Our report in 2012, ‘Primary Care ‘Today and Tomorrow: improving general practice by working differently’, highlighted the significant challenges facing general practice and the need for general practice to work differently to cope effectively with the increasing demands it was facing.i Some three years later the findings still resonate.
More importantly the demands facing general practice have, if anything, exceeded our predictions while the resources available to primary care have declined as a percentage of overall healthcare spending. Meanwhile, the new policy ‘road map’ for the NHS, the Five Year Forward View (FYFV), makes it clear that general practice remains the bed-rock of the NHS and that a reformed general practice is key to the future sustainability of healthcare.
However, as the past 15 years have shown, reforming general practice is incredibly challenging. Indeed, the NHS Plan 2000 emphasised that development of primary care services was key to modernising the NHS and set out an ambition to make primary care more accessible, offer patients more choice and move more services from secondary to primary provision. It also acknowledged that this would require more staff who would be paid more but who would work differently.ii This Plan was published against a background of general practitioner (GP) unrest, with a broad consensus that the GP workload was unsustainable, morale was endemically low and there was an alarming recruitment and retention crisis.iii
Fast forward 15 years and the headlines today are remarkably similar to those in 2000. Yet in the intervening period the number of general practitioners (GPs) and practice nurses increased. GPs were also paid more (initially a lot more but over time this has been eroded) for working less hours (but again hours have increased in an attempt to keep up with demand). Indeed, demands on general practice have grown year on year; driven by an expansion in the size of the population, the range of services provided and an expectation that GPs will manage an increasing array of more complex, long term conditions. There is, however, limited evidence of GPs adopting at scale new ways of working. Leading, once again, to a crisis in general practice.
In April 2015, a King’s Fund report argued that delivery of the FYFV is in danger due to shortages and “critical pressures” in the NHS workforce with major disconnects between strategic goals and workforce trends. In particular that the aim of the FYFV, to deliver more care in the community, is at odds with the slow rate of increase in the number of GPs. It points out that pressures on primary care, including fewer training posts being filled and more GPs planning to retire early, have resulted in a growing shortfall in the number of GPs. The report highlights survey findings that show a third of GPs are considering retiring in the next five years (because of excessive workloads, un-resourced work and not being able to spend enough time with patients). Moreover, a further 30 per cent are considering going part time. Modelling by NHS England and the Royal College of General Practitioners shows that the current rate of increase in supply will not come close to meeting future demand and that under supply and worsening morale pose a serious risk to ambitions to shift to models of care that rely more heavily on general practice.iv
The 17 June Nuffield Trust briefing (Transforming general practice: What are the levers for change?) argues that financial rewards and incentives to improve GP services risk being overused in the NHS and may not be the best way to encourage lasting change and widespread reform. Instead it suggests that policymakers need to supplement financial incentives with a more enabling approach to improving general practice. The briefing examines how policymakers and regulators might support change in general practice in the context of the FYFV and the Prime Minister’s Challenge Fund; both of which envisage a strong future for a reformed general practice.v
The Nuffield briefing concludes that the current combination of national and local incentive schemes and contract performance measures, risk overwhelming GPs and limiting their ability to engage with sustainable change. It also points out that previous attempts to reform general practice in England focused on initiatives that incentivised small scale improvements on specific issues, such as tackling specific conditions (like diabetes) in return for financial rewards. While academic reviews of the Quality Outcomes Framework (QOF), introduced as part of the new GP contract in 2004, show that QOF has led to improvements for those conditions targeted by the payments, they also distorted priorities and in some cases detracted from patient care.vi
In the midst of all this scrutiny and debate, it’s important to remember that GPs have studied for many years and most are dedicated healthcare professionals with a deep commitment to their patients. They are used to working independently, providing continuity and consistency, with high satisfaction ratings from patients. The scale of organisational change now envisaged for general practice requires not only investment in the workforce, infrastructure and efficient operational processes; but also the development of new partnerships and professional relationships between all stakeholders in the new models of care. This will take time which, if history is anything to go by, is something that is likely to be in short supply.
Today’s media headlines, announcing the Secretary of State for Health’s pledge of £10m for a ‘turnaround programme’ to prevent practices closing as part of his ‘new deal’ for general practice, illustrates the urgency of the current situation. Announced as part of a package of measures to put the ‘inspiration and magic back’ into GP’s working life, including increasing the primary care workforce by 10,000, golden hellos to attract GPs to areas of ‘greatest need’ and a national marketing campaign to promote general practice. In return, however, GPs will be expected to move towards a seven-day service.vii
Our 2012 report identified the need for primary care to work differently and it appears that the time has come when not doing so will no longer be an option. But care needs to be taken that in reforming primary care we don’t lose sense of its strengths. A good place to start could be to scale up some of the examples in our 2012 report, which proposed a range of solutions involving new business models, some of which were already being trialled by a number of GPS, others have yet to be adopted at scale; all promote new ways of working.
ii The NHS Plan: A Plan for investment, a plan for reform. Department of Health 1 July 2000.
iii NHS Pay modernisation: new contracts for general practice in England. National Audit Office February 2008.