Plugging the holes in the crumbling plasterwork of GP practices

Being a GP is the most important job in Britain, says Simon Stevens; one of the most difficult jobs in medicine, says Sir Bruce Keogh; and no longer tolerable or sustainable, say many GPs.

Since ‘integration’ was established as a cross-system goal in 2013 we have predicted that the reform of primary care would rise up the agenda.

Now it has – with the publication of NHS England’s GP Forward View and a simultaneous inquiry report by the health select committee. So how do their proposals measure up?

Here I attempt to answer that, but I do so through a particular lens. I am not asking whether the initiatives and recommendations are welcome - many clearly are. But do they point the way to a better model for person centred care?

Since ‘integration’ was established as a cross-system goal in 2013 we have predicted that the reform of primary care would rise up the agenda.

Need for a new model

The select committee sets the scene by approvingly quoting National Voices’ evidence:

“Two thirds of consultations are for people with long-term conditions and a third of consultations are for people with multiple conditions.

“The core customer has changed but the model has not. The model remains reactive, in that it waits for people to turn up with an exacerbation or a symptom. It is episodic.”

It notes our argument that person centred coordinated care, defined in the ‘narrative’ adopted across the English health and care system, depends upon stronger primary and community care which is able to partner people in a proactive, planned approach to care and support.

‘Two thirds of consultations are for people with long-term conditions and a third of consultations are for people with multiple conditions’

GPs can’t do that alone, and need to be part of multidisciplinary teams, with identified care coordinators, integrated and patient friendly records and information, using patient focused interventions (such as care planning and support for self management) and referring into well developed, community based support.

But is that what they are aiming for?

Looking at the workforce recommendations is a good test here.

The select committee – like the Primary Care Workforce Commission which it endorses – has multiple recommendations for building a wider general practice workforce. A workforce with more health professionals: nurses, pharmacists, allied health professionals such as physiotherapists.

The GP Forward View has many practical initiatives – money, marketing, training, support – to obtain this expanded workforce, including new ‘physician assistants’.

The common aim here is to create more time for GPs with their patients. But what a modest aim it is – a couple of extra minutes per consultation.

The select committee has multiple recommendations for building a wider general practice workforce with more health professionals: nurses, pharmacists, allied health professionals such as physiotherapists

They have little to say about a workforce that can change the consultation to be a proactive conversation; or about the right range of skills and competencies to partner patients, support self management, implement personalised care planning, and coordinate people’s care.

Some of these are social care skills, but social care is absent from the discussion. Some could be non-professional roles; lay or volunteer roles; or roles based in community organisations. 

The running assumption that more demand means ‘more clinicians’ betrays the fact that these are (welcome, but) limited adaptations to the traditional model, not a redesign.

NHSE and new models

The GP Forward View document wants new models to develop; but meanwhile must focus on supporting practices suffering GP recruitment problems, burnout, stress, red tape, administrative burdens, high demand and inadequate premises.

The new national director, Arvind Madan, from the innovative Hurley Group, argues that: ‘For GPs to believe in a better future we must first start to feel the impact of changes now.’

As with the NHS planning guidance and the Sustainability and Transformation Plans, this risks shoring up current struggling providers while missing future goals.

Dr Madan’s vision for primary care is compelling, but the document is a trawl net that catches a shoal of programmes and initiatives large and small.

For GPs to believe in a better future we must first start to feel the impact of changes now

Many of these are needed, but key areas of person centred and community based care are either absent (care planning), tokenistic (a national ‘champion’ for social prescribing) or dealt with through technocratic enhancements (wifi and apps in practices), rather than genuine new approaches.

‘Practice without policy’

At a recent Reform event there was a sense that primary care will transform over the next five years – and that this would happen because progressive GPs take the reins, without waiting for a definitive policy model.

The current shift towards groups of practices working together offers a major opportunity

Reform’s report helpfully describes some of the ‘super-practices’ that are scaling up primary care to deliver different care for people and a better working life for GPs.

The GP Forward View seems to rely on these initiatives to do any ambitious redesign. ”The current shift towards groups of practices working together offers a major opportunity”, says Simon Stevens.

We know that greater scale is central to all ‘future gazing’ proposals for reform; and that over half all practices are now signed up to a larger entity.

But as the Reform discussion identified, many of these are defensive formations (”formed so we can say we’ve formed one”, as one participant quipped), or mainly oriented at cost efficiencies or winning new business. Only a small subset is really redesigning ways of working with people.

Transformed care is most likely to come locally and regionally from, for example:

• these super-practices;
• the pioneer areas that are co-locating services and adopting care planning and coordination;
• the vanguards that started early; and potentially
• the Primary Care Home model developed by the National Association of Primary Care.

Strangely, NHS England has investments in most of these examples, but the GP Forward View rarely foregrounds them.

The GP Forward View sets out to plug many holes in the crumbling plasterwork of GP practices. It is no blueprint for a new primary and community care building.

Don Redding (@mightydredd) is Director of Policy at National Voices, the coalition of health and care charities