Primary care is under unprecedented pressure at the moment. The media is awash with stories of lengthy waiting times to see a GP; people turning up to A&E because they cannot get a GP appointment; GPs leaving the profession; and patients staying in hospital beds longer than they need to because the “system” simply is not capable of supporting them as they convalesce.
The RCGP has set out a 10 point plan to save general practice. Its manifesto calls for a rise in the share of the NHS budget spent on general practice from 8% to 11% by 2017.1
The focus on primary care is going to intensify exponentially over the next few months. The twin drivers of winter and the looming 2015 general election will ensure that primary care remains centre-stage.
I will examine the current situation and consider what the answer may begin to look like.
But what are the issues?
Increased demand by the public for GP services
We expect more and more from our GPs. We want them to see us quickly and we want them to see us when it is convenient to us. Advances in medicine have allowed patients with chronic complicated conditions to stay alive a lot longer than they would previously have, but managing these input and complex treatment times. The result is that GPs’ workloads are increasing. This may not be such a big problem if there were an army of GPs or if newly qualified doctors were flocking to the specialty; unfortunately, it’s not working out like that at the moment.
A lack of GPs
General practice is facing a staffing crisis. Newly qualified doctors are not pursuing it as a career in the numbers they once did. As senior GP partners retire, there is simply not the enthusiasm from junior GPs to take ownership of the premises and drive the practice forwards. The reasons for this are manifold. Some GPs do not want to be “tied down” by commitments such as owning premises and employing staff. The younger generation of doctors may have a different view about this than the older generation. They may prefer a flexible career path with the possibility of say, practising abroad, may prefer to be a salaried GP or may leave the profession. The primary care market may look complicated at the moment from a business perspective with issues around minimum practice income guarantees; quality and outcomes framework points; and enhanced services contracts being tendered. There may be too much uncertainty for a junior GP to want to fully commit to owning a business.
There are then the new business models that are emerging such as GP provider organisations. Again, to really get the most out of these organisations GPs need to be business savvy as they line themselves up to bid for enhanced services contracts or maybe community services contracts. Doctors considering their next career move may decide it is easier to become a salaried GP or even pursue a different specialty.
The profession may be more attractive if the “architecture” was perceived to be modern, flexible and capable of responding to the demands placed upon it. Whilst in some cases this is undoubtedly happening, it is not the case everywhere.
An estate that requires investment
As more and more is expected from primary care, the response from those on the front-line is that investment in the estate is required. As matters currently stand, there seem to be very few developments underway. This seems unsustainable in light of the increased and changing demand for services. Modern, safe, clean buildings are essential to provide the sort of care expected from GPs.
Pressure from secondary care to alleviate its pressures
Attendances at A&E departments have increased by 50% in a decade, to 21 million visits annually. Arguably, one factor in this increase is difficulty in accessing GPs quickly, causing some patients to go to A&E instead.
In addition, some acute trusts have already written to some GP practices to remind them of their obligations in respect of referrals.2 GPs feel that they are in an invidious position: they fear criticism from the acute trusts for referring too much whilst also feeling under pressure from patients for not referring enough. There is a call for some sort of “step up” care to provide the necessary halfway house. At the other end of the patient pathway is the issue with delayed discharges: convalescing patients blocking expensive acute beds – with a need for ‘step down’ care.
So what might answers to these problems look like during the next Parliament?
The Conservatives’ position on primary care has become clearer over the last few months with both Prime Minister David Cameron’s and health secretary Jeremy Hunt’s speeches at the party conference including new commitments.
They include:
- By the end of the Parliament, everyone to have 8am to 8pm and weekend access to a GP. There has already been some movement towards this with the Prime Minister’s Challenge Fund supporting innovative ways of working. However, extending it to the whole population will be a considerable challenge – especially with current spending restrictions. It is extremely unlikely that patients would be able to see their GP or even a GP from the same practice at every point in these extended hours. It is more likely that practices will start to work together to provide this cover – as is already happening in some of the pilot schemes. It is also unclear whether access would be for urgent cases only or whether patients would be able to have routine appointments at weekend or during the evening – which would require more GPs on duty.
- Train and recruit an additional 5000 GPs. This will help address the shortages developing in general practice – and may go some way towards staffing surgeries for longer hours. However, the challenge may still be attracting medical students and junior doctors to a career in general practice.
- From 2015 everyone is to have a a named GP on their record and responsible for their care. This reverses decisions of a decade ago which saw more patients registered with a practice without a named GP. The introduction of named GPs for over-75s is already in place of course – but they are a very different part of the population, more likely to have chronic conditions and need regular attention from a GP. Continuity of care will be very important for them. It is less clear how this will work for the whole population: many people may opt to see a GP at the most convenient time, rather than waiting for ‘their’ GP.
Much of this can be seen as following the direction of travel already set by the present government. The Labour Party’s policies are perhaps more interesting as they would – if enacted – represent a significant change.
Filling the gap between secondary care and “social care”
At the Labour party conference in September, Labour put primary care at the centre of its approach to reforming the health service. Labour leader Ed Miliband spoke about an NHS with “Time to Care” with extra funding from a mansion tax and taxes on the profits of tobacco companies. He addressed the need for GPs to work differently and referred to integrated care organisations employing salaried GPs. Shadow health secretary Andy Burnham spoke about whole person care and the need to bring health and social care together.
This is particularly important for those people who fall in the gap between being well enough to be discharged from an acute hospital bed and being able to live independently.
A package of both health and social care is likely to be needed to fill this gap. The closing of this gap is a stated aim of the Labour Party and one suggested approach is that of integrated care which could see some foundation trusts offering primary care services. He acknowledged that the payment by results system had caused a problem and suggested a new model whereby acute trusts employ GPs and social care staff and potentially provide the whole package of care – primary, secondary, community and social.3 There have already been some innovative approaches to primary care in the North-East where Northumbria Healthcare NHS Foundation Trust has been in discussions to create an integrated primary care organisation
providing services to GP practices.This raises wider questions about the future of the traditional GP partner practice if Labour is elected. 4 Mr Miliband maintained that he does not intend to sweep away the independent contractor model as it would still have some part to play. The reaction from GPs to this has been nuanced. A poll carried out by GP magazine found that 40% (out of 602 who responded) would support working in some form of joint provider organisation.However, those figures change where the suggested model is GPs working for a primary care organisation operated by an acute trust (46% against).5 6
Recruit more GPs
Mr Miliband has said that the £2.5bn “Time to Care Fund” would be used to employ 8000 new GPs. This would certainly help address part of the problem but raises wider questions.
How long would it take for these GPs to be on the “front-line”? What would their status be? Would they be employed by an integrated care organisation? If so, would that alienate those GPs who have independent contractor status?
These must be approached carefully because further crumbling of the “GP bedrock” is an unintended consequence that must be avoided.
Increased commissioning powers for local authorities?
Mr Burnham has said that a Labour government would integrate health and care budgets and commissioning under the control of local authorities enabling them to have a more closely aligned health and social care strategy.
Invest in the estate
All of the aims above are laudable but they will not have the desired effect unless there is a primary care estate that is modern and fit for purpose across the country. The estate is the platform from which any primary care reforms are to be delivered. Some practices will struggle to provide additional services from outdated premises while even practices with modern premises may want to expand their facilities – potentially housing some community services.
Conclusion
There are undoubtedly examples of world-class primary care in this country – patients being seen quickly by competent, dedicated primary care professionals in modern fit-for purpose buildings. This needs to become the rule, not the exception. One final thought though: GPs are at the heart of our primary care system. The profession has already lost practitioners and it cannot afford to lose any more – it is imperative that any reforms have the support of the GPs. Dr Richard Vautrey, deputy chair of the BMA’s general practitioner committee, said Labour’s proposals for investment in primary care would be welcomed by GPs but not at the expense of their independent contractor status.
Click here to read our other newsbrief articles on alliance contracting, fit and proper person requirements and the Mitchell Judgment.
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