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Overview
General practice is in crisis. Previous work from The King’s Fund found general practitioners (GPs) dealing with a rising, more complex workload. Funding has not been growing at the same rate as demand, leading to a profession under enormous strain and facing a recruitment and retention crisis.
New clinical delivery models are needed to meet demand, altering the way in which general practice operates and interacts with individuals, families and local communities.
In this report, we look at innovative models of general practice from the UK and other countries and identify key design features we believe will be important in designing effective GP services in the future.
We set out five attributes that underpin general practice: person-centred, holistic care; access; co-ordination; continuity and community focus. Models that focus on access at the expense of other attributes may not provide the most effective and comprehensive care for patients.
Successful new models of general practice often focus on building relationship –between patients and professionals, between professionals within general practice and beyond, and between general practice and wider communities.
Making radical changes to the model of general practice is complex and takes time, leadership and resources. General practice often has less access to the financial or human resources needed to undertake change than other NHS organisations. External support for improvement will be critical.
Our research
We looked at national and international literature and spoke to primary care leaders in the UK and internationally. We drew up a long list of different delivery models of general practice from around the world and shortlisted those we felt could offer most insight for English general practice. Where models were too new to have been formally evaluated, we carried out telephone and face-to-face interviews to ask more questions about the model and identify any lessons learnt during the implementation phase. We used this information to develop a set of principles that might guide the development of new models of care for general practice as part of whole-system redesign.
What is general practice?
As general practice has evolved from single practitioners to multidisciplinary enterprises, an underpinning philosophy of general practice and family medicine has emerged. In this report, we have developed a five-part model that sets out this philosophy as a series of attributes, with a renewed focus on relationships and community. Some attributes may be more or less important for some patients and at particular times and the balance between them may change, but all are needed if general practice is to provide effective and comprehensive care.
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Person-centred, holistic care
This is the core tenet of general practice. This approach increases patient satisfaction and supports people to take control of their own health. Having enough time to listen and deal with the ‘whole person’ is clearly critical for both patients and clinicians.
Accessible care
Access includes factors such as proximity, timeliness, choice and range of services. There is a strong association between quality of GP clinical care (measured by performance against the Quality and Outcomes Framework) and the level of patients’ satisfaction with access measures in the GP Patient Survey. Much recent policy activity in English general practice has focused on increasing timeliness of access, particularly extending access beyond traditional working hours.
Continuity of care
Continuity of care includes:
relational continuity – between a patient and one or more health care professionals
management continuity – a consistent and coherent approach to managing a patient’s health problem
informational continuity – using knowledge of relevant past events and personal circumstances to deliver appropriate individualised care.
The advantages and benefits of relational continuity include increased patient and staff satisfaction; increased security, trust and respect; reduced costs; and reduced use of other health services. Current national policies, particularly those promoting general practice at scale and extending access in general practice, may well have the unintended consequence of decreasing relational continuity of care and in turn creating more pressures within the wider system.
Co-ordination of care
Patients report that they want to tell their story once; to know that the professionals involved in their care are talking to each other; to know who is co-ordinating their care; and to have an identified single point of contact. There is also an increasing need to co-ordinate care properly between clinical staff within practices, and between practices and the wider health system.
Community focus
The community in which we are born, live, work and socialise influences our health and wellbeing. General practice has traditionally been rooted in local communities and ‘community orientation’ is a core competency for GPs in training. General practice has an important role in building trust with local communities to support effective improvements in health across the wider community.
Design for the future
How might general practice of the future deliver a service that provides all the above dimensions of care? The innovative examples of general practice included in our report have used different approaches to tackle similar problems. Any new model of care for general practice will need to include all five core attributes of general practice. Models that focus on just one of these at the expense of the others risk providing a less effective and equitable service. In this report, we have identified common design features that we believe will be important.
Building and maintaining strong relationships
Many of the models we studied had a renewed focus on relationships.
Between patients and professionals – many models had focused first on building stronger, more proactive and continuous relationships, often using a team-based approach. This had facilitated better access by freeing up time for GPs to see patients who most need them. This approach improves relational continuity and builds trust between patients and professionals. Many models had also involved patients in producing better health and health services and future models of community-based care should be designed to empower people to take control of their own health and care. Some models focused on the needs of particular groups of patients, particularly high-needs, high-cost patients, to create teams that can meet needs in a more bespoke way and provide an enhanced service.
Between professionals – many models had created stronger relationships between professionals by moving away from the traditional one-to-one patient–practitioner interaction to a ‘micro-team’ approach, which involves a core team of professionals – for example, a GP, a nurse practitioner, a case manager, a medical or health care assistant and an administrator – working together to support a registered list of patients. These teams appear to provide a number of benefits, including better relational continuity of care for patients; improved access; and longer appointments. Having professionals located in the same place was also important, providing multiple opportunities for informal handoffs and discussion rather than going through more transactional referral processes.
Between professional and communities – many models had invested time and money in working with their local populations to determine the best model for that population and saw ongoing involvement with their communities as key. With a growing recognition of the role of place and community in people’s lives, new models of general practice will need to find creative ways of connecting people to the wider range of resources that communities can offer.
A shift from reactive to proactive care
Many models in the report had made a fundamental shift from reactive and transactional care to proactive and planned care. This shift involved using electronic records, with administrative staff contacting patients to carry out pre-appointment checks, for example, checking tests had been completed and, after the appointment providing follow-up care. Models that focus on more proactive approaches are more able to provide ongoing support for comprehensive care, and less likely to require repeated clinic attendances to complete preventive measures.
Developing skill-mix
Challenging the boundaries of traditional roles and supporting medical and non-medical staff to extend their scope of practice provides a real opportunity to manage the demands on general practice teams. New roles include clinical pharmacists, physician associates, health coaches, behavioural health practitioners and paramedic practitioners. These roles can improve access to care, enhance patient safety and streamline patient pathways, ensuring that holistic care is delivered more efficiently. Understanding how these roles work in the core general practice team or the wider team, and building relationships between professionals so that care is seamless for patients will be key to the development of general practice in the future. We found that systems that promote informal referral, advice and consultation were more effective than transactional form-based referral processes.
Using technology
There are many ways in which digital solutions aid effective general practice, but these innovations should underpin ways of working rather than replace them. Digital access should complement rather than replace teamworking, and is not appropriate for all patients. Effective information-sharing systems are fundamental to the success of networked models of care, with professionals able to access and share information easily, including out of hours and on home visits. The regular use of data for quality improvement and development was a feature of many of the models we studied.
General practice working within a wider health system
While not a focus of this report, the ability to access a wider network of care services is important if general practice is to deliver comprehensive, patient-centred care. For too long, general practices have worked in isolation and initiatives such as Primary Care Home are beginning to connect practices with the wider health and care system in an xciting way. There is increasing recognition that general practice must be a core component of efforts to integrate health and care services through the emerging integrated care partnerships and systems.
Common to many of the models was a move away from a transactional referral process to a more collaborative model of care. The ability to locate specialist advice and support alongside general practice was also important, as this enabled informal discussion and support. Patients may also be more likely to engage with wider services if they are located in a familiar setting. Focusing on particular populations through segmented models of care may make this more cost effective, for example, providing a focus for the care of groups who need a common set of specialist inputs, such as frail older people or homeless people.
The King’s Fund has previously argued that general practice should take the lead in developing care out of hospital by taking responsibility not only for its own services but also for other services in the community: a move away from the model of small, independently minded practices towards new forms of organisation that enable practices to work together and with other providers to put in place integrated services.
Supporting general practice to change
Making radical changes to the current model of general practice is complex and takes time, leadership and resources. We have previously emphasised the importance of the time needed to build local relationships and transform local services, and this is echoed in this report, as is an iterative approach that builds on the energy and engagement of the local community, allowing time for continual testing and refinement of plans.
While general practice in England has potentially more freedom to ‘get on and do’ than in the past, it often has less access than other NHS organisations to the financial or human resources needed to undertake the kinds of change we have highlighted in this report. For example, it has less access to the management skills required, such as organisational development intervention, improvement expertise and experience in using techniques such as Lean. Key to any successful intervention is understanding the motivations of the different stakeholders involved, and ongoing engagement with professionals, patients and communities.
This takes a significant investment in leadership time, which is challenging when general practice is under pressure. It may be that opportunities to work at a larger scale will mean that time can be freed up for clinicians and managers to implement change both within practices and in the wider community, without losing the local community focus that is core to general practice.
Conclusion
We realise there is a real tension in developing a model of general practice that:
provides person-centred, holistic care
is easily accessible
provides long-term relational continuity of care where this is important
co-ordinates care for those patients who need this
grounds everything in local knowledge and a commitment to the local area without a significant increase in capacity.
While more resources are still required, the challenge is for practices to have the organisation and structure to enable all these elements to be in place, while having the flexibility to find the unique ‘sweet spot’ across these dimensions for each individual patient.
Delivering patient-centred and holistic care requires general practice to be at the heart of the development of new models of care and integrated care systems across the NHS. These models and systems should start with individuals and families, and the communities in which they live, and general practice must maintain its position within these communities.
New models of general practice may be the key to unlocking the potential of new system-wide models of care; grounding them in local communities and providing holistic, continuing and co-ordinated care for patients, that is based on strong, trusting relationships with professionals who know them and their communities. There is clear evidence that this approach delivers benefits to the whole system, reducing pressure on specialist services, delivering better health outcomes for patients and improving the working lives of professionals in general practice.
Based on our research we have set out a series of recommendations for general practice, system leaders and commissioners, and national policy-makers. Underpinning all of these recommendations will be access to adequate resources to meet rising demand.