Response to “Digital-First Primary Care” consultation on patient registration, funding and contracting rules

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Responding to the consultation on amendments to the out of area registration rules and other measures intended to support and develop the “Digital First Primary Care” model as outlined in the recently published consultation from NHS England, headlines from the Londonwide LMCs’ submission are detailed below.

The consultation closes on 23 August and responses can be made online using a digital form covering a series of questions posed by NHS England, or via a written submission sent to: Digital-First Consultation Primary Care Strategy and NHS Contracts Group, NHS England Floor, 2D Skipton House, 80 London Road, London, SE1 6LH.

Headlines from the Londonwide LMCs’ response 

  • Since the introduction of the out of area registration rules, there have been a number of policy changes in the NHS; the most notable is a focus on place-based care in which services are brought together around patients with need and their local communities. Digital initiatives that are currently in place, and ongoing innovation in digital accelerator sites, are increasing convenience of access to groups such as commuters rather than working toward the stated goal of effective digital technology that supports GP practices to deliver available and effective care on an equitable basis. These changes mean that the current out of area registration rules can no longer be justified on the grounds stated in the consultation paper.
  • Any new delivery model must be designed with the aim of meeting the needs of people and communities. Commissioners are responsible for reviewing service provision, analysing needs and current legislation, performing a gap analysis, designing services to meet need and developing the market, and, once commissioned, commissioners must undertake thorough assessment and evaluation. If funding is being diverted to deliver the new services, the impact on all populations must be evaluated. These processes do not seem to be in place. Indeed, perversely current evidence suggests that those with greater health need do not register with new digital first models, or re-register with their GP practice.
  • Given the parlous state of the general practice workforce and workload at present, it is unreasonable to conclude that abolition of the out of area registration rules “…would unjustifiably limit patient choice…” (p9:23) when care close to the point of needs is a core tenet of general practice. This point was also made in our earlier consultation response on digital first proposals, last year.
  • In order for investment in digital health tools to fit with the values of general practice, such tools must directly reduce health inequalities, or free up resource which can be directed to other methods of care delivery which are proven to do so.
  • Areas that are under-doctored may (and probably do) have patients with a high level of complex need, patients who may struggle to use a digital first model, issues regarding IT literacy, and infrastructure and access challenges which add to health inequalities. Digital services should be developed in an integrated way, alongside other services within existing practices so that they are there to be used if required.
  • Evidence shows that primary care is best delivered by expert generalists working with registered lists in defined geographic communities. The core funding that allows and supports this care delivery at individual and population level must be maintained and, where possible, increased.
  • GPs in London are adept at managing their practice resources and can adapt the services they offer to their practice lists, treating each patient as an individual, without the need to move patients between practices when their health care needs change. However, there are significant workload pressures which must be addressed to allow all patients appropriate access to their chosen GP. There are significant infrastructure issues relating to digital working that also need to be addressed. There are also additional costs – often referenced as the “Market Forces Factor” – borne by general practitioners operating within the greater London area, including elevated property and staffing costs, which are reflected in current resource weightings.
  • There are concerns that some of the proposals being consulted on might result in unintended financial risk to the delivery of core primary care services in the Capital and the stability of practices delivering them, since they equate to a redistribution, rather than any new digital technology-related investment. In effect they amount to already finely balanced fixed practice resources being cut to pay for digital change. Before further decisions are reached we believe that a full review of the financial impact of these changes should be provided, including regional breakdowns, rather than the single practice examples included in the consultation document. We are also concerned that the recommendations for amendment to the out of area registration rules contain calculations which have not been adjusted for patient characteristics (p12:37) and that later refers to age and gender as the sole characteristics affecting payment rates (p14:44). We believe that there must be a full, independent and robust analysis of the clinical and cost effectiveness of diversion of funding, to any new delivery model, on all populations.
  • We are concerned that APMS contracts are notoriously unstable and poor vehicles for the provision of the continuous and effective health care relationships beneficial to patients and staff. Considering the benefits of stable and continuous patient care and a sustainable and stable workforce, we believe that commissioners would see improved patient outcomes through increased investment and support for GMS contracts which are nationally negotiated, and provide long term stability for patients and staff.
  • For the potential of digital health to be realised, all practices need the infrastructure to provide it, the knowledge to use it effectively, and the patient demand to justify the investment of time/ money in new systems and ways of working. Online access and consulting could reduce the need for attendance at GP practices and appointments in the long-term. How to apply the technology in ways which actually do this needs to be established by rigorous evaluation, rather just the belief that rolling out more online services will somehow inherently reduce workload.
  • More focus is needed on understanding the high turnover rate for patients registered with digital first providers. Noting the figures quoted, it would appear that these national proposals show a disproportionate impact on London.
  • Any and all proposals should be considered against the quadruple aims of care, health, cost and meaning in work to prevent any unintended consequences which might destabilise existing general practice and patient care.

Additional points

In addition to the overarching comments above, we have chosen to respond to specific points within the consultation. You can read our full response here.

You can also download a Word version of our response here.

For further information or enquiries please contact Sam Dowling, Director of Communications

Last updated : 19 Jul 2019