David Oliver: Towards a GP consensus on the future of UK general practice
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2949 (Published 20 June 2017) Cite this as: BMJ 2017;357:j2949
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In the last few years, the terms "Unsustainable" and "Not fit for purpose" have been levelled at hospitals, general practice, and the NHS as a whole. The 5YFV 's descent towards a shrunken, centralised, fully managed and largely privatised system wherein general practice becomes an outreach service for hospitals, is effectively the end to general practice that the Lords' Committee deems necessary and the STPs facilitate. Not all change is progress.
A local STP plans to improve quality of primary care under a capped expenditure process, by cutting the number of GPs by over 150 (25%) - to be replaced by 100 pharmacists, 38 physicians' assistants, - and a focus on IT and 111 'self-help support'. Simon Stevens's 5YFV would have us as extras in A+E triage or Urgent Care Centres. This, on the back of more than seven years consistent impoverishment by an 11% to 8% fall in the share of the NHS budget. GPs' increasing workloads are significantly added to by the evidence-poor forced initiatives from NHSE which barely keep many Practices financially afloat. Too many are closing. And A+Es. And Maternity Units. And hospitals. And Day Centres. And Children’s Centres. And social care access.
It looks like we're ignoring the bedrock of the UK NHS, being eroded in a politically managed process of decline, ready for fracking. Dressed up as 'preparing the NHS for the future', these are regressive changes - a shrink-to-fit NHS solution for cuts which jeopardises our ability to meet appropriate need.
We can't go on like this, but we can't accept what is being proposed - landsale money or no landsale money, this is not the future of the NHS I want to see in England. Would I "Throw money at it?" no, I'd fund it properly commensurate with need and according to GDP, from taxation. The NHS works and gives good value. I am not convinced that these micro-managed plans for a downskilled, cash-starved community workforce are fit to manage the proposed workload shift from secondary care, nor the genuine medical needs of an ageing population, nor the fallout from 500,000 people losing their entitlement to social care.
Chris Hopson laudably cracked and finally stood up against the managed cuts which have crippled our hospitals since 2012. In doing so he put the safe care of patients above control totals, and he brought a very obvious point to light: the narrow margins of cost pressure within which the NHS operates have been exceeded. The same is true in general practice.
GPs, Hospital doctors, and Nurses are being driven from the profession and from the NHS by Govt’s political choices, relentless meddling, obsessive regulation and increasingly intolerable conditions.
I believe the current direction of travel will worsen quality of patient care , and it will affect medical education, training and research. GPs' Independent Contractor status is valuable in maintaining a voice for GPs as GPs: medical carers and advocates for patients, embedded in the community.
There is nothing obsolete in the medical model, as the ideologues and commercial opportunists would have us believe. GPs are well-placed to manage co-morbidity, if only we had specialised nursing, social work and communications to help. Unless we are prepared to say no to what is being forced upon us, the rationed-down 'integrated' NHS will become a locked door to a mass of medically denied, socially isolated, unsupported older people whose dependence for care on friends and neighbours will be both shaming to them and shameful upon all of us.
Competing interests: No competing interests
Dear Editor,
Oliver asks what direction primary care should take. (1) The answer is simple, the direction that serves our patients and the economy best.
From a payment point of view, under the General Medical Services (GMS) contract funding formula all practices receive the same basic funding per patient per year, as the payment is dependent on patient characteristics. However all publications on payments identified Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) receive more funding than the GMS funding formula would afford to those practices.
However, the PMS model was brought in to enhance quality of services, mostly through additional staff funding, and some APMS contracts allow practices to offer services that GMS practices have not been able to offer, like fee for service payments for seeing patients registered at a different practice. Dr Bradley in the comments on this article identified that there is no evidence to justify these additional payments.
From an economical point of view, the GMS contract provides our economy with the best value high quality primary care. (2)
The GP Patient Survey (GPPS), despite it's shortcomings, provides us with information about what patients value and about the diversity of what practices deliver. This is a consequence of the discrete choice patients are faced with, for instance continuity of care may be offset by choice of practitioner. (3) I am not aware of any publication examining this, but some years ago we failed to identify practice characteristics like size or contract status being associated with GPPS satisfaction ratings.
The capitation payment system in the UK (a fixed fee per patient per year) incentivises practices to deliver poor quality care, high intensity patients will leave the practice as they are the ones most affected by the poor care, more patients can be served and more income is generated. It is only the professionalism that counterbalances this economic driver, something lost in an employee service and probably the reason why Employee Medical Services cost more.
From a personal point of view, I applied to my current single-handed practice as the income generating incentive in a partnership will be different for different partners, and the balance between quality or income is not under the control of the individual partner. Our GPPS ratings are in 98th centile nationally, despite our practice population factors. However I have been subject of three CQC, two NHS England, one NCAS and one GMC investigation since 2014. The CQC determined "The GP and practice nurse/manager focused on delivering clinical care, which resulted in a lack of focus on governance arrangements." (4)
Despite our high GPPS ratings and commitment to providing access to high quality clinical care, we are starting to struggle with the rising demand experienced around the country. (5) Disengaging professionals from the responsibility for access to care and the quality of care (waiting lists and care delivered by unqualified staff) can only do so much on the supply side, and at some point demand issues will need to be addressed through co-payments, the only intervention with evidence of it's efficacy. (6)
(1) Oliver: Towards a GP consensus on the future of UK general practice.
BMJ 2017;357:j2949 https://doi.org/10.1136/bmj.j2949 (Published 20 June 2017
(2) Morgan, Beerstecher. Primary care funding, contract status, and outcomes
http://europepmc.org/articles/PMC1927089/
(3) Baker, Streatfield. What type of general practice do patients prefer?
British Journal of General Practice, 1995, 45, 654-659 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1239467/pdf/brjgenprac00013...
(4) www.111crs.co.uk
(5) Baird et al, The King's fund. 2016 Understanding pressures in general practice
https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file...
(6) RAND's Health Insurance Experiment (HIE).
http://www.rand.org/health/projects/hie.html
Competing interests: Found by NCAS to be unsuitable for "a modern NHS". Found by CQC as inadequate practice by focusing on delivering clinical care.
David Oliver rightly points out that a ‘consistent, aligned set of messages’ would help those who value general practice support its ‘vital cause’.(1) While differences of opinion on funding, contractual and structural models are likely to continue, there are a range of areas where consensus is regarding workforce and system redesign is possible.
We need to address the workforce crisis through multiple interrelated mechanisms: a) support retention and return of existing GPs by increasing flexible working (hours, location), developing new roles (home based telephone triage, nursing home support, mentoring), and improving team based and professional morale; b) developing a new community and primary care workforce, though new pathways (eg physician associates), and supportive transition for other hospital and community based practitioners to new roles; c) recognition of the difference (on a spectrum) between high volume replicative healthcare activities that require protocolised care, light touch support or even self care (eg immunisation, monitoring hypertension, minor illness) and those requiring analytically demanding generalist skills to interpret complexity, uncertainty and a limited evidence base;(2) d) improving well being and morale (and thence motivation, productivity and retention) through organisational processes that empower practitioners to make individualised decisions with patients, simplify the range of guidelines that need to be followed, reduce unnecessary administrative tasks, identify and support struggling practitioners, and foster a learning response to inevitable mistakes rather than risk aversion.
Whatever structural changes emerge, we need to improve the design of clinical delivery for both the routine and complex care within the range of existing and new models of care: a) develop proactive care for those with complex care needs, taking account of a full bio-psycho-social understanding, led by patients’ life goals and concern to reduce care burden, (ie person centred care); b) build organisations which work together to support proportionate multidisciplinary team working (including into acute hospitals) through flexible routines and a single updatable plan of care c) IT solutions for real time sharing of clinical records and for supported self care of short and long term conditions.
Having experienced partnership and salaried status work effectively (and falter!) I caution against fighting over which contractual model is best. I agree we should fight the whole sale dissolution of the partnership model which still generates flexibility and stability in many areas, but also test out and improve a range of salaried models (within and outside of ‘New models of care’) to work out how and in which context they are most effective.
Lastly I suggest NHSE and CCGs should urgently consider different models of commissioning practices in localities with workforce crises – for one potential solution I look back to my time in Lewisham, from 1995-1999, when, working with other salaried GPs, we were tasked and supported by the then FHSA to lead the development of a vacant practice in a deprived under-doctored area into a thriving innovative multi professional team.
1. BMJ 2017;357:2949
2. Reeve & Byng, Realising the full potential of Primary Care: uniting the ‘two faces’ of generalism. (Editorial, accepted BJGP, July 2017)
Competing interests: No competing interests
Now is not the time to seek a consensus about either the future structure or governance arrangements underpinning general practice. Now more than ever IS the time to seek a consensus about the values and principles underpinning the most important and most complex branch of the medical profession. My top 3 are:
1. Whole person care (integration of biomedical, social, psychological and spiritual care)
2. Expert medical generalist care with an emphasis on the management of multi-morbidity
3. Patient advocacy
All of these require a strong focus on the therapeutic relationship between patients and their doctors than the current system seems to encourage.
Competing interests: No competing interests
As a GP and a Patient I see that General practice needs to provide availability and continuity as the two key priorities. Smaller practices do this better.
These get muddled and lost in the complexity of the payment systems and a (? healthier) radical change if work/life wishes of more recent entrants to the profession. The abolition of out of hours commitment by the Blair government removed the subtle but definite feelings of total responsibility. Fewer and fewer now own their own surgery but are tied to a lease legally This makes the need to keep a viable service a personal risk; they would happily give back to those who pay the rent (the NHS) but the NHS is abysmally awful at property provision and maintenance. With so many income streams part of the week is spent concentrating on these (needed to run a practice not just to increase personal wealth) . As a profession we have convinced ourselves we are in a bad place but is this true compared to colleagues in Europe who work harder and earn much less but seem happier?
The trend seems to be to diversify the workforce ; this solution should enable the GP to be more available tough this does not seem to be happening. It may be unpopular to say but the NHS keeps providing money to practices whether they provide a service or not; there are those who do spend the money on patient care but a minority do not. The partnership model is decaying as the entrepreneurs and some NHS trusts take over, once they have shown a readiness to take over leases this might accelerate exponentially. What safeguards though can be put in place for availability and continuity?
Competing interests: No competing interests
David Oliver rightly notes there is no clear direction for change in general practice.
The small practice model is being made redundant, possibly for largely politically motivated reasons. However much this model gives good value (in terms of doctor effort), responsiveness and continuity (for patient care), it also may no longer fit modern health technology. Just as everyone wants their local district general hospital and A&E at the end of their garden, sub specialisms, expertise and availability of expensive equipment mean bigger, centralised hospitals are necessary for care. Maybe now we need to relinquish the idea that one GP can offer care for 2000 patients from cradle to grave. Actually, a specialist nurse can look after your chronic disease much better. A specialist team would keep you well and in the community once if you are older, frail and approaching the end of your life.
Out of hours needs to be linked to patient records and to surgeries. Referrals and investigations can usefully be taken forward during 8-8, 7 day appointments. Bigger practices or groups are needed to achieve this. This is the model we are being asked to, or told to, embrace as part of our democratic, political process.
Holding on to small practices and small hospitals maybe keeping our health care in the 20th century, with, for example, high infant mortality rates and low cancer detection rates when compared to our European compatriots.
New models of care combining primary with community or secondary care seem to be thought of as fringe ideas. However, this is not only where we are headed, with new Trusts to be negotiated and in place by 2020 but also key to abandoning the internal market. The purchaser-provider split is under exposed, neither discussed within our journals, among ourselves or as part of an electoral or political debate. It is very expensive, in terms of management and information costs and destructive, for instance to specialists or hospitals taking an overview of the population's health.
The reason there is no consensus among my primary care colleagues is clear to me. Most GPs earn around the rates of pay of a train driver; £60,000 for a 4 day week (driver) or a 32 hour, 2 day in surgery week (partner) or a 3-3.5 day, salaried GP, 35-hour week These GPs would happily hand in undated resignations, for instance. However, CCGs provide many GPs and practices with an inordinate additional income. My pension suggests I brought £200,000 extra into my practice for a 2 session a month post lasting two and a half years. These CCG post GPs would neither want to give up the internal market, combine primary and community care or have any reason to want to give up their job-for-life as a small/medium sized practice partner. The conservative coalition in the government before last have pulled a very clever divide-and-rule move, which only our LMCs seem to have acknowledged.
Clearly primary care is failing, both our patients and us, the staff working within it.Vested interest is holding us back. A clear direction, or a generalised and helpful acceptance of the direction being offered, would be one big step forward for us as well as our patients. It might also bring us more respect for doing a better job among our acute sector colleagues, such as David Oliver..
Sarah Evans
Salaried GP, Bedfordshire
(previously a partner in Hertfordshire)
Competing interests: No competing interests
Interesting article and responses that return to two basic facts: there is underfunding of general practice and there is no consensus.
GP principals are becoming an endangered species, because who wants to take responsibility for a sinking ship? There are two hats for a GP partner, on the one hand to deal with the individual patient's clinical needs, and on the other to monitor, audit and improve the care services provided for the community (or at least for their registered list of patients). Current demands and lack of support means simply dealing with the former is taking more time than available. We are working in what could be considered "normal-illegal" (cutting corners by reading letters and results faster than probably we should; squeezing more patients into clinics, so far from the suggested 15 minutes' time current complex patients need, according to the RCGP; and having patients wait for weeks to see a GP for issues like a concern about a symptom that could mean cancer, so a 2 week referral could become a 6 week referral in the making, to name but a few serious examples).
The importance at present is not about consensus, it is not about what model to be applied, because we must accept that one path does not fit all. At present, what is important is that a career as a GP partner is challenging but not a risk, is enjoyable and not a constant worry, allows time to process the amount of information we deal with having appropriate time rather than working regularly at 100% capacity, having time to read and question previous decisions rather than doing the minimum requirements for appraisal, etc.
Every year more GPs are promised by politicians who aim to protect the NHS, but there is no delivery of them. GP practices are closing down around the country and more patients are put at risk because of it.
Before any consensus we need funding so general practice does not disappear. Then there will be time to discuss how we improve services on a bigger scale, sharing approaches among the different models available in general practice, adapting to the different communities and demands.
Competing interests: I am a GP partner.
Oliver makes a fair point about the apparent ambivalence amongst GPs for how we see the future of primary care. Partly this is unsurprising, GPs are a heterogeneous specialty, larger in absolute numbers but dispersed in usually much smaller units than our secondary care colleagues. My sense from day to day clinical life, is that these debates are not ‘hot topics’ in the staff room.
The fully salaried model clearly has some attractions and I personally I would happily work directly for an NHS trust, rather than through a quasi-independent provider. But the prospect of transferring the entirety of primary care seems pretty far-fetched. Any government would be foolish (admittedly, foolishness is no stranger to health policy) to take on additional accountability that is now diluted across countless providers, at great cost and incurring an outcry from GP partners. Arguably, a salaried model is expanding piecemeal by default, through the collapse of individual practices and their absorption into trusts or larger organisations. It is worth remembering that some of the advocates for salaried vision are effectively partners in vast practices, who might well be happy to be at the helm but perhaps wouldn’t envisage being an employee themselves.
The proponents of ‘new models’, although highly vocal, seem to be drawn from a fairly sparse fringe of enthusiasts. Some of their optimism is probably amplified by the policy wonks whose job it is to believe that we will achieve more with less. We should be grateful to the innovators, these are the people who have the courage to run with new ideas and push us towards constant incremental improvement. But we should also be realistic about what the ‘new models’ might achieve. In a few cases cases, there is some encouraging evidence, for example in some of the projects involving care homes. By contrast, much of the impetus behind ‘working at scale’, seems based on assumption rather than evidence and is motivated by the assertion that traditional General Practice is ‘not fit for purpose’ and ‘unsustainable’. By unquestioningly abandoning traditional features of primary care, such as continuity of care and the gate keeper function, which have successfully contained cost and reduced iatrogenic harms we risk losing much more than we gain.
From my experience what most GPs want for primary care is straightforward; survival. They want the stabilisation of the health service. Few of us really believe this can be delivered by service tweaks substituting for adequate investment. Most of us seem happy to have the freedom to choose whether they work as salaried GPs or become partners. This sensible, if often discreet, corpus of front line doctors should continue to demand evidence and apply a rational dose of scepticism to every great new solution that comes along.
Competing interests: No competing interests
I'm one of those people who still likes their job. Probably through an accident of location and job roles. I work in a small rural practice, 5000 patients, but despite being a small practice we still punch above our weight. I sit on the board of the local Fed, which provides a fascinating insight into how GP's can work together in a variety of different ways.
Our "cornershop", partner led model still works. We have GPs, a pharmacist, an NP, nurses, HCA and a relatively stable albeit aging rural population. Our pressures are those of distance and social isolation, rather than sheer patient volume. We are investigating working with other rural local practices.
Life as a GP is a rich and varied career, but many of my colleagues are not so fortunate as I. Unsafe patient numbers, increasingly unrealistic patient expectations, deprivation and inequality contributing to a tide of humanity needing care.
We practice community based medicine, translate complex science and treatment plans into understandable English, advocate for our patients in a system that feels messy with increasingly Byzantine pathways of care.
General practice is expert medical generalism, and in a world of increasing specialisms and multimorbidity, generalism is all the more important for the foundations of care.
Where can general practice go from here? Keep what's good, change what isn't, and let the solutions be local to the population it serves. A supermarket of care may suit urban populations, but for widespread rural communities this may result in no care at all.
Competing interests: Fed NED.
Re: David Oliver: Towards a GP consensus on the future of UK general practice
Oliver asks for opinions about the future of UK primary care and hopes for consensus.I am a GP with 27 years experience as a partner and our son is a final year medical student so we have had many discussions about this. Taylor senior became a GP in days of hope, choosing a rural practice 25 miles away from a district general hospital, serving community beds and providing the comprehensive service still desired and needed by older patients even now. We of course saw every other type of patient as well but the ability to spend time on complex patients was rewarding for them and us and we were able to offer continuity. Since then our beds have closed, the population has aged and there has been no increase in manpower and resources to allow us to continue "going the extra mile:" for all.
Our standardised admission rates have steadily climbed from outstandingly low to just below average and the quality of our service is close to being compromised by a lack of time for the multiple tasks we now have to complete in a day. We also maintain an incredible resource which should be available to all medical personnel--the comprehensive computerised patient record which could easily improve efficiency throughout the NHS if only it was available to colleagues like Oliver.
Like many other older GPs Taylor senior has reduced to half time and collected his pension at age 57. Taylor junior has enjoyed primary care as much as any attachment but neither of us feel that embarking on a career as a GP under the present circumstances is attractive. There is much lip service to the value of good quality primary care, which I know most if not all GPs, like me, are providing in difficult circumstances but no convincing solutions to our current situation.
The future shape of primary care depends on where it is being provided, the population it serves and what society wishes GPs to do. City primary care may able to achieve economies of scale perhaps becoming part of larger organisations with a clearly specified role for the GPs within the organization. Out in "the sticks" there is an increasing need for GPs to be specialists in out of hospital care for complex people and for resources to match. If general practice is homogenized, instead of allowing it to address the differing needs of the people it serves then it will diminish to the lowest common denominator, able to deal with the relatively trivial and referring the more serious to hospital specialists, as was once the case.
Maybe the need for skilled generalists will be rediscovered sometime soon by our masters? Maybe soon enough for Taylor junior?
Competing interests: No competing interests