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.
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.
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.
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.
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.
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.
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.
I know from 'bitter' experience that those adults suffering from 'severe and enduring mental illness' are all but forgotten, and who really Cares? I have long campaigned for all those Agencies 'responsible' for delivering 'patient centred' 'patient choice' and finally an 'Holistic' approach actually attend 'training' courses for them to understand these meanings.
My latest personal experience was those Carers actually providing Health & Social Care, have been identified by the LGO (myself) as not 'a suitable representative and so decided not to investigate', this is quite extraordinary as I was accepted as the Carer Representative for the National Service Framework, and responsible for 'adding' the Carers assessment, and continued Caring for the past Thirty years.
West Berkshire Council and now the LGO obviously have NOT read the 'eligibility criteria of a CARER (that I clearly satisfy).
Carers are acknowledged by ALL as crucial in the 'delivery' of Health and Social Care, without our 'input' the NHS would collapse financially, and the Delivery of Health & Social Care would be even worse.
The 'KEY' agency in the entire exercise of 'who is delivery what and where' is the CQC. Those most 'vulnerable' placed into 'Supported Accommodation' subject to Section 117 are being 'neglected' by a system that has 'failed' to understand GP are Primary Carers, they hold Patient RECORDS, this is where the TRUTH of what is gong wrong. If you don't have a 'Statutory' Care Plan' ask why? is you have NOT had a 'NEEDS assessment' ask why, if you don't have a 'key' worker. ask why? and ask 'why they won't speak to a Carer' defined in LAW.
The LGO need a 'wake' up call, they are failing to investigate complaints, either because they are 'lazy' or require more 'TRAINING' to deliver the RIGHT response in such a serious COMPLAINT as mine, that will continue to fail the lives of others in a similar position.
How do we change the way we communicate and deliver a service that will improve the lives of Patients with LTC? it is NOT by 'sitting' and waiting to see your GP or others, we have the technology, why are we not using it. Large telephone KEY PADS photos over, help those with limited mobility and others who would find it difficult to dial a number. Computer 24/7 access 'integrated' system that is linked to others involved in your Health and Social Care this would remain accessible 24/7 ' Care Plan' would identify 'key worker' and others in your team, each conversation will be relayed to every member of your team? including CARERS, a conversation can take place at anytime, by anybody, this is a seamless conversation on your CRISIS EMERGENCY and Appointments dates. TWITTER has proved very useful and ALL are in agreement the PATIENT must hold the conversation that appears in your Medical RECORDS (which this could replace).
SKYPE and FACEBOOK is another useful tool as it allows 'face to face' conversation.
I will leave you all with this STATEMENT: if I were NOT here to clean my son's flat, launder his cloths, cleaning his fridge purchasing fresh fruit and food, who would be? the answer is nobody? read and learn, and 'join' the campaign for those we LOVE and CARE for are provided with the Health and Social Care they are entitled.
Patient Health and Social Care 'person centred' 'patient choice' holistic; are just WORDS.
I wholeheartedly agree with all the conclusions above. However we must also consider new ways of evaluating every GP Practice - large or small. I hope the following stimulates further conversation about this aspect of GP Practice.
The Hallmark of a successful General Medical Practice.
The hallmarks of a successful General Medical Practice within the NHS are:
The provision of a non-discriminatory service to all sections of the community.
Satisfaction of the stakeholders.
Esteem rather than profitability.
Patients and carers are seen not as consumers and the staff do not simply deliver medical and nursing care. The philosophy and the ethos of the practice encourages patients , carers and staff to see that finding and securing health has a lot to do with problem solving, learning to learn, and acquiring the capability for intelligent choice in exercising personal responsibility. A healthy General Medical Practice will encourage participation and active citizenship as a way of promoting the health and well being of individuals and of the community.
Adapted from the writings of Helena Kennedy QC by
Dr Malcolm Rigler GP
As the GP practice becomes “a place of learning” through “guided web surfing” and numerous interventions by clinical psychologists and “arts and health” projects the GP practice will become more and more like a “college of further education” . About such colleges Helena Kennedy QC has written:
The Hallmark of a successful college of further education.
For the overwhelming majority of colleges, the driving force for excellence remains the provision of a non-discriminatory service to all sections of the community. The hallmark of a college’s success is as it should be, public trust , satisfaction of the ‘stakeholders’ and esteem rather than profitability. These colleges do not see their students as ‘consumers’ or learning merely as ‘training’. They see education as being more than the acquisition of knowledge and skills. In a system so caught up in what is measurable, we can forget that learning is also about problem solving, learning to learn, acquiring the capability for intelligent choice in exercising personal responsibility. It is the weapon against poverty. It is the route to participation and active citizenship.
Helena Kennedy QC
From “Learning Works – Widening Participation in Further Education”
Dr Malcolm Rigler July 2015
All that you say is very valid, but my response is that it still talks too much about change. As you point out, the function of the system is the important thing, not the form. Obviously some systems need changing but by no means all. Some have been hampered by central pressure to change in the wrong way ( again I think you allude to this when you talk of prioritising access over other concerns)
It would be great to hear about the need to be better rather than the need to be different. The only thing we really have control of as professionals is our own performance, and it would be good to have appropriate incentives to monitor and improve this. After all, better professional performance relies on all the attributes you talk about.
It would be great if we could trust in quality and professional development - and then the appropriate change would follow naturally.
One of the issues that this excellent report fails to discuss is the fragmentation of the Primary Health Care Team over the last few years. We used to work closely with Health Visitors and Midwives and good teamwork helped everyone, especially the patient. This has been lost in most urban areas of the country. The Report does not mention Health Visitors once. Does this mean they are no longer considered a part of the team? I think this cannot be right and is a serious oversight.
A most informative study. I would like to see all in primary care working more closely together. As a Type2 diabetic I experience how my GP practice works with pharmacy, optician, podiatrist and so on. But despite the conclusive evidence of a link between diabetes and periodontal disease, dentists and dental hygienists are out of the loop. Needs rectifying.
This article is waffle. It merely states some general principles and that you have made some recommendations without detailing them. I wish I hadn't bothered reading it.
Some interesting material but there's no acknowledgement of the significant differences in the UK devolved nations. When the report says the NHS, it really means NHS England. And we're not all the same.
Qualified 1963 then 3 years GP before pursuing hospital career. Holistic medicine was at its best when the term "family doctor" meant just that. Communication and coordination was no problem when the GP phoned the consultant and priorities and actions were determined.
The report nobley wants to re-invent the outcome but not the method of delivering it. Too much change, electronics, complexity of disease and treatment backed by too little money has gone on to ever re-invent the past. New ways of doing things are essential but I have the worry that the main problem is being "hidden" under a mass of re-organisation. (? the 7th major attempt).
There are too too few GP's per head of population! Look around Europe, The average GP has at least half as many patients to look after. Underlying these changes is an attempt to massage away the GP shortage. Since the trend is to even fewer GP training applicants and earlier retirement because of overwork and poor job satisfaction, the sustainable solution does not seem to be more and more delegation of GP tasks. All the efforts should go into reducing the GP to Patient ratio.
It would be naive in the present crisis not to delegate simple tasks but it is not a long term solution.
The lessons of the past are not being learned.
I agree with David Hutchinson. The most salient weakness in the organisation of British general practice is low GP density (number of GPs per 100,000 patients) compared to other developed nations. This is deteriorating as GP numbers fall (1000 fewer FTEs since September 2015 I think it is) and as the population increases, exaggerated by older-age skewing of the population. There have been several Kings Fund reports into primary care in recent years that duck this issue, including a report that failed to measure/report GP density according to a measure of socioeconomic deprivation of the population, where lower GP density contributes further to the inverse care law. It is unfortunate that the primary vehicle for measuring outcomes in primary care in the UK using individual patient data, the Clinical Practice Research Datalink, does not record or derive this, which is a sustained blind spot.
Until we address GP density we are tinkering at the edges and deceiving ourselves. Meanwhile, the recruitment and retention problem worsens.
Like many others, I am a former GP partner who retired from partnership to work as locum in order to manage workload. A recent BMA survey reported that about 50% of locum GPs are former partners.
I agree with all this, but 'holistic' is belief in body, mind, spirit, and relationships with the environment (also known as the 'biopsychosocial model') whereas the NHS is still on the 'medical model', which only accepts drugs as evidenced based interventions. Pavlov proved the mind/body connection a century ago. The NHS should heed the prince of Wales keynote address to the health ministers of the world in May 2006 and 'integrate the best of complementary medicine', by socially prescribing it, and paying the licenced therapists on production of the used prescription vouchers, as pharmacists are paid for drugs. see 9.141 of www.reginaldkapp.org .