Transforming primary care

The new Department of Health document, Transforming primary care, mostly looks to improve services for those with the most complex needs. While the focus on this group is no doubt right, what does it tell us about transforming primary care for the rest of the population?

From the media coverage you could be forgiven for assuming the document was mostly about improving access to GPs at weekends and evenings – a measure most likely to appeal to the much larger working population. For this group, the document does confirm that the one-year £50 million Challenge Fund announced last September will establish pilots covering a population of 7.5 million people (out of a total population in England just short of 55 million). Some of this is indeed about extended opening hours but it also includes a range of other measures designed to improve access to GPs, including the use of new channels for consultations such as Skype and email. Interesting and valuable though these pilots are, given their limited coverage, experimental nature and one-year funding, they will be marginal to patients’ experience of primary care in 2014. The time for a fanfare should be when new policy based on the outcomes of these pilots is announced – though that, of course, will be some time away.

There is recognition that capacity is already an issue in primary and community services, with a range of measures designed to help recruit, retain and train the workforce alongside a slimmed down Quality and Outcomes Framework. There is also helpful recognition of the longer term workforce challenge implied by new models of care, with Health Education England leading the work to address this challenge. More left field is that by 2020 there is a commitment to `make available’ (a new phrase to me) 10,000 primary and community care professionals, though whether this means new staff or re-trained staff, and whether this nicely round number meets forecast demand is not said. Perhaps confirmation that it also looks affordable would be comforting in the present environment.

The document contains a lot on new technology and its use, whether to connect different parts of the health and care service or to make access more convenient for patients. Again, this is good stuff, although it’s hard to find anything here that wasn’t already in the public domain.

It’s good to see acknowledgement of innovation in commissioning and contracting and the commitment by Monitor and NHS England to provide more support and guidance. However, the document misses a trick in failing to explicitly recognise innovation in new models of primary care provision. Federations and networks of practices are likely to be necessary to deliver integrated care at scale (with potentially easier access) as we argued in our recent report on commissioning and funding in general practice.

Depending on your point of view, the document either merely repeats a lot of existing commitments or refreshingly does not embark on too many new ones. This should not be surprising – after all, the mandate to NHS England was set some time ago. Equally the GP contract is done and dusted, and the NHS should have already signed off its plans for 2014/15 and 2015/16 – getting close to its strategic plans for the full five-year period. Although there is little operationally new in the document, I can’t help thinking it should have come before the planning round rather than after as CCG plans apparently have to specify how the £250 million being made available to support GPs to commission new services is to be spent.

Lastly, on the basis of this document it’s clear that the future NHS must be flexible enough to deliver on commitments – whether these are expressed as outcomes, money (the £250 million) or workforce (the 10,000). It would also have been helpful to flag more clearly the task still to be done on getting better measures of outcomes in primary and community services as there is still a tendency to measure quality in these areas by their impact on acute hospitals, including emergency admissions, readmissions and length of stay, which has a rather old world feel to it – particularly as it is CCGs who are committed so spending the money – let’s hope it’s not a surprise to them.

This blog is also featured on the Health Service Journal website

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Comments

#41980 Harry Longman
Chief Executive
Patient Access Ltd

Richard I really would like to show you our work because we are not just talking about transforming primary care, we are doing it, practice by practice. We have comprehensive measures of the change (eg GP talking to patient within minutes, always offered same day appt) and we use these not only for evaluation but for improvement. Yes it's about access, but just as much about continuity. I won't say it's easy but it is possible, and within existing resources. Rather than go around the world for case studies, they are right under your nose and in terms of policy impact, what could be greater?

#42030 Con

I really wonder whether I am in the same system as those who write the blogs I read !
I am, and have been for 30 years, a 'jobbing' GP, who actually enjoys the job, but struggles to enjoy what the job has become. When I started out in General Practice in my current, but oh so very different practice, appointments were 3 minutes, and I inherited a 'regular' visiting list of 80 'chronic' patients each month. It soon became clear the chronic regularly visited patients tended to wait until the next visit to declare any problems, which resulted in significant late diagnosis with expected associated outcomes, and that appointments were often filled with patients wanting repeat medications, and an occasional BP check. So we changed the system and visited when necessary. This was not felt to be an improvement as far as those patients, though I'm sure it led to more patient empowerment, and hopefully better care, as after this visit requests were never questioned and patients felt confident that we were trying to improve an outdated system.
3 minute appointments soon became 5 minutes, and as we soon became a teaching practice, then 7.5 minutes, and soon after 10 minutes became the norm, with what felt to be better care, and a better relationship with patients.
Following that we became a 2 trainer practice with one partner becoming course organiser, and because of our cover of our local cottage hospital, to which we admitted and cared for our patients with both acute illnesses, and provide high quality, local and empathic care to our palliative patients, we all felt fulfilled and enjoyed our job. We did our own out of hours and also provided cover as 'Flying Doctors' to those in our area in more acute need.
We strived to provide continuity of care with personal lists,, which we all felt was fundamental to general practice, and saw the opportunity to visit patients acutely at home at night and weekends as a privilege and useful insight into family medicine. And I felt like I was working in a caring profession.
So why do I, and most other GPs I know, now feel so disappointed and unhappy with our profession. What has happened. Surely life should be easier and better with no nights or weekends on call, and more part time work still affording a good living. Yet I have not met a happy, relaxed GP for years, with most bemoaning a system that has so little to offer unless the correct boxes are ticked, with little regard to patient welfare.
I certainly no longer feel I am regarded as a caring professional by a Government that is obsessed by figures and cost. I sit on a CCG board whose message is constantly about cutting costs in ways which they try to pretend is about improving patient care, but all it does it pressurise a general practice service that is collapsing. A local practice is bankrupt and others that are unable to fill vacant posts become ever more stressed. How can this be a sign of a healthy NHS. It is a sign of a system that needs to change but is being allowed to collapse rather than being developed into a newer, better, stronger, system. And collapse it will as more GPs 'retire', unhappy with their lot.
And in the transition, it will be patients that will ultimately bear the heavy price.

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