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NAO: Extending GP access unlikely to deliver ‘value for money’ for NHS

There is no evidence that plans by the DH and NHS England to increase hours of access to GP surgeries will prove cost effective, the National Audit Office (NAO) has found.

Since 2014, NHS England has spent £175m on 57 GP Access Fund capacity pilots, and further funding has been promised.

However, the NAO found that extra capacity funding costs an average of £230 an hour, compared to £154 for core hours, and that NHS England had not set out how it would assess whether local spending of the money represented good value for money.

It also cautioned that longer hours could make it harder to provide continuity of care, and could lead to commissioners paying for access which was already being provided by another service.

Sir Amyas Morse, head of the NAO, said: “The Department and NHS England have set some challenging objectives for improving access to general practice, have increased available funding and sought to make allocations to local areas fairer.

“They are, however, seeking to improve access despite not having evaluated the cost- effectiveness of their proposals and without having consistently provided value for money from the existing services. Without a more co-ordinated approach and stronger incentives to secure the desired results, the NHS is unlikely to get optimal value for money.”

The NAO urged NHS England to “fully consider the consequences” of extending access to GP surgeries.

The DH is insisting on driving forward a seven-day NHS, despite leaked papers revealing it is concerned that the project could be doomed due to ‘workforce overload’.

In response to the NAO, David Mowat, the health minister, said that increasing GP access did deliver value for money by relieving the pressure on areas such as A&E.

CCGs struggling to hold GP practices accountable

The NAO also said that NHS England needed to do more to guarantee that existing services in core hours meet patients’ needs, after finding that almost half of GP surgeries close at some point during core hours.

The report also showed that, although theoretically the transfer of commissioning to CCGs meant they were better placed to respond where GP practices had problems with access, in practice their ability to oversee GP practices was limited.

According to the NAO, CCGs lacked understanding of whether their local practices were meeting people’s needs, as well as the capability to manage service changes such as a practice handing in notice on its contract. They were also afraid of damaging their relationship with poorly performing practices if they did use tools such as breach notices.

In addition, the NAO warned that the goal of recruiting 5,000 additional doctors by 2020 may not be met.

The GP Forward View set a target of 3,250 additional trainee GPs a year, but in 2015-16 there were only 2,769, and in 2016-17 there were 3,019.

GPs criticise ‘bizarre’ report

Professor Helen Stokes-Lampard, president of the Royal College of GPs, said the NAO “hit the nail on the head” in questioning the value of increasing GP access.

However, she said GPs sometimes needed to close their practices during core hours for reasons related to guaranteeing patient care, and that it was “bizarre” to question the value of increasing GP numbers at a time when general practice is under immense pressure owing to increasing numbers of patients with more complex conditions.

A recent BMA survey found that eight in 10 GPs think their workload is so excessive it is putting patient safety at risk.

“General practice is the most cost-effective part of the NHS and it’s very disappointing that the NAO has chosen to criticise hardworking and hard pressed GPs rather than praising them for the sterling work they are doing to improve care and keep patients safe,” Professor Stokes-Lampard concluded.

She urged the DH to deliver the pledges it made in the GP Forward View “swiftly and effectively”.

Furthermore, the Forward View committed to recruiting a larger GP support workforce, including 3,000 clinical therapists, 1,500 clinical pharmacists, and 1,000 physician associates. However, the NAO warned that there are wildly different means of payment for different types of staff. For example, Health Education England pays the salaries of trainee GPs, but practices have to pay for their nurses. This means that practices are not incentivised to seek the most cost-effective balance of staff.

It was also noted that funding distribution between GP practices is also currently unfair. For example, funding to practices in Islington would need to be increased by 47% to bring it up to the same level as Knowsley.

NHS England has committed to reduce this, with no variation greater than 26% by 2020-21, but it will not update the formula used to redistribute funding, despite this being recommended as early as 2007.

The NAO said that NHS England should explore how it can encourage GP practices to employ a wider mix of staff in a sustainable way, and promote sharing of best practice in improving capacity and better data on the pressures on general practice.

Responding to the report, an NHS England spokesperson said: “The NAO seem to be criticising the rather obvious fact that it inevitably costs more to provide evening and weekend urgent primary care services than it does during Monday-Friday, 9-5. The alternative would be that patients simply head to A&E, with all the consequences that brings for more major cases.

“No one is suggesting each individual GP practice should offer this extended access, but there’s quite wide agreement that – as GP numbers expand – practices do need to club together to offer this service, a bit like the out-of-hours duty chemist rota.”

They added that across much of London, Manchester and a fifth of the country GPs are already doing this, and more areas will follow next year.

“The NAO are wrong to criticise the value for money of general practice, given that the per patient cost of a year of GP care is less than the cost of just two A&E visits,” the spokesperson noted.

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