The debate about whether general practice should be organised through an independent contractor model (GP partnerships) or whether it should be provided by staff salaried within an NHS organisation is as old as the NHS itself.
Partnerships are still by far the most common model for general practice, although fewer doctors are expressing a wish early in their careers to be partners. Current partners rightly point out that their responsibilities and workload could not easily be replaced by salaried or locum doctors, especially when the numbers of GPs working full-time in practice continues to decrease. There is also no obvious home for general practice – where there would be the skills and expertise to manage general practice – within current NHS organisations. Meanwhile, private companies and GP-owned federations are increasing their market share, particularly through acquiring the contracts of practices in difficulty.
Given these challenges perhaps the conversation should be approached in a different way?
Let’s begin with what general practice is all about. Last year in England there were more than 340 million appointments in general practice. At the heart of this is the consultation, the unique interaction between the patient and the professional. Focusing on this and exploring the role of general practice for people and their communities should be the starting point for conversations around how general practice should be organised. This bottom-up approach would build on the core of what people, communities, and GPs themselves need.
'Focusing on this and exploring the role of general practice for people and their communities should be the starting point for conversations around how general practice should be organised.'
A professional can be defined as someone who applies knowledge with people (patients in general practice) for the creation of customised solutions. This concept contains two critical elements first, the centrality of the person (patient) and their problem and, second, the GP having three important and interlinked characteristics.
The first characteristic is the knowledge that they have. This knowledge has many facets: technical knowledge acquired from a broad training, ‘know how’ gained from putting that knowledge into practice, acquired knowledge of the patient and of the community in which the patient lives. Some of this can be written down in patient records (codified), and some of which remains unrecorded and even unrecordable (tacit). Both types of knowledge increase over time and are key parts of shaping professional experience. This is the GP as an ‘expert generalist’.
The second characteristic is that of a ‘managerial navigator’. Having knowledge is not enough on its own; knowing how to conduct a consultation well, using management techniques, planning care and navigating the health system requires a particular skillset. This characteristic includes the ability to co-ordinate care for the patient and balance the input of multiple specialists and needs both transactional and relational skills.
The third characteristic is that of ‘care innovator’. Each person has a unique set of problems and requires personalised care. This may well require solutions that are novel to either the GP, the patient or both. These innovations need to be shared for the benefit of other patients and professionals.
What does this tell us about how general practice should be organised?
'Organisations that can harness the wisdom, as well as the managerial and innovative expertise of professionals, will attract both doctors and patients alike.'
If a consultation involves these three characteristics within a GP’s role and is centred on the patient, then how general practice is organised also needs to encourage this patient focus and actively seek to ensure these three elements can be performed well. With the growth of multidisciplinary team approaches and new roles, GPs will need to build on their skills as expert generalist, managerial navigator and care innovator as both members and leaders of teams. Increasing capacity, capability and training is needed to facilitate this, recognising that for some career paths, certain elements may need more emphasis. For example, a GP aspiring to devote more time to management will need to hone their managerial navigator skills, whereas a GP looking after nursing homes will require further knowledge as an expert generalist. Organisations will need to ensure the correct balance of clinicians and non-clinicians, bringing together the appropriate expertise. However, clinical leadership is key, so any new organisational model will have to have that expertise clearly supported, promoted, and enshrined within it. These three characteristics and the principles that they encompass should be embedded into governance, organisational structures and business models. Organisations that can harness the wisdom, as well as the managerial and innovative expertise of professionals, will attract both doctors and patients alike.
The partnership model is one way to do this, as long as partnerships have access to wider infrastructure to support GPs to realise the potential of these core characteristics. There might also be other models that can do this too, provided they can ensure the appropriate clinical leadership and expertise needed to provide general practice teams with support to deliver these crucial elements. It’s these core characteristics of expert generalist, managerial navigator and care innovator that should be starting place for thinking about the best way of organising services. Let’s keep the focus on these characteristics and the central function of general practice, building confidence with both the public and professionals, rather than going straight to a business model.