A sample of headlines about general practice over any seven day period for the last six months would likely describe a service either on the brink of – or already engulfed within – a serious and potentially intractable crisis.
The falling investment in primary care has led some commentators to predict in the region of 500 doctors’ surgeries going out of business.
Others highlight the demographic split of the GP workforce – with a disproportionate number within five years of viable retirement – and incomplete take-up of training places, suggesting a growing gap in the future workforce that will significantly reduce access to services over the next decade.
And unlike funding, which is ultimately about political choices, the workforce tap is a great deal harder to turn back on quickly if the service starts to seriously decline.
A further narrative has developed in the press about quality, modernisation, and efficiency. The positive side of the debate offers a vision for a future model of primary care – practices coalescing around populations of up to 100,000 patients, offering seven day services from purpose built facilities.
But for a GP working in the average practice of three to four partners serving less than 10,000 patients, and working from a converted residential property, the message can rationally be interpreted as ‘your building is not compliant, your systems are not robust, and your business model is not fit for purpose.’ It is unsurprising – in the face of such relentlessly negative press – that insufficient numbers of trainee doctors are selecting general practice as a career choice.
And if the analysis that 90% of all patient contact occurs in primary care is accurate, the consequences of service decline are serious for every part of the NHS.
In excess of 10,000 patients per day visit their doctor’s surgery in Norfolk. By comparison, the total daily attendance at A&E across the three local hospitals is around 600. Small ripples in primary care make for very large waves across the rest of the service.
However, careful analysis of the stories reveals mostly speculation, anecdote, and extrapolation from small data. The absence of reliable information on the national picture makes it difficult for policy-makers to distinguish a genuine crisis from the general picture of the wider NHS under sustained financial and operational pressure.
This month’s policy briefing and accompanying survey, from the Nuffield Trust brings much needed objective analysis and information into the debate, and should be required reading for policy-makers and NHS leaders.
The briefing confirms and quantifies the finance and workforce issues, and highlights how policy-makers can support the changes that general practice must make to meet the challenge of an ageing population with rising levels of chronic disease.
The gradual shift away from partners to salaried doctors, and from full to part time working are of real significance for the future business model; they suggest that the small business owner-practitioner model of general practice is gradually giving way to an employed workforce operating at a larger scale and with a wider range of community-based services.
The recommendation for transformation funding is welcome, necessary, and echoes the NHS Confederation 2015 Challenge Manifesto.
The Nuffield Trust report points out that the GP is still a well-paid role in the UK, and continues to deliver high levels of patient satisfaction. There is much in the report to suggest that this is an exciting time to enter the profession and have a hand in reshaping it for the future. It is to be hoped – if not expected – that this message of opportunity also finds its way into the headlines.