As England’s population both expands and ages, so the demands on primary care will grow. Within the current commissioning and funding system innovative models of primary care provision are already being used. This report describes examples of these through four case studies in different areas of England. It also highlights how the existing system is imperfectly understood, particularly regarding contracts.
Building on ideas articulated in previous work, the report argues for a new approach that brings together funding for general practice with funding for many other services. It would entail new forms of commissioning, with GPs innovating in how care is delivered. Over time, the report foresees ‘family care networks’ emerging that provide forms of care well beyond what is currently available in general practices.
Key findings
Demographic changes, increasing multi-morbidity, clusters of risk factors and the rising needs of frail older people are piling pressure on primary care.
General practice is well placed to respond to these pressures, due to its registered list of patients. This permits practices both to tailor treatment and act preventively.
When developing integrated community services, there must be engagement with social services to help people stay independent and out of hospital. Making high standard out-of-hospital services available 24/7 is essential to halting the rising use of hospitals.
Currently practices cannot fully meet their ambitions to develop innovative care due to challenges posed by structural instability, shifting accountabilities, provider engagement and payment models.
The case studies demonstrate considerable innovation within the current system, but also great complexity and instability. Organisational change and loss of organisational memory compound this. Technicalities of contracting are imperfectly understood, inhibiting the flexibility that already exists.
Policy implications
A rapid, radical shift is needed from the current model of general practice to the use of federations and networks of practices able to work on the scale required for effective integration of services.
Without changes to commissioning and funding arrangements, the argument for new models of care will remain theoretical. At the heart of this approach is the use of a population-based capitated contract under which providers would be expected to deliver defined outcomes for the populations they serve.
Practices will need new skills in various areas: risk stratification of the population, quality improvement, collaborative working with other providers, greater capability in managing financial and clinical risks.
There are a number of problems with this plan to change GP contracts - the first being that NHS England has already torn up all previous agreements: would anyone planning a long-term investment be happy to go ahead in the certain knowledge that the next Secretary of State for Health - or 3 to 5 yearly top-down reorganisation of the NHS will leave you responsible for any debts and agreements, while any hope of fulfilling them is pulled out from underneath?
The second problem is that from the individual GPs point of view, this might seem to be the worst of all possible worlds: too far from power (and we all know that power is concentrated in very few hands..) in the organisation, no room for individual development, need (unless the premises questions are solved) to accept financial loss if investments have already been made - and not even the protection of EWTD!
In science fiction, robots became dangerous when they started asking "what is there in it for me?"
Has anyone considered this for GPs, current and future?
‘family care networks’: just sounds like lower-grade medical care on the cheap. So poor people get poor quality care, whilst the wealthy can avoid what we currently have.
It's all about money and the lack of it. All happening without any mandate.
Cant find any detail in this or other papers about how we get more out of general practice with same budget.
There is talk of incentivising doctors to produce better outcomes but no detail about what these outcomes might be. If it is reducing morbidity/mortality for a whole population then there are so many factors outwith the control of GPs that you would be mad to accept such a contract.
Ultimately though the elephant in the room is completely ignored, that is the growing lack of GPs. No solution to this is offered and therefore no solution to the problems of general practice. It has got to be made attractive and making GPs responsible for the ills of the whole country where we have the number of healthy years of life not increasing at the same rate as life expectancy is not going to help.
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The second problem is that from the individual GPs point of view, this might seem to be the worst of all possible worlds: too far from power (and we all know that power is concentrated in very few hands..) in the organisation, no room for individual development, need (unless the premises questions are solved) to accept financial loss if investments have already been made - and not even the protection of EWTD!
In science fiction, robots became dangerous when they started asking "what is there in it for me?"
Has anyone considered this for GPs, current and future?
It's all about money and the lack of it. All happening without any mandate.
There is talk of incentivising doctors to produce better outcomes but no detail about what these outcomes might be. If it is reducing morbidity/mortality for a whole population then there are so many factors outwith the control of GPs that you would be mad to accept such a contract.
Ultimately though the elephant in the room is completely ignored, that is the growing lack of GPs. No solution to this is offered and therefore no solution to the problems of general practice. It has got to be made attractive and making GPs responsible for the ills of the whole country where we have the number of healthy years of life not increasing at the same rate as life expectancy is not going to help.
GPs will not receive more money, but their lives are supposed to be made better?
There will be no room for innovation, or the ability of individual GP Practices to make their own changes, leading to better patient care?
Next we will hear of Psychology tests for GPs to ensure they all think the same, like they do in some industries.
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