The 10 Year Plan: A Political Response
This document outlines Doctors in Unite's (DIU) perspective on the government's 10 Year Plan for primary care. As a part of Unite the Union, DIU believes in a publicly funded, publicly provided, and comprehensive National Health Service. Our aim is to ensure primary care, with General Practice as its cornerstone, is at the heart of the NHS.
PART 1: A CRITIQUE OF THE 10 YEAR PLAN
DIU wants to engage with the principles underpinning the 10 Year Plan, as we believe in responding constructively with ideas that can work. However, it is our considered view that the main thrust of the Plan is antithetical to our core values and vision for NHS primary care. While some ideas, if effectively delivered, would garner our support, we are deeply concerned that the dominant strands being advanced rely heavily on privatisation and unrealistic technological promises. We must not become accomplices in merely window dressing a plan that will not genuinely strengthen the valued aspects of NHS primary care.
Our primary concerns are as follows:
Reliance on Privatisation and Commercialisation
The Plan says that increased private provision will be used to improve NHS services, particularly in disadvantaged areas.
This approach also envisages successful financial trusts, appointing their own Boards, becoming Integrated Health Organisations (IHOs) empowered to manage health budgets for their areas, including primary care. We view the emergence of IHOs as a trojan horse for corporate capture and are wary of models resembling North American Accountable Care Organisations (ACOs). This risks introducing market forces that fundamentally do not work for healthcare.
Misdirection of Funding and Undermining General Practice
There is a significant risk that promises to increase funding to Primary Care could result in Trusts or private performers providing community services to replace hospital-based clinics, rather than providing funding directly to General Practices. This would probably lead to fewer General Practitioners (GPs) being employed.
The Plan's emphasis on contracts for GPs to lead teams working at scale or offering enhanced services fails to address the contractual needs of GPs working as GPs within practices. We believe that practices should remain key to delivering local services, and that they need strengthening regardless of new neighbourhood initiatives.
Public Health
The Plan offers an inadequate focus on funding Public Health, Health Creation, and the social determinants of health.
Unrealistic Technological Promises and Staff Reduction
The Plan appears to be based on the primacy of IT solutions and envisages an overall reduction in NHS staff compared with 2013 workforce planning predictions. While technology has a role, it cannot substitute for adequate staffing or address the fundamental issue of capacity versus access. Simply keeping doors open does not solve the problem if there are not enough doctors to provide appointments.
Lack of Detail and Unproven Concepts
The Plan often feels like a scrap book of thoughts and ideas some of which, like polyclinics, have failed before. The press release commitments, such as shifts from analogue to digital, illness to prevention, and hospital to community, are acceptable and attractive in principle, but the Plan rarely explains mechanisms whereby these might actually be achieved. The Plan expects a shift of resources to community, but how that might happen is not clearly described.
Neglect of Continuity of Care
This concept is hardly mentioned. The current system, and potentially the Plan, risks further eroding continuity of care, which is essential for both practitioners and patients, and is known to improve health outcomes. The transactional approach, often prioritising throughput over relational care, is deeply concerning. Formal named registration for a regular GP often doesn't work in practice.
Exacerbation of the Inverse Care Law
We fear that the Plan does not adequately address the Inverse Care Law, where the availability of good medical care tends to vary inversely with the need for it. The current variability of service provision between practices is not based on population or need.
Patient Power
Cutting Healthwatch is probably a retrograde step. It wasn’t very effective, but having no such organisation at all is inadequate. There needs to be organized channels for patient experience to have influence. We don’t agree with reliance on individual feedback scores, and believe that Trust income should be based on the needs of the population served.
The suggestion that Trust income should be based on patient reported outcomes and experience data linked with new Patient Power Payments sounds intriguing – but needs a great deal of exploration. We believe that patient feedback is important but it seems contrary to take money off organisations that appear to be failing – that is only likely to hasten their demise.
PART 2: OFFERING CRITICAL FRIENDSHIP TO GOVERNMENT AND THE DEPARTMENT OF HEALTH AND SOCIAL CARE
Doctors in Unite is committed to a constructive dialogue and offers its expertise to the government and the Department of Health and Social Care. We believe it is possible to restructure General Practice to meet health needs, reduce inequalities, improve outcomes, and provide a satisfying working life for all primary care staff.
There are some aspects of DIU’s strategy for general practice which have echoes in the Ten Year Plan. Community workers are an essential part of our vision of neighbourhood, and the recognition of the need for increased primary care resources and specific targeting of deprived areas is welcomed. However, the Plan appears to see neighbourhoods developing as contractors of private services, potentially under the control of integrated health organisations, which is far from our vision.
We propose the following areas for collaboration and improvement, building on our vision for primary care:
NEIGHBOURHOOD HEALTH TEAMS
DIU advocates for Neighbourhood Health Communities (NHCs), serving populations of 25,000 to 75,000, aligning with natural communities. Within NHCs, smaller practices covering up to 10,000 people would host a wide "primary care" team including GPs, nurses, therapists, pharmacists, social care workers, and many other skilled professionals, ensuring that good primary health care depends on a range of workers, not just substitution for GPs. There are strong overlaps with some suggestions within the 10 Year Plan.
Democratic Accountability and Local Authority Integration
DIU would see NHCs directed by health professionals, community representatives, and local authority elected representatives, strengthening democratic accountability.
The suggestion that Trust income should be based on patient reported outcomes and experience data linked with new Patient Power Payments sounds intriguing – but needs a great deal of exploration. DIU could assist with planning that.
Community Development Workers
Their role would be to help identify issues raised by communities and work with the statutory sector (health, police, education etc) to help respond to those issues.
The community workers would be integral to the Neighbourhood Teams, possibly jointly funded and managed by the NHS and Local Authorities, with their primary professional responsibility remaining with the community. These are not the same as Social Prescribers.
They are very similar to the Community Health Workers highlighted in the 10 Year Plan.
Support and Commissioning
NHCs would be supported by district and regional bodies (250,000+ population) responsible for commissioning and overseeing hospital and less common services, accountable to local authorities and NHCs.
WHAT KIND OF GENERAL PRACTICE IN A NEIGHBOURHOOD?
Prioritising Continuity of Care
DIU would argue for mechanisms to maximise continuity of care which is strongly evidenced to improve health outcomes at reduced cost. It is hardly mentioned in the Plan.
List-based GP practices
DIU strongly advocates for list-based local practices as key within neighbourhoods, capable of offering continuity of care, This requires registered lists where continuity is enabled with tools for practices to measure the continuity they provide. It is not clear to what extent this may be threatened by the proposed contracts and the suggestion that practices could be run by Trusts. The BMA is concerned about this and DIU can help the debate.
Strengthening the Workforce and Working Conditions
NHS morale remains very low. A manageable workload is crucial. We propose expanding the primary care team, reducing average practice sizes (ideally to 1,200 patients per whole-time equivalent GP), and increasing self-referral pathways. GP line managers should be clinicians or experienced primary care colleagues, respectful of professional and public service values. DIU argues that APMS contracts be abolished.
Salaried and Independent Options
We believe in both salaried and independent contractor options, but with a strategic shift towards GPs positively choosing the salaried option within a fully publicly provided NHS. This necessitates well-constructed job plans and attractive contracts that offer career progression and a finite working day. We would recommend trials to explore the risks and benefits of salaried options. DIU has considered this issue for many years, and we feel we can offer constructive options.
Reversing the Inverse Care Law
Resource allocation must be designed to counter the Inverse Care Law, prioritising disproportionate funding increases in deprived communities and areas with the lowest healthy life expectancy. This issue is hardly mentioned in the Plan, but it is central to improving equitable provision across England the devolved countries.
PUBLIC HEALTH
Investment in Public Health and links with Primary Care and the Neighbourhood Teams
There are some useful Public Health recommendations in the Plan, but DIU would like to see these strengthened with significant re-investment in Public Health and with a clear link into the Neighbourhood Health Teams. DIU argues for Public Health leads with joint primary care and Public Health backgrounds in each neighbourhood.
The social causes of ill health, such as poverty and poor housing, must be a government priority. Unless the social and economic determinants of health are addressed locally and nationally, little health gain will result. Our long experience in Public Health can contribute to development of the Teams.
SHIFT FROM HOSPITAL TO COMMUNITY
Increased and Targeted Investment
We call for a considerable increase in health and social care spending, with a greater proportion allocated to Public Health, primary care, and social care than to hospital services. Our proposals involve an extra £20bn per annum (2021 prices) for primary care, with significant investment. The Plan does not allocate extra spending to primary care but aims to shift spending from hospitals to primary care – a shift that has never happened despite many past commitments.
TECHNOLOGY
Effective and Ethical Technology and Data Utilisation
While acknowledging the importance of IT, systems must be high quality, fit for purpose, and well-maintained, enabling appropriate use of face-to-face and remote consultations. Digital exclusion must be addressed to prevent growing health inequalities. Population data should be available for research and analysis but not for commercial exploitation, with robust consent and confidentiality safeguards.
Tech is a moderate part of the solution
DIU has a realistic technology strategy which does not expect the massive benefits described in the Plan. Tech needs to make life easier for clinicians, organisations and patients, but we know how hard it is to implement even small improvements. DIU experts would be happy to consider how to support tech improvements at local and national levels.
There is a danger of outsourcing the UK’s tech expertise to other countries, notably the US. DIU would be happy to debate that issue also.
CONCLUSION
Doctors in Unite, as a part of Unite the Union, has a history of influencing debate and policy. We are keen to engage with government, the Department of Health and Social Care, and relevant stakeholders, including our contacts within Unite, to ensure that any reforms genuinely strengthen the NHS and place the well-being of patients and staff at its core. We are prepared to offer our expertise and actively participate in discussions to refine and improve any proposed reforms.
PART 1: A CRITIQUE OF THE 10 YEAR PLAN
DIU wants to engage with the principles underpinning the 10 Year Plan, as we believe in responding constructively with ideas that can work. However, it is our considered view that the main thrust of the Plan is antithetical to our core values and vision for NHS primary care. While some ideas, if effectively delivered, would garner our support, we are deeply concerned that the dominant strands being advanced rely heavily on privatisation and unrealistic technological promises. We must not become accomplices in merely window dressing a plan that will not genuinely strengthen the valued aspects of NHS primary care.
Our primary concerns are as follows:
Reliance on Privatisation and Commercialisation
The Plan says that increased private provision will be used to improve NHS services, particularly in disadvantaged areas.
This approach also envisages successful financial trusts, appointing their own Boards, becoming Integrated Health Organisations (IHOs) empowered to manage health budgets for their areas, including primary care. We view the emergence of IHOs as a trojan horse for corporate capture and are wary of models resembling North American Accountable Care Organisations (ACOs). This risks introducing market forces that fundamentally do not work for healthcare.
Misdirection of Funding and Undermining General Practice
There is a significant risk that promises to increase funding to Primary Care could result in Trusts or private performers providing community services to replace hospital-based clinics, rather than providing funding directly to General Practices. This would probably lead to fewer General Practitioners (GPs) being employed.
The Plan's emphasis on contracts for GPs to lead teams working at scale or offering enhanced services fails to address the contractual needs of GPs working as GPs within practices. We believe that practices should remain key to delivering local services, and that they need strengthening regardless of new neighbourhood initiatives.
Public Health
The Plan offers an inadequate focus on funding Public Health, Health Creation, and the social determinants of health.
Unrealistic Technological Promises and Staff Reduction
The Plan appears to be based on the primacy of IT solutions and envisages an overall reduction in NHS staff compared with 2013 workforce planning predictions. While technology has a role, it cannot substitute for adequate staffing or address the fundamental issue of capacity versus access. Simply keeping doors open does not solve the problem if there are not enough doctors to provide appointments.
Lack of Detail and Unproven Concepts
The Plan often feels like a scrap book of thoughts and ideas some of which, like polyclinics, have failed before. The press release commitments, such as shifts from analogue to digital, illness to prevention, and hospital to community, are acceptable and attractive in principle, but the Plan rarely explains mechanisms whereby these might actually be achieved. The Plan expects a shift of resources to community, but how that might happen is not clearly described.
Neglect of Continuity of Care
This concept is hardly mentioned. The current system, and potentially the Plan, risks further eroding continuity of care, which is essential for both practitioners and patients, and is known to improve health outcomes. The transactional approach, often prioritising throughput over relational care, is deeply concerning. Formal named registration for a regular GP often doesn't work in practice.
Exacerbation of the Inverse Care Law
We fear that the Plan does not adequately address the Inverse Care Law, where the availability of good medical care tends to vary inversely with the need for it. The current variability of service provision between practices is not based on population or need.
Patient Power
Cutting Healthwatch is probably a retrograde step. It wasn’t very effective, but having no such organisation at all is inadequate. There needs to be organized channels for patient experience to have influence. We don’t agree with reliance on individual feedback scores, and believe that Trust income should be based on the needs of the population served.
The suggestion that Trust income should be based on patient reported outcomes and experience data linked with new Patient Power Payments sounds intriguing – but needs a great deal of exploration. We believe that patient feedback is important but it seems contrary to take money off organisations that appear to be failing – that is only likely to hasten their demise.
PART 2: OFFERING CRITICAL FRIENDSHIP TO GOVERNMENT AND THE DEPARTMENT OF HEALTH AND SOCIAL CARE
Doctors in Unite is committed to a constructive dialogue and offers its expertise to the government and the Department of Health and Social Care. We believe it is possible to restructure General Practice to meet health needs, reduce inequalities, improve outcomes, and provide a satisfying working life for all primary care staff.
There are some aspects of DIU’s strategy for general practice which have echoes in the Ten Year Plan. Community workers are an essential part of our vision of neighbourhood, and the recognition of the need for increased primary care resources and specific targeting of deprived areas is welcomed. However, the Plan appears to see neighbourhoods developing as contractors of private services, potentially under the control of integrated health organisations, which is far from our vision.
We propose the following areas for collaboration and improvement, building on our vision for primary care:
NEIGHBOURHOOD HEALTH TEAMS
DIU advocates for Neighbourhood Health Communities (NHCs), serving populations of 25,000 to 75,000, aligning with natural communities. Within NHCs, smaller practices covering up to 10,000 people would host a wide "primary care" team including GPs, nurses, therapists, pharmacists, social care workers, and many other skilled professionals, ensuring that good primary health care depends on a range of workers, not just substitution for GPs. There are strong overlaps with some suggestions within the 10 Year Plan.
Democratic Accountability and Local Authority Integration
DIU would see NHCs directed by health professionals, community representatives, and local authority elected representatives, strengthening democratic accountability.
The suggestion that Trust income should be based on patient reported outcomes and experience data linked with new Patient Power Payments sounds intriguing – but needs a great deal of exploration. DIU could assist with planning that.
Community Development Workers
Their role would be to help identify issues raised by communities and work with the statutory sector (health, police, education etc) to help respond to those issues.
The community workers would be integral to the Neighbourhood Teams, possibly jointly funded and managed by the NHS and Local Authorities, with their primary professional responsibility remaining with the community. These are not the same as Social Prescribers.
They are very similar to the Community Health Workers highlighted in the 10 Year Plan.
Support and Commissioning
NHCs would be supported by district and regional bodies (250,000+ population) responsible for commissioning and overseeing hospital and less common services, accountable to local authorities and NHCs.
WHAT KIND OF GENERAL PRACTICE IN A NEIGHBOURHOOD?
Prioritising Continuity of Care
DIU would argue for mechanisms to maximise continuity of care which is strongly evidenced to improve health outcomes at reduced cost. It is hardly mentioned in the Plan.
List-based GP practices
DIU strongly advocates for list-based local practices as key within neighbourhoods, capable of offering continuity of care, This requires registered lists where continuity is enabled with tools for practices to measure the continuity they provide. It is not clear to what extent this may be threatened by the proposed contracts and the suggestion that practices could be run by Trusts. The BMA is concerned about this and DIU can help the debate.
Strengthening the Workforce and Working Conditions
NHS morale remains very low. A manageable workload is crucial. We propose expanding the primary care team, reducing average practice sizes (ideally to 1,200 patients per whole-time equivalent GP), and increasing self-referral pathways. GP line managers should be clinicians or experienced primary care colleagues, respectful of professional and public service values. DIU argues that APMS contracts be abolished.
Salaried and Independent Options
We believe in both salaried and independent contractor options, but with a strategic shift towards GPs positively choosing the salaried option within a fully publicly provided NHS. This necessitates well-constructed job plans and attractive contracts that offer career progression and a finite working day. We would recommend trials to explore the risks and benefits of salaried options. DIU has considered this issue for many years, and we feel we can offer constructive options.
Reversing the Inverse Care Law
Resource allocation must be designed to counter the Inverse Care Law, prioritising disproportionate funding increases in deprived communities and areas with the lowest healthy life expectancy. This issue is hardly mentioned in the Plan, but it is central to improving equitable provision across England the devolved countries.
PUBLIC HEALTH
Investment in Public Health and links with Primary Care and the Neighbourhood Teams
There are some useful Public Health recommendations in the Plan, but DIU would like to see these strengthened with significant re-investment in Public Health and with a clear link into the Neighbourhood Health Teams. DIU argues for Public Health leads with joint primary care and Public Health backgrounds in each neighbourhood.
The social causes of ill health, such as poverty and poor housing, must be a government priority. Unless the social and economic determinants of health are addressed locally and nationally, little health gain will result. Our long experience in Public Health can contribute to development of the Teams.
SHIFT FROM HOSPITAL TO COMMUNITY
Increased and Targeted Investment
We call for a considerable increase in health and social care spending, with a greater proportion allocated to Public Health, primary care, and social care than to hospital services. Our proposals involve an extra £20bn per annum (2021 prices) for primary care, with significant investment. The Plan does not allocate extra spending to primary care but aims to shift spending from hospitals to primary care – a shift that has never happened despite many past commitments.
TECHNOLOGY
Effective and Ethical Technology and Data Utilisation
While acknowledging the importance of IT, systems must be high quality, fit for purpose, and well-maintained, enabling appropriate use of face-to-face and remote consultations. Digital exclusion must be addressed to prevent growing health inequalities. Population data should be available for research and analysis but not for commercial exploitation, with robust consent and confidentiality safeguards.
Tech is a moderate part of the solution
DIU has a realistic technology strategy which does not expect the massive benefits described in the Plan. Tech needs to make life easier for clinicians, organisations and patients, but we know how hard it is to implement even small improvements. DIU experts would be happy to consider how to support tech improvements at local and national levels.
There is a danger of outsourcing the UK’s tech expertise to other countries, notably the US. DIU would be happy to debate that issue also.
CONCLUSION
Doctors in Unite, as a part of Unite the Union, has a history of influencing debate and policy. We are keen to engage with government, the Department of Health and Social Care, and relevant stakeholders, including our contacts within Unite, to ensure that any reforms genuinely strengthen the NHS and place the well-being of patients and staff at its core. We are prepared to offer our expertise and actively participate in discussions to refine and improve any proposed reforms.
