The Government must ‘mandate’ the redirection of NHS funding to primary care and remove GP ‘micro-financial incentives’ in order to achieve its shift to community care, a leading think tank has argued.
In a report setting out the ‘policy levers’ available to the Government, the King’s Fund called for the acute sector’s share of NHS funding to return to less than 50%, through the use of both the GP contract and investment standards for ICBs.
This is to counteract the fall in general practice’s share of NHS funding, with the proportion spent on acute services having risen from 49% in 2010 to 58% in 2021, while primary care’s share fell from around 28% to 18%.
The King’s Fund outlined a series of actions which could successfully lock in the Government’s goal to shift care out of hospitals, unlike ‘the previous 30 years of attempts’.
It highlighted that England is an ‘outlier’ in its use of ‘micro-financial incentives’ in general practice, pointing to the use of both QOF and the additional roles reimbursement scheme, for which the evidence base is ‘surprisingly thin’.
New analysis by the think tank revealed that a fifth of total GP investment is ‘tied up in these narrowly prescribed funding incentives’, which create ‘a large number of hoops a practice must jump through’.
It found that when excluding Covid-specific activity, the total proportion of funding tied up in these micro-incentives rose from 14% in 2018/19 to 19% in 2022/23.
The think tank argued that this can ‘hinder the development of effective local services’ as GP practices are ‘incentivised to chase specific pots of funding rather than think strategically about local need’.
While the Government’s move to invest most of the new funding for 2025/26 into the core GP contract is ‘cause for optimism’, the King’s Fund said the next multi-year contractual framework must lock in this ‘direction of travel’.
It also urged the Government to move funding for staff from the ARRS into the core contract – a call echoed by many GP leaders.
The report also claimed that the ‘primary reason’ for previous governments’ failure to shift care to the community is the belief that hospital waiting times must be fixed first.
For this reason, the King’s Fund called on the Department of Health and Social Care (DHSC) to ‘urgently reassess current elective waiting-time targets and whether they can realistically be delivered at current timescales’ without hindering the shift to primary and community care.
On workforce, the report highlighted that professional regulators such as the GMC have ‘struggled to adapt’ to ‘emerging roles’ such as physician associates (PAs).
‘Government should ensure that each regulator is consistently developing and testing plans for the regulation of emerging and changing roles that will arise as a result of this move to increased community working, particularly the changing risk profile and the increased need for multi and cross-professional working,’ the King’s Fund argued.
Other recommendations
- Competing incentives in general practice and community pharmacy contracts: DHSC should work to ensure that national care contracts across primary care are designed in a way that is coherent and complementary, and that they encourage collaboration.
- Estates barriers: GP rent reimbursement rules that restrict the ability of GP practices to host community or secondary care services are a prime candidate for change and should be prioritised as part of wider contract reform in general practice
- As should the separation of premises ownership from GP partnership.
- Low status attached to working in primary care: Government should ensure that staff doing the same roles are subject to the same terms and conditions, particularly addressing the fact that staff directly employed in general practice and settings other than NHS trusts are not subject to Agenda for Change. This will mean reform to the GP contract so that funding can reflect that change.
- Capacity issues within ICBs: If ICSs are to lead the strategic changes required, they need to be incentivised to increase their capacity and understanding of care closer to home and this will require changes to the staffing within them. Government should therefore avoid the false economy of blunt headcount reduction targets.
Source: The King’s Fund
Following news of the Government’s plans to abolish NHS England, ICBs were asked to cut their workforce by 50%, which equates to around 12,500 staff across the health system.
In response to the King’s Fund report, the RCGP said that ‘for too long’ governments have dealt with NHS pressures by ‘directing the majority of funding into hospitals’.
College chair Professor Kamila Hawthorne said: ‘We understand the pressures our hospital colleagues are under, but we greatly appreciate this recognition from The King’s Fund that we need to radically change this approach, and its timely recommendations for more focus and funding for primary care.’
‘The forthcoming new 10-year Health Plan must allocate a much greater portion of the NHS budget to be spent on primary care if we are to resolve the GP workforce and workload crisis and rebuild our infrastructure so we can provide the safe and timely care our patients need and deserve,’ she added.
DHSC said it will carefully consider the recommendations in the report, and emphasised that shifting care from hospital to community is a ‘key priority’ for this Government.
A spokesperson said: ‘Along with an extra £26 billion investment to get the health service back on its feet, we are bringing in fundamental reform that will mean more people treated in the communities they live in, as well as a vital shift from analogue to digital and sickness to prevention.
‘We have also reduced the number of targets for NHS leaders and are abolishing NHS England – the world’s largest quango – to cut red tape and divert hundreds of millions to the front line.’
micro managemnet is inefficient?
If only someone had mentioned that before.
Watch how the same people who have stated in the past how influential the King’s fund is now will state it is unimportant and laugh at their lack of consistency, integrity and hypocrisy.