A new deal for general practice: doing things differently, not just more of the same

Jeremy Hunt’s speech last Friday sent out a strong signal that general practice will be one of the government’s top priorities during this parliament.

The Fund believes that the future of general practice rests on a combination of investment and reform. Investment is needed to reverse the decline in the share of the NHS budget going into general practice. Reform is needed to improve the working lives of GPs and the experience of patients.

The priorities for investment include recruiting more staff to work in general practice and modernising premises. The priorities for reform include using the skills of all members of the primary care team and embracing the opportunities offered by information technologies.

The importance of the practice and registered list as the organising principle of primary care should never be underestimated. At the same time, the potential benefits of working at scale in federations and networks are considerable. These benefits include offering access to patients outside normal working hours by taking shared responsibility for seven-day working and providing a wider range of services than most practices are able to deliver on their own.

The decision of practices in many parts of the country to work together shows that the case for federations and networks is increasingly understood and accepted by GPs. The emergence of super practices like Vitality in Birmingham, chosen by the Prime Minister as the location for his first speech on the NHS since the general election, is further evidence that the cottage industry model of general practice is on the wane.

To be sure, there are risks in these developments, including loss of continuity for patients, and reduced autonomy for GPs in a more organised model of family medicine. It is particularly important that the discretionary effort GPs have traditionally put into running practices they own is not lost, although growth in the number of salaried doctors has, for some time, created a divide between GP partners and providers.

The bigger prize on offer from new ways of organising general practice is for GPs to lead the development of integrated out-of-hospital services. Our analysis of emerging models of primary care in England underpinned the argument we advanced last year for family care networks to be developed. These networks would be led by GPs and encompass a range of community services, out-of-hours primary care, and some specialist services usually provided in hospitals, as has been proposed in the NHS five year forward view.

We proposed that a new contract should be available to GPs wishing to develop family care networks. The contract would offer funding for a much wider range of services than usually provided by practices and would be linked to the delivery of outcomes including access to care, patient experience, and clinical quality. Next year’s contract negotiations between the government and the British Medical Association (BMA) provide an opportunity to put this in place alongside existing contracts.

New models of integrated out-of-hospital services are best led by the federations, networks and super practices, but if GPs choose not to work in this way then the new contract should be available to other providers including NHS trusts working in partnership with GPs. The leadership expertise available in NHS trusts will enable GPs to manage budgets and services on a much bigger scale than they are used to and also to access the resources needed to invest in technology and premises. 

Family care networks could also help improve the working lives of GPs by offering a range of flexible working arrangements. This is critical if general practice is to be an attractive choice for newly qualified doctors and to offer job satisfaction for GPs later in their careers. The experience of Group Health in the United States, which redesigned how its primary care teams work to tackle burnout among family doctors, is a practical example of how this can be done.

The ingredients in Group Health included use of email and telephone consultations and of the full range of skills in the primary care team, including medical assistants and pharmacists. These changes were possible because of the expertise available to family doctors and their colleagues within the organised framework of care available in Group Health. Just as important, they entailed using resources differently, not just doing more of the same.

The ideas put forward here are most likely to gain traction if they are embraced by doctors themselves, extending the advocacy by the Royal College of General Practitioners of GP federations since 2008. The alternative is an unedifying stand-off between the government and the BMA in which the needs of patients take a back seat. Now more than ever the medical profession needs to demonstrate leadership and to embrace reforms which are good for doctors and for patients.

This blog is also featured on GP Online

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#544175 Pearl Baker
Carer/Independent Mental Health Advocate and Advisor
Independent Advocate and Advisor

I see the advantages of 'Group Health' and the disadvantages, firstly the advantages of an onsite Pharmacist Is useful, however the fact you many not see the same GP more than once is not good for LTC patients, particularly in Mental Health, and their Carers. I can see 'integration' being effected.

I can see problems ahead when correspondence, regarding concerns are sent, who to? no continuity of anything.

emails and telephone conversation do have their place, but care would need to be taken, and not seen as a replacement for 'face to face' consultations which tell the GP so much about the person.

My understanding was when you reached 76 you would be allocated a designated own GP, what has happened to this idea?

I envisage a 'factory' like 'set up' galloping through one door and out of the next.

There was no mention of 'improvements for patients' only for GPS

'Integration' has been thrown out of the 'window' it would have been better to give more emphasis on 'integration' and less on the reason it is being done, NOT for the Patient, but an idea to retain GPs

#544179 Stewart

The vast majority of GP's want to do as good a job as possible but this has become virtually impossible as the funding for Primary Care has fallen from 11% of NHS budget to 8%. At the same time GP workload has increased enormously and there has been a toxic GP bashing agenda by ill informed journalists and Government alike who are only too happy to blame GP's for all of the problems of an underfunded NHS which has less doctors and nurses that the OECD average and spends less on health care. And now we have Jeremy hunt actually saying that he wants already overstretched GP's (my working day is never less than 12 hrs) to work 7 days per week. It's hardly surprising that young doctors are shunning general practice and older GP's are rushing into retirement. It's sad that Mr Hunt continues to ignore the genuine crisis that is modern day general practice - I think the analogy is fiddling while Rome burns.

#544184 David Wheeler
Programme Director
Greenwich GP Training Scheme

Change in the way GPs work is inevitable but I see this as evolutionary rather than revolutionary, meeting local needs in local ways rather than following a top-down agenda. Federations may be a great idea but its difficult to engage local GPs when they feel so exhausted. We need support now in what we currently do then we can start to adopt new approaches alongside current working practices. And don't lose what is the key strength of GP: continuity of care for those who need it and ongoing conversations with our patients. Let's not fall into the trap of extending a hospital model of care (specialised and fragmented) into the community. Finally, for inspiration from elsewhere, I would look to Alaska (Nuka project) or Fife (Margaret Hannah - Humanising Healthcare) not the rest of the American healthcare system.

#544187 Malcolm Rigler
Stafford Medical Group

David Wheeler has firmly "hit the nail on the head". The book by Dr Margaret Hannah , Deputy Director of Public Health in Fife called "Humanising Healthcare" is truly inspirational and tells us about well established - over the past 20 years - Primary Health Care work in Alaska. The views presented in the book were wholeheartedly supported and approved of by he Chief Medical Officer for Scotland at a recent presentation of the work in Scotland. Dr Margaret Hannah should be invited as soon as is humanly possible to be a visiting Fellow at the Kings Fund and should be encouraged at this critical time for Primary Care to make widely known the work that has been going on almost unnoticed by the UK over the past two decades in a State just a short distance away from the UK. A second point to note is that in Occasional Paper No 64 from the RCGP John MacDonald , then Senior Lecturer in Education at Bristol University states that for the future
" within Primary Care there needs to be a huge and sustained educational programme if patients and carers are to be fully involved in their treatment and care". This was written long before the Wanless Report that makes the same point. For this to become a reality we need to have urgent and serious conversations with the House of Commons Committee responsible for "Culture , Media and Sport" because it is only through the development of the "Arts-Education-Health" projects and programmes ( now recognised as being very important for both Health and Well Being by a Cross Party House of Lords based special interest group ) that this aspiration of working with "fully engaged patients and carers" can become a reality in the UK.

#544198 Lawrence Donaldson
GM Integration and Innovation
Bayside Medicare Local (Melbourne Australia)

It is difficult to advocate for change without appearing disrespectful to those who have committed so much to caring for patients under the prevailing system of care. As one GP colleague put it "when you are up to your elbows in alligators the last thing you are thinking about is how to drain the swamp".

The challenge for change advocates is to find those GP visionaries willing to co-create a better way of delivering care that will inspire the next generation of doctors while honouring the contribution of the current generation.

#544206 Chris Ham
#544208 Julie Ann Racino
Cornell and Syracuse Maxwell Alumni
Community and Policy Studies

Chris Ham: General practice in the US needs to reattract family physicians who can serve families with difficult situations. I still rely myself on my gynecologist (Dr. Howard Weinstein) as the highest local physician during my lifetime! In part because he specializes in well baby and family care with an almost lifetime precancerous condition! I did propose to the Gate's Foundation Individual, family and community health as the One health concept versus the behavioral health care approach which grew in the US due to a special education versus mental health leadership.

#544213 Zoe Neill
Freelance GP

This new deal is nothing of the sort. Since it was announced, Mr Hunt has reneged on the numbers of GPs (unsurprising, since they're all leaving their jobs, the NHS and the UK) and on the money (£10million was to be 19 pence per patient per year to provide 40% more opening hours, but apparently this is money taken from elsewhere in the budget). Primary care is on its knees and will collapse if urgent action is not taken. Bundling GPs together in enormous groups will not impact on the number of empty chairs in those buildings. GPs everywhere are planning their exits. This is a nationwide urgent patient safety problem and no-one is listening to the GP whistleblowers, choosing instead to beat them with ever larger sticks, aided by an anti-GP media agenda coming from the DoH whose only plan is selling-off what's remaining of the NHS.

#545711 Harry Longman
Chief Executive
GP Access Ltd

While the volume of complaint from GPs, and indeed their patients, continues to rise, it's actually quite OK for GPs not to change. They feel threatened by loss of control and autonomy in larger groups, and rightly they value relationships and continuity of care in local GP partnerships. Neither larger structures nor extended hours have shown value for money, indeed the reverse. But change, I would argue, is needed. It needs to go with the grain of general practice, with the ethos of clinical quality, and with powerful evidence. For all these reasons, we believe the change should be in thinking, from the supply led model to one starting with demand. The structural form this takes is much less important, proven by the many forms which do work.

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