In our latest HSJ Briefing, we look at the growing pressure for general practice to meet rising NHS demand. Policy direction focuses on local commissioning board teams and CCGs working on a slow but steady path of improvement. This is a summary version.

Read the full briefing to find out:

  • Details of workforce and practice size changes
  • The place of integration
  • How the NHS Commissioning Board and clinical commissioning groups will commission
  • Data on practices’ income


What’s the problem?

General practice is regarded as critical to the NHS and its affordability, but there are also widespread calls for significant transformation and improvement.

It needs to: meet growing and unmet need particularly in deprived communities; improve long term conditions care, including use of new technology; better co-ordinate care and work with other sectors; host services traditionally found in hospitals; improve disease prevention; and promote self-care.

A King’s Fund inquiry last year said the sector must move from a “cottage industry” to “post-industrial” approach. Meanwhile, there is believed to be significant variation in quality and value.


Is progress being made?

The NHS has not yet improved performance on some key indicators of efficiency which are linked to primary and community care and co-ordination.

In many cases the size of practices needs to increase, and more GPs and non-GP staff need to be employed. These shifts have begun to take place but there is a long way to go. There is a shortage of GPs, particularly limiting access in deprived areas.

HSJ analysis this week details the huge variation in the rate of funding to practices in 2011-12.

There is a widely held view that the government’s commissioning reforms have delayed progress in reforming GP provision.


What are the possible drivers of change?

One example of many possible drivers for change is the proposal for contract change announced last week by the Department of Health (see box). There is doubt about whether the measures will be agreed then applied rigorously. If they are, they will to some extent press the changes described above. In order to meet new requirements and remain viable, practices could be forced into joint working arrangements.

Secondly, clinical commissioning groups, although they will not hold GP contracts, will have a strong incentive and duty to improve primary care. Extending services around practices will be a high priority for many. However some CCG leaders are wary of turning on other GPs. A further barrier is ability to fund changes as acute demand rises.

Thirdly, from April the NHS Commissioning Board will contract general practice. It is expected to create a performance/quality dashboard for general practice, and a primary care strategy will be published in 2013-14. GP quality indicators are also increasingly being made public.


What’s likely to happen?

For both CCGs and the commissioning board there are significant barriers to change. Some providers will resist it. Senior national officials recognise the value already provided, and the likely pitfalls and difficulties of dramatic moves which could damage general practice. This probably means policies such as major further changes to contracting, or widespread introduction of new providers, are ruled out.

Improvements are likely to rely on the ability of CCGs, commissioning board local area teams and practices to agree change. In some areas the system may be able to succeed where many PCTs have not.

However, the commissioning system is untested and in some ways radically new. There is serious concern at senior levels about whether it will function well. There is therefore a risk that improvements will be slow and patchy.