1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department), NHS England and Health Education England.
2.Most of the contact that people have with the NHS is with general practice, and this is the first step for most patients in diagnosing and treating health conditions. On 31 March 2016, there were around 42,000 doctors employed in some 7,600 general practices in England. GPs work with nurses and other staff to treat and advise on a range of illnesses, manage patients’ conditions in the community, and refer patients for hospital treatment or social care where appropriate.
3.GPs are independent contractors with practices typically owned and managed by an individual GP or group of GPs. In 2015–16, £9.5 billion was spent on general practice, once the costs of out-of-hours services and dispensing drugs are included. Until April 2015, NHS England commissioned general practice services directly, but is now delegating more responsibility to local clinical commissioning groups, with 88% (184 of 209) now having a greater role.
4.The Department is ultimately accountable for securing value for money from spending on health services, including general practice. It sets objectives for NHS England through an annual mandate, and holds it to account for the outcomes the NHS achieves. The Department also holds Health Education England to account for ensuring that the future general practice workforce has the right numbers and the right skills. The Department and NHS England have a number of key objectives relating to access to general practice, including evening and weekend access for all patients by 2020, and 5,000 additional doctors in general practice by 2020.
5.Core general practice services are commissioned through contracts with GP practices, with most practices holding either a General Medical Services (GMS) contract (64% of practices) or a Personal Medical Services (PMS) contract (32% of practices) which is broadly based on the GMS contract. The GMS contract sets core hours of 8 am to 6.30 pm Monday to Friday, and requires practices to provide routine services at times within this period “as are appropriate to meet the reasonable needs of its patients”. Practices must provide services in case of emergency across all core hours. As at October 2015, 46% of practices closed at some point during core hours, including 18% that closed by 3 pm on a weekday. The extent of closures varies considerably by area, with the proportion of practices closing by 3 pm ranging from 0% to 42% in our constituencies alone.
6.NHS England explained that three-quarters of half-day closures are concentrated in about a quarter of clinical commissioning groups, with particular areas such as North-East London more heavily affected. It told us that there did not seem to be any obvious reason for these patterns and it believed it to be due to cultural and historical circumstances. These shorter opening hours are linked to worse outcomes for patients, with practices that are open for 45 core hours or less per week having, on average, 8% more A&E attendances per 1,000 patients.
7.NHS England agreed that it needs to ensure that core hours are functioning effectively, and told us that it is not leaving it up to clinical commissioning groups alone to address the closures. NHS England expressed concern about the link between practice closures and A&E attendances, and the implication that problems in accessing primary care would spill into parts of the NHS such as A&E which are more costly. It told us it is addressing practice closures during core hours by following up with every practice that reports closing by 3 pm to establish what services are still available during these closures and what alternative arrangements are in place. In areas with significant concentrations of practices closing early, it also committed to support practices to meet local needs.
8.Three-quarters (76%) of practices that closed by 3 pm on a weekday received additional funding in 2015–16 to provide access outside of core hours, averaging £8,224 per practice. NHS England said that from October 2017 the GMS contract will change and practices will no longer be eligible for these enhanced services payments if they have a half-day closure on a weekly basis.
9.The Department and NHS England explained that GP contracts have traditionally been high trust contracts, and historically the health system had largely let GPs conclude what was in the best interests of patients. NHS England accepted that local commissioners have not had a consistent view of how to interpret and enforce the reasonable needs of patients. NHS England explained that up to now a definition of these reasonable needs has not been written down, but it said that as part of the 2017–18 contract it has agreed to work with the British Medical Association and local medical committees (which represent GPs in their geographical areas) to set out what these are. NHS England suggested a common sense list of what reasonable needs might be, including booking an appointment, picking up a prescription, dropping off a specimen, and having somebody available within the practice to act on urgent test results if required.
10.NHS England explained that the system of assurance in place for general practice sought to manage the contract rather than manage performance. Practices can be incentivised to deliver services through funding streams or through peer review. For example, there are local funding arrangements to provide additional funding to practices to improve access and quality during core hours. In addition the quality and outcomes framework ties a proportion of practice income to a set of clinical quality indicators. In 2015–16, some £685 million (7%) of practice income was paid in this way. But NHS England said that this framework had probably become a “time-expired, tick-box scheme” which no longer serves its purpose as a quality improvement tool. Instead, NHS England has developed a primary care web tool to measure quality of care and outcomes, and highlighted its importance for practices to be able to use it as a peer-to-peer review. We were concerned that there are several ways to incentivise practices but very few ways of penalising practices that do not meet patients’ reasonable needs.
11.We raised our concern that local clinical commissioning groups, who by their nature are made up of GPs, may not have the independence to effectively challenge member practices. In addition, the National Audit Office report highlighted that GPs had mixed views on whether commissioners deal with concerns about access in a fair way. NHS England said that it has worked hard to be clear about managing conflicts of interest in clinical commissioning groups, and stated its guidance on this was very clear.
2 , para 1
3 , paras 1, 1.4
4 , paras 1.3, 1.6, Figure 2
5 , para 1.5
6 Q16; , para 2.2
7 Q20; , paras 2.2, 2.4
8 Qq16, 34–35
9 Qq20, 26; , para 2.4
10 Qq15–16, 27, 38
11 Qq20, 22–23, 89
13 Q16; , para 2.4
14 Qq16, 18, 34
15 Qq19, 77
18 Qq80, 84; , para 3.9
19 , figure 10
21 Qq77–80, 83
22 Qq38, 75–76, Q81; , para 2.11
25 April 2017