The alleged crisis in GP recruitment is a political red herring - the bigger issue is the deep need for a change to the structure of commissioning, writes Andrew Haldenby
Ministers will struggle to meet their target to recruit and retain 5,000 GPs, according to reports. The bigger question is whether the target is justified in the first place. It is reasonable to talk of a “crisis” in general practice but it is a crisis of an out-of-date model rather than a lack of resources. The 5,000 GP target is a sticking plaster when much deeper change is needed.
The small size of most practices remains a tremendous barrier to improvements in care. The Care Quality Commission has shown the correlation between size and quality. In 2014-15, the average size of an “outstanding” practice was seven or eight GPs. The average size of an “inadequate” practice was three or four. New research by the think tank Reform published today, however, shows that the average patient list in 2016 is only 7,500. Around three-fifths of GP practices have fewer than four partners. Only 6 per cent have 10 or more.
Meanwhile access via new technology remains in a relative Stone Age. Only 7 per cent of people report that they have booked appointments online
Partly as a consequence of size, access remains inadequate. In January 2016, around 40 per cent of full-time workers reported that GP opening hours were inconvenient. This puts pressure on the rest of the system. The National Audit Office has estimated that around 6 million appointments are handled out-of-hours at a cost of £68 per appointment. That compares to £21 per GP consultation. If patients seek access at A&E departments, the cost rises to £124 per attendance.
Meanwhile access via new technology remains in a relative Stone Age. Only 7 per cent of people report that they have booked appointments online.
Some “super-practices” have transcended these problems and are delivering a genuinely new model of care. Lakeside Healthcare, an NHS vanguard based in Northamptonshire, provides an urgent care centre for 200,000 patients at one-third of the cost of an A&E visit. It has also reduced overnight stays in local A&Es by up to 50 per cent.
Taurus Healthcare, in Herefordshire, has refuted the argument, made by the BMA and others, that populations do not want a seven-day service. In fact it simply takes time for people to pick up on the new opportunities. For Taurus, the proportion of weekend appointments taken up by patients rose from 40 per cent to 80 per cent between January and December 2015.
These kind of positive changes can go much further. At present, GPs take around two-thirds of the 370 million appointments at their surgeries each year. More rigorous triaging of patients would see that proportion fall to a third, taking advantage of multidisciplinary teams in primary care. Even if nurses only delivered the 57 million appointments each year which deal with minor ailments, the NHS would save over £700m a year.
These changes would free up GPs’ time and enable them to offer longer appointments, up to 20 minutes, for those in greatest need. Multidisciplinary teams are the goal, another reason why the 5,000 extra GP target should go.
New technology will support triaging and diminish unnecessary demand. A trial conducted by practices covering 130,000 patients across London found that around a fifth of people will seek self-care after following online signposting, saving around £250m per year.
Larger practices will have the scale to invest in new teams and new tech. Experts interviewed for the Reform research envisaged practice size reaching populations of over one million.
These ideas are entirely in line with the vision set out in the Five Year Forward View. The current policy framework will not however turn the current examples of good practice into system-wide change. CCGs are too small to hold super-practices to account.
Commissioning responsibilities are fragmented, divided between CCGs, local authorities and other bodies. They should be rationalised within a smaller set of bodies. There is a natural wish not to engage in “top down structural reorganisations” but the major flaws in the structure of commissioning have to be tackled at some point.
Contracts must also change. Rather than being open-ended, as at present, they should be completed at most every 15 years. Contracts must also focus on appropriate outcomes for patients, rather than the inputs and outputs that GPs are currently paid for through the Quality and Outcomes Framework.
Faced with the prospect of significant policy change, ministers may think that they have enough on their plate already. In fact they would be going with the grain of the progress in primary care already, progress that has gone somewhat under the radar screen as hospitals have dominated the national policy debate. Their focus should be structural change rather than a recruitment target that is misguided in itself and unlikely to be achieved.
Andrew Haldenby is director of the independent think tank Reform and Alex Hitchcock is a co-author of Who Cares? The future of general practice, published by the think tank Reform today.