Intended for healthcare professionals

Opinion

GP crisis requires more than just technology to fix it

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1670 (Published 08 July 2022) Cite this as: BMJ 2022;378:o1670
  1. Simon Hodes, GP partner1,
  2. Shan Hussain, GP2,
  3. Helen Salisbury, GP partner3,
  4. Ellen Welch, GP4,
  5. Phil Whitaker, GP partner5
  1. 1Watford
  2. 2Nottinghamshire
  3. 3Oxford
  4. 4Cumbria
  5. 5Radstock

The sweeping reforms described in a recent document by UK think tank Policy Exchange, At your service: A proposal to reform general practice and enable digital healthcare at scale, have triggered discussion and concern among GPs.1 The report envisages a radically redesigned NHS “front door,” with patients triaged by technology. In this vision, GP partners, currently responsible for designing and delivering services for their local community, have gone. In their place is a salaried workforce consulting, in under-doctored areas, by video link and potentially from abroad. As far as we can tell, none of the report’s three authors has experience of general practice and several of the 38 acknowledged contributors have interests in the digital technologies being promoted. While ideas from outside the profession can be valuable, meaningful engagement with more practising GPs would have contributed a far deeper understanding of what GPs actually do—both for our patients and the NHS as a whole.

When patients are unwell, a holistic bio-psychosocial diagnosis is needed. GPs are experts at this. From our diagnosis flows an appropriate management plan—often provided by ourselves; at other times by allied health, psychological, or social care professionals; and sometimes by secondary care. The current crisis in general practice arises because of insufficient capacity and surging demand. In many parts of the country there are no longer enough GPs to deliver our vital role in a timely manner. Access is worse in deprived areas, further exacerbating health inequalities.

Policy Exchange’s proposed solution is to create an “upstream” entry point, with all 111 and practice phone lines feeding into an “NHS Gateway.” Here, unwell and worried patients will encounter the “latest AI technology,” which will supposedly signpost many to alternative sources of help. The GP will be moved “downstream,” to deal solely with those patients deemed to require a medical generalist’s input.

This vision has been tried for over a decade in the guise of NHS Pathways, the algorithmic software used by NHS 111, which has arguably compounded the crises currently crippling ambulances, out-of-hours services, and emergency departments.

Algorithmic products are capable of generating—with varying degrees of accuracy—only bio-medical differentials. Hence they misconstrue presentations that clinicians would interpret in bio-psychosocial terms. AI differentials are without context. Patients can experience around 200 symptoms, but over 10 000 diseases.2 In almost any scenario there are potential serious causes. Not all symptomatology falls neatly into AI pathways, thus generating inappropriate emergency dispositions in at least 20% of cases.3 Even the world’s most sophisticated attempt at an AI diagnostic tool, IBM’s “Watson,” failed to replicate the role of humans in formulating definitive diagnoses4; and no AI can safely manage the risks inherent in uncertain differentials—something GPs are adept at doing.

The report acknowledges a landmark study involving 4.5 million patients in Norway that showed that progressively longer relationships with one lead GP for all ages and types of patient leads to 30% reductions in use of out-of-hours services and emergency hospital admissions, as well as a 25% reduction in mortality.5 This implies an urgent need to restore adequate capacity and continuity of care to general practice. The report offers no proposals on how to achieve this. Instead it conflates “longitudinal continuity” with “informational continuity” brought about by technology, and elsewhere consigns longitudinal continuity as being important only to certain subgroups of patients—contentions that research does not support.

A central suggestion of the report is that general practice should transition to a salaried model despite the 2019 government review, backed by the NHS Confederation, which concluded that the partnership model remains central to general practice.6 The partnership model is both cost effective and innovative for the NHS, in part due to the extent of the unseen work being undertaken by GP teams nationwide.7 During the rollout of covid-19 vaccination, for example, GP teams demonstrated flexibility and efficiency by delivering vaccines more swiftly and at a substantially lower cost than the mass vaccination centres.8

Implying that the partnership model is a barrier to technological innovation is not valid. Within a few short weeks in spring 2020, partnership-led general practice universally implemented remote-triage-first models of care in response to infection control imperatives during the covid-19 pandemic. GPs are able to rapidly and enthusiastically adopt new technologies when these will enhance effective, efficient, safe, and patient responsive care.

The report advocates working at scale. The speculative economic dividends it cites have not been evidenced. We have no problem with differing sizes of organisations in general practice. Two of us (SH and PW) are partners in practices at either end of the spectrum—32 000 and 5 000 patients, respectively. Both practices achieved outstanding patient satisfaction results in the 2021 annual GP patient survey against a markedly deteriorated national picture. The interdependent common factors are adequate medical staffing, timely access, and a commitment to providing continuity of care. This is what policy should be directed at restoring nationwide.

General practice currently finds itself in a predicament that is unacceptable for patients and staff. We have a dwindling, demoralised workforce that must not be destabilised further by major, untested, imposed reforms. Sajid Javid, the former secretary of state for health and social care, wrote the foreword to the report. By publicly associating himself with the report’s proposal to phase out the partnership model within a decade he has introduced a powerful deterrent to GPs to enter partnership,9 which will only compound existing problems with recruitment and retention.

The GP crisis long predates the pandemic. The existing GP contract allows unlimited work to be transferred to primary care without sufficient resources to support it. GP teams are now attempting to provide countless unresourced roles while supporting 6.4 million patients on hospital waiting lists and managing 1.8 million cases of long covid.10

In this respect we agree with the report: the existing GP contract requires radical overhaul. However, the quality of care provided by the proposals is likely to reduce patient satisfaction, increase costs and fragmentation, diminish relational continuity, and potentially spell the end of the “family doctor.” This is not the remedy our health service so desperately needs.

We are encouraged by the ongoing Commons Health and Social Care Select Committee inquiry into the future of general practice, particularly its focus on continuity of care. We also welcome the recent Fuller Stocktake, including its emphasis on recruitment and retention of GPs and the need to stabilise and support practices of “all different shapes and sizes.” Fuller underlines the imperative for national policy to enable locally designed solutions to current challenges in primary care.11

We call on the government to build on these initiatives in consultation with experts: patients, health professionals, and policy leaders such as the Health Foundation, The Nuffield Trust, and The King’s Fund. A renewed general practice will inevitably require improved funding, but the prize will be a first class service that meets the needs of all patients, as well as providing satisfying and sustainable careers for its workforce.

Footnotes

  • Competing interests: SH works as a private GP at The Cleveland Clinic London, a GP trainer, appraiser, and an LMC rep. SH has previously served on the GP committee for the Doctors’ Association UK and was recently elected on to the BMA Council. HS is a GP trainer, writes a weekly column in The BMJ, and has recently been elected to the BMA Council. EW is an editorial lead with the Doctors’ Association UK. PW was a partner in a GP practice in Oxford, and has also worked as a salaried GP. He is a GP trainer and medical editor of The New Statesman.

  • Provenance and peer review: not commissioned, not peer reviewed.

References