General practice needs new models: here are some ideasBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2460 (Published 06 June 2018) Cite this as: BMJ 2018;361:k2460
All rapid responses
The ideas presented here by King's Fund are not new at all. The pretext for claiming that the current model of healthcare delivery is broken is jarringly familiar. Joining the specious claims that: "The whole NHS model is broken", which preceded the 2012 H&SC Act, lately we have NHSI telling us the "outpatient model is obsolete". NHSE's Medical Director for Innovation told us in 2016 that the entire hospital model of care is broken.
It is notable that the proposed five core attributes of General Practice for new models actually describe the existing model of General Practice. Internationally recognised as exemplary and fundamental to the NHS's high ratings in studies, what is this evidence that we need change? To cite the current pressures or "the ageing population" as the basis for change is completely fallacious.
In fact, the background to this latest clarion call is a GP service which since 2010 has lost >£3bn pa in funding, and 1,500 practices to closures, mergers and acquisitions. GP FTE numbers are falling, more closures are planned (5YFV plans to cut nearly 6,000 more Practices). Half our District Nurses have gone.
So much for "Community Focus", which is defined in the article more in terms of access to other community services - like simply having an OT or advice worker on site, or outsourcing to a "wellbeing practitioner", is somehow innovation.
Pump-primed funding enables these initiatives to exist, not new modelling.
We already have co-opted Paramedics, practice Pharmacist, Community Matron, social prescribing, advice worker, psychologist, specialist Dermatologist and MSK services on-site - but we are as vulnerable as the next Practice is to closure, and struggling equally in the current environment to provide care to our patients.
We have a secondary care clinical advice service (via two different IT platforms), e-investigations, e-Consulting, e-prescribing, and intrusive and inefficient cost-monitoring prescribing software. The fact that each of these platforms has a different private provider means that proper integration cannot and clearly will not happen. None of this is breakthrough medicine; it's natural progress, but the lack of a truly integrated single joined-up national IT system shows a distinct lack of attention to purpose from NHSE.
Moreover, their promotion of 'disruptive innovators' such as GP at Hand shows how NHSE couldn't care less if General Practices fail due to competitors hiving off chunks of well patients at the expense of ill ones. Much of the hype - for transformation, remodelling of outpatients and general practice, self-care, care closer to home, and choice – seems to point towards an overpromotion of the Tech industry’s agenda, rather than usefully adopting what works for the NHS.
We are also subject to a host of performance-related pay contracts requiring care plans for thousands of patients, a key component underpinning so-called pro-active care. Notwithstanding the large burden of administration and bureaucracy associated with these LES/DESs, moving finite and overstretched resources over to preventative care further reduces the time, staffing and resources to cope with responding to existing demand. It is simply wrong to pretend that we can reduce emergencies by these measures by anything like the 20%+ projected by the Transformationalists. Any significant savings in secondary care would take decades to materialise, if at all, so any reductions in existing primary or secondary workforce or resourcing must be strongly resisted.
The greatest proposed new model of them all - ACOs, or whatever name comes next - will end GMS General Practice forever. This is required for the ACO to function; because the populations must be congruent, GPs will be required to formally cede their patient lists to ACOs. The three or five intermediate ‘alignment’ options offered as a workaround are ultimately not viable, and GPs will be passively forced into resigning their lists. Arguably, the actual end of General Practice.
Looking at the examples of new models presented, there is little new, and the realities are disappointingly familiar. While vaunting General Practice as the jewel in the crown of the best healthcare model in the world, we are simultaneously bombarded by cognitively dissonant messages telling us that General Practice is not fit for purpose.
The current GP model, appropriately funded, is ideally trained, placed and predisposed to expand to manage the challenges of increasing co-morbidity coterminous with social care needs. But that is not what Govt/NHSE/I plans intend.
Competing interests: No competing interests
I read the report on GP innovation with interest, especially the segment discussing Healthy Prestatyn Iach. I recognise the many challenges faced by the launching team of managing a very large practice of nearly 19000 patients with a lack of doctors. From the description they are now making progress, however I read the figures of clinicians per team with frustration. Dr Stockport states they have 2 FTE GPs with nurse practitioners, OTs, pharmacists and a coordinator for around 5000 patients. Working in a practice in north wales who could not recruit a GP partly due to the pressure on recruitment caused by healthboard run practices paying over the odds I await unfolding events in north wales with interest.
Competing interests: No competing interests