Changing health needs are prompting a number of GPs to build organisations capable of preserving the personal, local nature of general practice whilst offering their patients and communities a greater range of services, according to an independent review by the Nuffield Trust and The King’s Fund for the former NHS Midlands and East Strategic Health Authority.
However the report, Securing the future of general practice: new models of primary care also warns that many other GPs, although keenly aware of the need for change, are caught on a treadmill of trying to meet the existing pressures from supply, demand and health service factors, meaning they lack time to reflect on how to provide and organise care for the future.
Radical change will depend on support, incentives, and GPs feeling that they have permission to test out new approaches to the delivery and organisation of care Dr Judith Smith, Nuffield Trust Director of Policy and lead report author
The report examines different approaches to primary care organisation in the UK and overseas and, calls for a new national framework, outlining a vision for the future of primary care, to be developed by NHS England in partnership with GPs, clinical commissioning groups (CCGs), professional bodies and patient groups.
Commenting on the research, Nuffield Trust Director of Policy and lead author Dr Judith Smith said:
“General practice in England is under significant strain. GPs are aware that more of the same is not the answer, but there is a shortage of analysis of how the future could be different, for the delivery and organisation of services, and the working lives of practice teams.
“Radical change will depend on support, incentives, and GPs feeling that they have permission to test out new approaches to the delivery and organisation of care. Policy-makers and commissioners will need to put in place imaginative measures that make the most of the strong history of independence and innovation within general practice.”
Dr Penny Newman, the GP who commissioned the review in her former role as Primary Care Advisor to the Strategic Health Authority agreed:
"The growing workload in general practice is unsustainable. We are overwhelmed. Patients needs are more complex, the GP workforce is changing, less funding is available and more assurance is required to ensure patients receive the care they deserve.
“General practice as organisations and GPs as leaders are rising to meet these challenges and this report outlines what is possible and a set of principles to guide us.
“By pooling ideas and resources these new and larger organisational forms have created innovative solutions beyond the scope of the traditional practice without losing the local access and relationships which are the trademark of excellent primary care.”
Dr Nicola Walsh, Assistant Director of Leadership at The King’s Fund and a report co-author added:
”Strong and effective primary care is critical to improving the health outcomes of the population, but general practice in England currently faces significant competing pressures leading to wide variations in the quality of care delivered.
“This report reviews how this critical element of the NHS can best meet the needs of the future. It is clear that no one model of care fits all populations and primary care must respond to the needs of the local population. Instead we outline a set of design principles to help determine how primary care should be provided to address the pressures facing GPs.”
21 different models of primary care organisation, covering 12 organisational types were covered by the review. These models were assessed for their capacity to offer an extended range of services in primary care, including rapid and local access to both generalist and specialist advice; effective population health strategies; and new forms of care for people with multiple long-term conditions.
Primary care models were also examined for the ability to provide career development opportunities for staff; and develop strong clinical governance arrangements, including effective peer review.
The analysis confirms that whilst the ability to extend the scope and scale of primary care is important, no one organisational model should be advocated. Instead the precise mix of functions must reflect the nature and priorities of the local population.
On that basis, the review proposes a set of design principles, spanning both clinical and organisational domains, to be used by commissioners, GPs and other primary care professionals when planning future provision.
It also sets out several concrete measures that could be taken at the national level to encourage further development of front-line primary care services. These include:
A national framework for primary care – NHS England, with GPs, CCGs, patient groups and professional bodies, should develop a plan that describes the outcomes and overall vision for primary care, both in relation to the services it provides and its place within the wider health and social care system.
This should not however specify details of implementation – this is a matter for local determination based on the use of design principles.
A new alternative contract for primary care – A new alternative contract for primary care is required, in parallel to the General Medical Services (GMS) contract, to encourage groups of practices to take collective responsibility for a wider range of population health and primary care services.
Alternatively, there is scope to use the existing NHS (Primary Care) Act 1997 to help promote the roll out of extended primary care services, tailored to local areas.
A role for CCGs in commissioning primary care – CCGs are well placed to work closely with patients and the public to design new forms of service provision that can assure accessible and high quality primary care and advice.
There is a need for further clarification by NHS England as to the precise nature of CCGs’ involvement in developing, commissioning and assuring the quality of primary care.
Regulation that supports primary care redesign – The economic regulator Monitor needs to examine carefully the experience and potential of ‘super-partnerships’, networks, multi-practice organisations and community health organisations and develop guidance that prevents the benefits of ‘at scale’ primary care from being compromised by concern about (actual or perceived) limits to choice and competition of practices working in more collaborative ways.
Resource for organisational development – NHS England needs to work with CCGs and local clinical leaders to fund and develop approaches to freeing up time in practices to enable reflection and planning. This should include imaginative ways of enabling GPs to access high quality organisational development and other planning support.
Alternatively, CCGs or commissioning support units (CSU) could be given resource to fund a programme of primary care development, drawing on advice and support from leadership development bodies.
Notes to editors
Securing the future of general practice: new models of primary care was written by Judith Smith, Holly Holder, Nigel Edwards, Jo Maybin, Helen Parker, Rebecca Rosen and Nicola Walsh.
It was commissioned by the former NHS Midlands and East Strategic Health Authority, with a brief to explore models that could increase primary care capacity, quality of care provision, and general practice leadership capability, and would be sustainable over time. The views expressed in the report are the authors’ own.