Lack of capacity means the specifications are set up to fail
These risks exist because of the multiple challenges to which primary care networks are meant to be the answer: firstly, to stabilise general practice given the current workforce and morale crisis; secondly, to bridge a gap in the evolving reformed structure of the NHS by acting as the principal link between general practice and the rest of the health and care system; and, lastly, to deliver key elements of the long term plan through a set of new service specifications.
In December, NHS England and NHS Improvement released five of these new service specifications for consultation, setting out requirements for enhanced services for care homes, structured medication reviews, services to support early cancer diagnosis, and plans for personalised care and anticipatory care. General practitioners responded with widespread and sometimes passionate condemnation.
Social media is full of GPs threatening to pull out of PCNs and the associated contract, a striking turnaround given the fanfare around its launch this time last year. The BMA’s General Practitioners Committee has now formally rejected the contract package and draft service specifications and called for a special conference of local medical committees to discuss PCNs. How has this happened, and what is the way forward?
The aims of the specifications look reasonable and seem to have been written by people who understand the subject and the evidence, at least as a basis for consultation. Where they slip up is the required call on general practice resources during the current deep capacity crisis. There is, of course, a commitment to increase capacity through more GPs and other staff, including pharmacists and physiotherapists. This promise of more staff in the future (when the specifications will really bite) is theoretically sound but risky. It assumes that new staff will be found and that the organisational challenge of developing new teams is quickly solved. Pent-up demand for access may also consume most or all of planned increases in capacity. For many GPs the specifications were also very detailed and prescriptive and left little room for local priorities.
An analysis may exist somewhere showing that this new supply will be enough to improve access to primary care, deliver the service specifications, and make the working life of GPs acceptable again. But if so, it’s not in the public domain. Tired, overworked GPs see only that the service specifications will increase their workload still further. The first steps should be to prove that additional resources will reach general practice; that the extra staff can be quickly integrated into the local team; and that demand can be met for core services without requiring staff to consistently overwork.
Need for prioritisation
The new service specifications suggest that NHS England and NHS Improvement are trying to pursue the three key objectives simultaneously. This might be from a desire to show that the extra resources going into general practice are linked to extra services. However, the first call on these extra resources should be to stop, and then reverse, the pressures on core general practice. Committing to new services before this stabilisation has been achieved clearly lacks credibility. Access to core services is the government’s key priority, as signalled by the Conservative Party’s commitment to 50 million extra GP appointments; a furious row with GPs about something entirely different may not be welcome in Downing Street.
What can be done to get the PCN project back on track? Everyone must take a deep breath, accept that these were only consultative documents, and recognise that the PCN model remains sound, as do the three objectives for PCNs.
Moving forward, the rate limiting factor for maintaining existing services and introducing new ones is capacity within general practice. If there are plans to increase capacity (particularly when the new capacity requires a different way of working), it is best to get this in place first before committing to new services. This is true regardless of how well designed and evidence based the new services (or specifications) may be. They will be no more than wish lists until there are enough staff to deliver them, improve access for patients, and make the working life of general practitioners manageable once again.
Interesting...however once again the potential of public health nurses to lead on for instance nursing home care and prescription reviews is completely ignored when will we be recognised as graduates technical and caring experts just the same as other professions in the NHS and potential independent leaders in care and practice development why is everything outside of hospitals always about GP’s?
Well said Richard. Yes, 'the fault, dear Boris, lies not in ourselves (GPs) but in Andrew Lansley's Act 2012, which dumped the statutoriy responsibility for £80 bnpa (one HS2 pa) on 30,000 GPs without their consent, and denied that statutory right to the 1,000 democratically elected councillors on Health and Wellbeing Boards, betraying the Act's pledge to fill the democratic deficit in health as badly as Theresa May's betrayal of Brexit.
The good news is that those councillors can now assume that right, and work with the GPs leading the PCNs to deliver social prescribing by creating a new presscribing system whereby the Community and Voluntary Sector can apply for a licence to treat and teach patients with social interventions and talking therapies, and be paid as pharmacists are paid for drugs, transferring money from the drugs budget. This will fill thedeep capacity crisiss overnight.
I concur, GPs are complaining every day about their workload yet voluntarily take on work that does not need to be done by a GP. When I was a district nurse in the early 1980s we visited every patient on our books over the age of 65 and did social and medical checks. Because we worked out of GP practices the GPs (mostly) had faith in our knowledge and abilities and trusted us to flag something up if we were worried.
Now we have social prescribing, with social prescribers employed yet I read an article in the BMJ that the outgoing chair of the RCGPs was taking over social prescribing and going to teach GPs about it. Why? Don't they have enough to do?
I would much prefer GPs to be taught to look at the person sitting beside them instead of a computer screen. Note GPs I am more than a list of figures from blood tests. LOOK at me occasionally, do what you trained to do and leave the extraneous work to others better able to take that one ostensibly leaving doctors to do what they trained to do which I thought was doctoring.