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Same day GP hubs: How will they affect access and continuity of care?

BMJ 2024; 384 doi: (Published 04 March 2024) Cite this as: BMJ 2024;384:q549
  1. Emma Wilkinson
  1. Sheffield

Plans for a new patient triage system across primary care in northwest London have caused “immense concern” among those directly affected and GPs in other parts of the country, reports Emma Wilkinson

What are same day GP hubs?

North West London Integrated Care Board (ICB) has said it plans to introduce same day GP access hubs so that all patients in its region contacting their GP for an appointment will be triaged to get them to the “right place.”1 Under the proposals, primary care networks, on their own or working with others, will provide a hub at one of the practices in the networks or other premises staffed by other primary care staff and overseen by at least one GP. The hubs will increase same day access to GPs and other primary care professionals for those patients who need it, the ICB said. Practices in the area will have to sign up to the scheme, which has been trialled in 10 PCNs, to receive any local enhanced service funding, it has been reported. After initially saying it would be introduced in April, the ICB has now said it will do a phased rollout of the scheme.

Are there any results from the pilot?

There are no results as yet, which has caused major concern among GPs’ leaders. In a letter to North West London ICB, Londonwide Local Medical Committees, the organisation that represents London’s GPs, emphasised that any wider rollout “should be based on evaluation and experience of pilot sites.”2 The letter, coauthored by Chaand Nagpaul, chair of Harrow Local Medical Committee, and who practises in one of the pilot areas, said local GPs were “still finding our feet” with the new approach. “There’s been no opportunity for feedback of our experience nor evaluation of our work. It would therefore be inappropriate to draw upon pilots that are themselves not yet delivering the model, nor been evaluated, as a basis for widescale rollout,” the letter said. North West London ICB told The BMJ, “We do not have anything further to publish at the moment.”

How have they come about?

The concept of urgent care teams in primary care was set out in the Fuller “stocktake” review of primary care commissioned by NHS England in 2022.3 In her review, Claire Fuller, a GP and chief executive of Surrey Heartlands Integrated Care System, found worsening patient satisfaction, teams stretched beyond capacity, and a Monday scramble for appointments. She concluded that primary care was quickly becoming unsustainable and recommended that single urgent care teams run by primary care across larger populations (or neighbourhoods) would free up capacity for continuity of care for patients who needed it the most. The recommendation was accepted in full by NHS England. It will be up to integrated care boards and primary care networks to decide how to put the model in place.

Who has raised objections?

Leaders of London’s GPs said the proposed model had raised “immense concern” among primary care professionals and have asked for more detail about safety, quality, logistics and to tackle the perception that the hubs were being forced on primary care.4

Paul Evans, a GP in Gateshead, is among those who strongly believe that the hubs will “destroy continuity of care” and could also lead to overprescribing and overinvestigation. “It will simultaneously miss important pathology, due to being staffed by people who don’t know the patients and who, in many cases, will not be doctors,” he told The BMJ.

Azeem Majeed, a GP in south London and professor of primary care and public health at Imperial College London, said there were arguments for and against GP access hubs. They may reduce pressures on practices and emergency departments and may be popular with certain groups of patients such as young adults with less complex health needs, he said. But the hubs could also fragment the delivery of healthcare. “This may lead to care being more episodic with greater scope for misdiagnosis and poorer management of patients with complex health needs and multiple long term medical problems,” said Majeed. “There may also be less emphasis on areas such as prevention, as the hubs are likely to focus on acute care needs.”

Commissioners and NHS managers will need to show that investment in hubs is a better use of NHS funding than investing in general practices, Majeed noted. His own view was that it would be better to invest in core general practice to provide the resources for holistic care.

Are other areas considering hubs?

Yes, ICBs around the country are working out how to implement the idea, including in Cornwall and Oxfordshire, but they are using different approaches. Selvaseelan Selvarajah, a GP in Tower Hamlets in east London, said that his ICB was in the early stages of developing a same day access hub model but that it was designed by practices rather than being imposed. “It will be a primary care led and delivered service. Triage will be run by practices, and they will control which patients can be booked into the hubs,” he said.

Primary care networks in Tower Hamlets have been working together for many years and already have a similar approach with extended hours, he explained. Tower Hamlets is a small, densely populated area, which makes collaboration easier.

The hope is to stop patients bouncing around the system, including going to A&E and existing urgent care services when they can’t get an appointment, but the hubs should also provide extra capacity for practices. “What it shouldn’t be is a one size fits all for everyone. The solution has to come from general practice,” Selvarajah added.

Foundry Primary Care Network in East Sussex was cited by the Fuller review for its work on urgent access to care. GP and clinical director Phil Wallek said their goal was to preserve continuity for those who needed it most by making the best use of their teams.

Across three practices, they “rag rated” their population into green (generally well or with non-complex health problems), amber (ongoing or long term conditions), or red (patients with frailty, complex comorbidity, dementia, or serious mental illness or who are at the end of life). Patients can move in or out of categories, which can be based on social not just healthcare needs, he explained.

It is the “green” patients who can be directed to the same day access hub, which is staffed by paramedics and nurses as well as GPs. This has helped to build relationships and makes staff more “resilient,” if, for example, one staff member is absent, he said.

“We have found GP retention is higher because they value the mix of work, and we’re also mindful of how many appointments a day they do. From a system perspective we have saved 12 500 bed days over three years,” Wallek told The BMJ.

What’s the longer term outlook?

A key problem with the hub model is ensuring that money is reinvested in primary care so GPs can keep working to improve access, said Wallek. And there needs to be a standardised approach. “We are a single organisation with single values; if you step outside that and set up separate hubs not really associated with practices, with different people staffing it, that is just creating urgent care centres again,” he said. “There is an opportunity to do something intelligent here. It should be about trying to improve the model of primary care, not creating a new entity.”

Joanne Reeve, a GP and professor of primary care research at Hull York Medical School, said that more of the same as now will not work and general practice needed to adapt but that the problem you were trying to fix needs careful consideration. “With 34 million general practice consultations per month—more than half the population accessing formal healthcare every month—we have a problem. We’re so busy pulling people out of the river, we don’t take time to go upstream and find out why they are falling in or being pushed in,” she said.

She pointed to research from 2013 that showed the importance of continuous, comprehensive, accessible, and coordinated care in efficient and equitable healthcare systems.5

“Any new service—knee jerk reactive or proactive—needs to be assessed against these four criteria before they roll anything out,” said Reeve.