCN, subject to the additional role being agreed between the PCN and local mental health provider.

GPC England recognises the difficulty many PCNs have in recruiting Mental Health Practitioners. NHSEI advises that ARRS recruitment remains on track. If this does not reflect your reality, then it is important to contact your commissioner and LMC (Local Medical Committee) to let them know that these figures are inaccurate and a misrepresentation of current day reality in your regions.

PCN Services

The existing Early Cancer Diagnosis service requirements will be streamlined and simpler, focusing PCNs on national diagnosis priorities arising from evidence around lower than expected referral rates for prostate cancer.

The planned Personalised Care and Anticipatory Care services requirements are delayed with 2022/23 being preparatory work only.

(NHSEI has clarified that it is just the implementation of the digitally enabled personalised care and support planning for care home residents element of the service for which 2022/23 will now become a preparatory year. As set out in the letter of 1 March, there are other elements of the Personalised Care service which will need to be delivered by PCNs in 2022/23.)

The requirement for digitisation of personalised care and support planning for care home residents has been deferred from 2022/23 to 31st March 2024.

The start date for Anticipatory Care and extension of planning period has been deferred to 1st April 2023.

(NHSEI has clarified that in 2022/23, PCNs must contribute to the development of the ICS delivery plans being developed and submitted in Q3, working with other providers with whom the Anticipatory Care service will be delivered jointly.)

PCN Leadership and Management payment

NHSEI is extending the funding to support PCN Leadership and Management, for the next two years. This means an additional £43m for each year.

PCN Investment and Impact Fund

In August 2021, NHSEI without agreement from GPCE, released indicators which start from April 2022.

Those indicators are SMR-01 (percentage of patients eligible to receive a Structured Medication Review who received a Structured Medication Review) and ACC-02 (number of online consultation submissions received by the PCN per 1000 registered patients).

NHSE/I has now set the thresholds, as follows:

NHSE/I will also introduce three new indicators in relation to Direct Oral Anticoagulants (DOACs) and Atrial Fibrillation, and FIT testing and 2WW cancer referrals. Funding for these indicators is additional to the existing £225m funding envelope for the scheme.

The GPCE team did not agree the changes that were published in August 2021, so by and large a £260M IIF investment embedded in 31 Indicators has not been agreed by the BMA.

Read the full details of the current Investment and Impact Fund (IIF): 2021/22 and 2022/23.

Next steps

GPCE has produced new guidance on safe working to help practices understand what they can do to continue to provide safe care to their patients in lieu of additional support from NHS England.

Opting out of the PCN DES

Practices have a right, written into the PCN DES Specification, to opt-out of the PCN DES. The next regular opt-out period is expected to be 1 to 30 April 2022.

Opting out is not a breach of the contract (PCN DES or the core contract).

Practices who opt out:

• cease providing the services and any other responsibilities or activities required through the PCN DES service specification
• lose the funding currently provided through the PCN DES (read a summary of PCN DES financial entitlements)
• might lose ARRS staff (depending on the employment relationship the PCN has with the ARRS staff), and the non-DES services the ARRS staff provide (potentially increasing workload for practice staff or increasing staffing costs for the practice)
• might still hold liability for ARRS staff (depending on the employment relationship the PCN has with the ARRS staff) but would not receive the associated ARRS funding that currently supports their employment.

NHS England is likely to transfer the funding, requirements and staff - likely via TUPE (Transfer of Undertakings) - to Trusts or alternative providers to maintain as much of the PCN DES as possible without general practice.

Whether to opt-out or remain in the PCN DES is an individual practice decision. Taking into account the proposed changes and the impact these will have on the practice and patients, as well as the current impact of the PCN DES on the practice and patients, it remains a practice choice to decide whether to remain within the PCN DES or to opt-out.