Back to first principles: primary care for the future

Looking back over recent blogs about primary care written by Jonathan Tomlinson, Clare Gerada, John Macaskill-Smith and Helen Parker, three things stand out.

First, there is consensus that general practice is under significant pressure, struggling to meet demand from patients, blamed for contributing to the alleged crisis in accident and emergency care, and exhorted to reassume responsibility for out-of-hours patient care.

Second, the ‘special sauce’ of general practice – the relationship between a patient and their family doctor – should be preserved and nurtured, this being the basis for effective care for people with complex needs, and for tailoring services to the specific requirements of local communities.

Third, they are clear that change is required if general practice is to be put on a sustainable footing for the future, with a need first of all for capacity and resource to give people headroom to work out how services could be organised and delivered in future.

With general practice on a treadmill of demand, trapped in often outmoded models of provision, policy makers need to shape and fund an environment that encourages GPs and their teams to plan a different future

In many other forums, there is extensive analysis of the problems faced by general practice in England. There is however much less examination of exactly what needs to be done to address these challenges.

With this in mind, last autumn the former Midlands and East Strategic Health Authority commissioned the Nuffield Trust and The King’s Fund to examine UK and international models of primary care, and suggest ways in which NHS general practice might learn from these and develop a more sustainable workforce and services.

Our subsequent report – Securing the Future of General Practice: New Models of Primary Care – sets out the case for change in general practice, describes the factors that define high performing primary care, and explores 21 UK and international models of primary care, almost all of which have been developed by frontline professionals keen to ensure that they can provide as wide a range of services as possible for local people.

We’ve used our analysis of these innovative models as the basis for proposing a set of 12 ‘design principles’ that can be used by local commissioners and practitioners when thinking about how primary care might be designed and organised for the future.

These offer a fresh way of thinking about the primary care services required for a specific local population. They are focused on the needs and perspectives of patients and the public, and include:

• patients benefiting from access to primary care advice and support that is underpinned by systematic use of the latest electronic communications technology;

• patients being offered continuity of relationship where this is important, and access at the right time when it is required;

• where possible, patients being supported to identify their own goals and manage their own condition and care.

When all or most of the 12 design principles are combined, fundamental changes to the organisation and delivery of primary care become necessary. In particular, it becomes evident that primary care must operate at a greater scale, with the linking together of practices in federations, networks or merged partnerships to increase the scope and organisational capacity of general practice.

This will need to be done while preserving the local small-scale points of access to care that are the ‘special sauce’ so valued by (at least some sections of) the population.

Design principles will not however suffice. With general practice on a treadmill of demand, trapped in often outmoded models of provision, policy makers need to shape and fund an environment that encourages GPs and their teams to plan a different future. This should include an overall vision for primary care and its role in the wider health system, underpinned by the design principles proposed in our report.

A new alternative contract for primary care is required, in parallel to the current general medical services contract, setting objectives and parameters, but not specifying details of local implementation. This should encourage groups of practices to take collective responsibility for population health (and ideally also social) care.

CCGs could be given a mandate to commission services from general practice (over and above core general and primary medical services) and other providers. This would be another way of encouraging the formation and extension of primary care federations and networks, with groups of practices bidding to provide services in accordance with the design principles proposed here.

Primary care will need practical and financial support for the work required to plan, establish and sustain new ways of organising general practice services. 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.

The development of larger scale organisations or networks, with new services, different skill-mix, professional management, and fresh leadership opportunities, is a pressing priority for primary care. Without this, primary care will find itself running ever faster to keep up, and in ever-decreasing circles.

This article is also posted on the Inside Commissioning website.