Emergency and acute services in some areas could increasingly be supported by up-skilled GPs, working across hospital and community settings, NHS England’s deputy medical director has said.
In an interview with HSJ, Mike Bewick set out the dramatic service and workforce shifts which would come to some areas as they move to new sustainable care models, as envisaged in last month’s NHS Five Year Forward View.
Dr Bewick, a former GP partner who also worked in acute services for several years, said some hospitals were finding it “very, very difficult” to staff accident and emergency and acute services to the minimum requirements set by royal colleges, combined with maximum working time rules.
He said: “If you put the acute side of the general practice workforce in there as well, and alter the skill levels [GPs] have, you’re starting to come up with a system where they can support each other, as opposed to repeating things.”
Dr Bewick backed the development of “specialist generalist” doctors. These “would be able to manage most situations most of the time”, covering both acute medicine and mental health, he added.
He said he wanted to see the concept of “GPs with a special interest”, in particular specialisms taken “to a different level”.
Such doctors, referred to in the US as hospitalists, could also be given the ability to diagnose and admit patients directly into acute hospital beds while working in practices, clinics or people’s homes.
Their focus would be patients with multiple long term conditions and urgent care needs.
Dr Bewick said some paramedics were trained to a level that meant they could also diagnose and treat more acute cases at people’s homes.
He said the approach would particularly suit “peripheral and remote areas with limited services”, giving the example of west Cumbria where he practiced as a GP, and where “they’re finding it very difficult to recruit acute clinicians”.
He asked: “Why can’t we train up some of the other doctors locally to be hospitalists?”
Being able to diagnose and admit patients from the community would reduce demand and create “a more fluid A&E department which isn’t just in a department”, he said.
The shift could be part of a move to the “multispecialty community provider” or “primary and acute care system” models proposed in the forward view.
Dr Bewick said these workforce changes, while not needed everywhere, would reduce the cost of running the acute beds, and improve care continuity, because the same clinician was overseeing hospital care and also “knows how to manage it and follow it up, and can make sure some of the contributory preventative factors can be attended to”.
He said the shift should include development of more “step-up” beds, with clinical staff but cheaper to run than many acute wards, potentially linked to care homes.
Dr Bewick said NHS England and other national bodies were working on how they could encourage local leaders to develop new care models and provide other help.
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Bewick: Up-skilled GPs should support emergency and acute services