This week I needed to visit my GP. On calling I got straight through, was offered the choice of an appointment that day or the next, and received a follow-up text confirming the appointment details. At the surgery, which is light and airy, I checked in electronically and was seen on time. My experience of my GP practice is one of continual improvement. Its opening hours have increased, appointments are easier to book, and staff manage peaks in demand through use of phone consultations. The range of services offered in the practice has grown and chronic disease management has improved. The practice employs a specialist nurse, a health care assistant and phlebotomist. Use of e-prescribing enables repeat prescriptions to be ordered via the pharmacy. I could go on...
Sadly, this experience is not true of all general practice. My daughter, fresh back from university, described a very different experience, including great difficulty getting an appointment, crowded waiting rooms and harassed doctors. And I was recently shown a picture of a GP practice with a sign on its door advertising minimal opening hours and encouraging patients to call 111. It is this variation in general practice that is its Achilles heel, as highlighted by our independent inquiry into the quality of general practice in England (2011), and, more, recently by our report on general practice in London. So the question in my head when looking at the RCGP’s new vision for general practice, The 2022 GP, was: will this new vision help to address such variation?
It is positive that The 2022 GP recognises the need to have much stronger services in general practice for the growing numbers of patients with complex and long-term conditions. In its vision of the future, the RCGP sets out objectives for training and development, service improvement and, the often neglected, research in primary care. Central to its vision is the proposal that GP practices come together as federated or networked organisations – working together to share back-office functions and educational and clinical services. Federations potentially offer the win/win solution of maintaining local access while creating the organisational scale and capacity needed to reduce the current variation in practice.
But there are other models – for example, one in which GP practices create scale by coming together in one building, an idea we explored in Under One Roof: Will polyclinics deliver integrated care?.We argued that it was important to retain local access to primary care services, particularly for more deprived populations and that a hub and spoke solution, similar to a federated model, was preferable. In 2010 I was part of a team, which included the Nuffield Trust and Hempsons health and social care solicitors, commissioned by the RCGP to develop a toolkit to support the development of GP federations. The toolkit provides many examples of how the federated model can drive improvements in quality and efficiency. As born out by wider research, primary care led organisations are good at planning and developing services within primary care and community settings. They are also effective in enabling shared clinical governance, peer review and audit. However, the federated model is not without its challenges. Like any organisation, a federation requires strong strategic leadership, and these skills are generally in scarce supply and require time and energy to foster. A sense of ownership is also critical for clinicians. Where this is compromised, the evidence shows that groups typically founder or fold.
Since we wrote the toolkit, clinical commissioning groups have been established. These too require strong strategic leadership from GPs and practice engagement. But can federations develop alongside CCGs? Are there enough hours in the day for GPs to engage in CCG commissioning and federated providing models? And will this exacerbate concerns about conflicts of interest as federations seek to deliver more out of hospital services?
Many of these problems would be resolved if CCGs operated more like accountable care organisations in the United States, holding a budget for a population and being held to account for the outcomes delivered. This budget would include primary care, however, given that the current statutory framework prohibits this, what could drive more federated models of primary care? The scale of the financial pressures faced by general practice is likely to be a major driver, as the sharing of back-office functions can deliver significant savings. NHS England could help by preferentially allocating improvement monies to federated groups of practices rather than individual practices. If the GP contract is be revisited, it too could offer incentives for practices to work on a more collaborative basis. The issue of leadership capacity is harder to resolve. Leadership development needs to be a core part of continuing professional development for GPs and other primary care clinicians but the benefits will not be felt immediately.
Highly organised primary care, delivered to consistent levels of quality, is a pre-requisite for the service transformation needed in our health care system. It would be tragic if, by developing GPs as commissioners, we undermined their growth and development as providers.