General practice has been at the heart of the delivery of primary healthcare in England for decades. Today it stands at a crossroads. One direction points to a future which threatens an inexorable erosion in the quality of care that GPs provide as they struggle to contend with ever-increasing workloads, rising public expectations and the complex management of growing number of patients with multiple conditions. All this following on from a decade-long underinvestment in general practice.
Another direction points to a different future: one where the core principles of general practice – that doctors lead the provision of primary care in local communities – are maintained but services are modernised and reconfigured in a way which responds to the priorities of patients, promotes better integration and addresses the recruitment and retention crisis which is currently enveloping the profession.
That crisis is underlined by the results of the largest-ever survey of GPs conducted by the BMA’s General Practitioners Committee (GPC). It finds that nine in 10 GPs say their workload has had a negative impact on the quality of care they that they give to their patients – as well as being the strongest factor which undermines their personal commitment to general practice. The results of this are clear: onethird of GPs hope to retire from general practice in the next five years, while nearly one in five current GP trainees hope to move abroad.
Listening to patients and practictioners
This report draws on findings from one of the biggest-ever consultation exercises that the GPC has undertaken to outline an alternative to simply continuing on the current path and hoping for the best.
In a series of deliberative events, patients said their priorities are most likely to be delivered by community-based GPs continuing to lead the delivery of primary healthcare, and they firmly reject alternative models, such as practices run
by commercial companies or surgeries based in hospitals.
GPs share their patients’ outlook: 80 per cent of doctors responding to our survey say they greatly valued continuity of care for patients, while having insufficient time with patients ranks in the top three factors that most negatively impacts on their personal commitment to a career in general practice. Moreover, doctors show overwhelming support for GP-led primary healthcare services and the retention of independent contractor status, while equally recognising the wish by a growing number of GPs for alternative contractual options.
The Government has suggested that greater access to care is best provided by a seven-day routine service across the NHS. Patients appear unconvinced about this claim: urgent care at the evening or weekend, yes, but less concerned
about being able to book routine appointments throughout the weekend. GPs share their patients’ scepticism about this initiative, seeing greater investment in the current 24/7 GP urgent care service as a more sensible way to meet patient
However, both patients and doctors recognise the need for change. Patients understand the need to balance access to care with continuity of care. They do not believe that very small practices can deliver the care they need when they need it, and they accept the benefits that larger practices can bring.
At the same time, it is evident that – while there is overwhelming support for the option of independent contractor status – some doctors want to be able to work in new and different ways. Thus while nearly three-quarters of salaried and locum GPs aged 30 and under say they envisage looking for a partnership at some point, two-thirds of salaried and locum GPs as a whole do not.
This report outlines five steps to meeting the aspirations, and responding to the concerns, of patients and their doctors:
- Developing new models for delivering care.
- Addressing the recruitment and retention crisis.
- Bridging the primary care funding gap.
- Modernising premises and infrastructure.
- Realising the potential benefits of IT and other technology.
Developing new models of delivering care
The independent contractor status model needs to evolve. A collaborative care model – which involves larger practices employing bigger teams which can, in turn, work together in networks, as well as with other local health and social care providers – reflects the core principle of GP-led primary healthcare which doctors and patients wish to see retained.
It also has the potential to deliver many of the other things which, our consultation suggests, they believe primary healthcare should be striving for. It balances convenience and continuity of care, giving patients timely access to a trusted and familiar local practice team, while also offering practices the potential to offer extra services.
Larger practices working together in networks will require:
- A culture change in the NHS so that the delivery of care in communities is more highly valued.
- Investment in the training of additional staff to deliver community-based care and long-term funding to allow practices to employ those staff.
- Funding and support for the running of GP networks, as well as assistance with the process of bidding for, and delivering, primary care contracts.
Realising the potential benefits of IT and other technology
New technology has the potential to improve patient care and help deliver a more integrated service and seven-day urgent care provision.
The following steps can help best utilise new technology:
- Support for practices to ensure they have the necessary time to investigate, plan for and implement new technological developments.
- Financial support for practices for major investment in new technology.
- The full transfer of electronic health records between different practices to reduce or eliminate the need for paper records.
- Appropriate access to patients’ electronic records in urgent care situations and other health and care settings.
Modernising premises and infrastructure
Overcrowded and antiquated premises have no role to play in the delivery of modern, high-quality primary care. The BMA’s premises survey in 2014 found that four out of 10 GP practices felt their current premises were not suitable to deliver
services to patients, while nearly 70 per cent felt they did not allow for the provision of additional services.
Ensuring doctors can work in premises that allows them to deliver the best for their patients will require:
- A long-term commitment to an infrastructure fund beyond the current timescale, with a comprehensive longer-term premises strategy.
- Offering more premises through the NHS or a third party to meet the needs of GPs who do not want to own practice premises.
Bridging the primary care funding gap
General practice provides excellent value for money. It costs on average only £131.45 to provide each patient with a comprehensive, unlimited service each year.
But, as Simon Stevens, the Chief Executive of NHS England, has recognised, there has been a systematic under-investment in general practice for at least a decade.
To redress this under-investment, and ensure the full benefits of other changes outlined in this report are realised, there needs to be a sustained, year-on-year increase in the proportion of NHS funding going to general practice on a recurrent, equitable basis for practices.
Addressing the recruitment and retention crisis
We lack the number of GPs we need to meet the demand for GP services. This decreases patients’ ability to get an appointment when they need it, cuts the time doctors can spend with their patients, and increases GPs’ workloads – thus contributing to a vicious cycle in which the ability to recruit new GPs and retain existing ones is reduced.
There needs to be a comprehensive strategy to boost the GP workforce. This should include:
- Measures to improve the image of general practice in medical schools.
- Increased resources to grow the number of GP placements for foundation doctors and full funding for returner and retainer schemes.
- Introduction of an equitable and fair tariff for GP practice undergraduate placements so that all practices across the country can participate.
Alongside this strategy, steps need to be taken to help GPs better manage their workload:
- Greater and sustained funding for general practice, with a payment system that delivers new resources for increased workload in community settings.
- An enlarged infrastructure of general practice, with improved premises and community-based estate and facilities.
- Measures to empower patients to manage their own care better through a government-backed national self-care strategy and encouraging commissioners and practices to promote self-care.
- Measures to manage demand and stem the shift of inappropriate and unresourced workload onto GPs.
Not all GPs wish to work as independent contractors. In our survey, sessional GPs ranked their partner colleagues being overworked as the second most important factor in their reason for being a sessional GP. To tackle the recruitment
and retention crisis it is, therefore, important that different employment models for GPs are available. The use of different contracting models can place greater, more clearly defined, limits on GPs’ workload and thus leave them with more time to
deliver the care that patients need.
It is now time to move beyond headline-grabbing political initiatives, constant tinkering with the GP contract in order to introduce transitory targets and incessant micro-management from Whitehall. If general practice is to take the road toward a responsive, safe and sustainable future, hard choices, additional investment and innovative solutions will be required. This report outlines how we can move towards this new future for general practice.
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