Reshaping general practice from within

I left our recent conference on the role of general practice feeling upbeat. Throughout the day we heard about a range of new ways in which GPs and primary health care teams are engaging with others to deliver more community-based care to frail older people and people living with long-term conditions so that hospital care is no longer the default option. So what are some of the primary care innovations happening both abroad and in the UK?

Craig Tanio and Gordon Chen from ChenMed in the United States spoke about their scaleable primary care-led delivery model, which offers pro-active and systematic care to patients with complex needs over the age of 55. The delivery model includes a one-stop shop for delivering multi-specialty services like onsite diagnostics (with physicians working alongside a range of specialists), a smaller patient-to-doctor ratio with 450 patients to every physician, and customised electronic health records for chronically ill patients. These innovations have lowered rates of hospital use, improved patients’ adherence to medication and led to higher rates of patient satisfaction

Critically, ChenMed have designed processes and structures to promote a culture of collaboration, transparency and accountability among the physicians they employ. For example, their primary care physicians meet three times a week to review hospitalised patients and other complex cases. Hospital specialists are invited to these meetings and the physicians talk through the clinical decisions taken together. Activating the professional culture in this way appears to have had a positive impact on staff motivation and on relationships between hospital and primary care physicians. 

One panellist at the conference – a GP – noted how the ChenMed model of care reminded him of the strong professional culture in UK general practice in the late 1960s and 1970s. Another panellist spoke of general practice in the UK today losing its way – I disagree; this may be the case in some parts of the country yet throughout the day we heard a number of examples of how GPs are instigating and leading the development of alternative care delivery models. 

At the conference we also heard some great examples of GPs using the monies from the Prime Minister’s Challenge Fund to re-shape local general practice. For example, in Folkestone GPs are enhancing community and out-of-hospital specialist services by setting up ‘branch surgeries,’ which will be open from 8 in the morning to 8 at night, seven days a week. These surgeries will be supported by staff from a range of local organisations. Although it’s very early days, it is hoped that this new operating model may also provide interesting and rewarding professional roles for GPs within a training environment. 

GPs in north Yorkshire told us how they have formed a new GP provider organisation (22 practices with a population of 142,000) to support the needs of their ageing population in a more sustainable way. In this rural and sparsely populated part of the country the local GPs are keen to start delivering care differently and more collaboratively. Initial plans include working with the local paramedic service and setting up integrated health and social care teams to systematically and pro-actively deliver care to all those aged 75 and over.

In Brighton and Hove, GPs are using the funds from the Challenge Fund to extend primary integrated care. This involves GPs working with nurse practitioners, pharmacists and the voluntary sector to deliver services and care to local people in different ways – for example, by establishing a team to respond to emergencies and people wishing for a ‘same day appointment’. A key element of the new model is for neighbouring practices to share resources and back office functions so that they can offer a wider and more efficient local service. We also heard how the super GP partnership in the Midlands – Vitality Partnership – plans to use digital technology to support patients more so that they can take control in managing their own long-term conditions. 

So as well as looking across to America for solutions on how to re-invent English general practice, perhaps we should also be looking more carefully at some of the new home-grown models of primary care that are emerging and exploring how we can support their development.

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#113975 Anas El Turabi
PhD Candidate in Health Policy
Harvard University

Interesting to see that one of ChenMed's principal 'innovations' is "a smaller patient-to-doctor ratio with 450 patients to every physician".

This is about a quarter of the typical GP list size in England. To what extent we can really think of this as 'innovation', rather than just greater resource investment?

Is improving primary care in the UK really just about increasing funding to better match demand?

#114577 David Sandbach
Retired Hospital CEO

If the reduction in spend at the hospital is 30% then there will be plenty of cash to hire more GP's working in the community. Also note the ratio is only good for those over 55.

The clear strategy is get your retaliation in first and stop seniors getting long term conditions or at least help seniors to manage their condition jointly with a GP to reduce the frequency of exacerbation's which need hospitalization.

#121832 Lesley Haig
Academic Head of Department
London South Bank University

If musculoskeletal extended scope physios were used in primary care to see patients with musculoskeletal complaints it could free up GPs to see those with greater needs and several co-morbidities. Would also provide a greater degree of expertise for advising and referring on those at risk of developing longer term msk conditions.

#161259 Richard Mejzner
New Devon CCG

The reason we struggle in primary care is we are poorly set up to deliver for our most complex patients often the very elderly 10 min consultations short visiting windows during the day do not address their needs for 5 % of our population consuming 45 % of the resource. The rest of our community needs a more accessible service for people working that primary care 's current model could deliver if it was not being swamped by the demands of the former.i feel we need to develop 2 systems within primary care one with very small list sizes and a MDT approach to care where the practice contracts with physio social care specialists etc around capitation budgets for our complex patients and a more typically recognisable model of primary care that exists to support the rest of the community.

#194611 Di

If I only had 450 patients, and they were all really complex, I wouldn't have time to care for them properly. Certainly not see them regularly.
I don't get this model. Arithmetically I mean.
To do a good job with a patient of this type I need 20 minutes for a "single " problem (eg COPD exacerbation) and I'd need 30 minutes for a review.
Say I work Full Time (like normal people not like the GPs I know). Say 30h face to face a week for 46 w a year to allow for holiday and training, and for meetings in the week. So that is 30x46 = 1380h per year. That's about 3h per patient per year. So 4 reviews and 3 single problem consults. These patients don't sound very sick to me.
Or, the model is vastly underestimating the time it takes to coordinate the care for these patients, which , after continuity of care from an excellent primary care physician, is the most important enhancement.

#462927 Trevor
Trainee Carer

I recently started training to work as a carer.
but I feel disillusioned now that I understand the pressures of being a carer
and that wages tend to be Low.
and the recent fare rise in using public transport Just makes the situation even more stressful.
when will the government accept that Their plans are not making things better for the working class?

#542931 Kadiyali M Srivatsa
Retired GP

NHS is a mess not because of lack of resources, funds or shortage of staff. Since 1996, universities gave more importance to the so called evidence base medicine, investigations and less importance to basic clinical examination skill. Unless we make sure primary care physicians with the best clinical skill and knowledge are the ones who can help sustain medical profession and not hightec hospitals or specalists

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