General practice needs more than money

It seems that hardly a week goes by without another report of workload pressure, lack of funding and general imminent doom in general practice. As a response to this, the Royal College of General Practitioners (RCGP) has its Put Patients First: Back General Practice campaign, and the British Medical Association have Your GP Cares. Both focus on the need for more money to ease the pressures faced by GPs and their teams.

The problem, and the pain, are real. From 2009/10 to 2012/13, funding for general practice fell in real terms by around £400 million. Deloitte recently produced analysis for the RCGP in April extrapolating a further real terms fall in total funding of £1.59 billion between 2012/13 and 2017/18.

On top of this, the phasing out of the Minimum Practice Income Guarantee – brought in over a decade ago to make sure no practice would lose out from the introduction of the new GP contract – is putting particularly intense pressure on many smaller and rural GP partnerships.

The profession is fed up of being told that general practice is the problem in the NHS, and then straight afterwards being told it is the solution

Even as funding levels fall, general practice finds itself asked to do more and more as the demand for consultations rises. Lack of access to general practice is blamed for exacerbating A&E pressures, and this all seems to go against the grain of a long-standing policy mantra of shifting resource from hospital to community settings – remember the ‘primary care-led NHS?’.

Indeed, as a GP commissioner remarked to me recently, the profession is fed up of being told that general practice is the problem in the NHS, and then straight afterwards being told it is the solution.

It is part of the job of GP leaders to give voice to this understandable frustration – but it will not be enough. I am reminded of the Royal College of Physicians’ report ‘Hospitals on the Edge’ which made the case for why acute hospitals were ‘on the brink of collapse’ in 2012. It was not shy about driving home the message: the front cover showed a hospital falling over a cliff.

What this report also did, however, was set out ten priorities for action, including ‘we must redesign services’ and ‘we must change the way we organise hospital care’. The Royal College of Physicians responded to this through the work of the Future Hospital Commission which published a bold and influential analysis of the large-scale change needed in the way that physicians work, and hospitals are organised.

Given that rising numbers of frail older people are one of the most pressing needs facing our health and social care system (alongside increasing demand for access to primary care advice and assessment) it is surely time for general practice, like the physicians, to think boldly about how to redesign services, maximise the use of technology, and change the organisation of care.

At a primary care reform conference in Brisbane recently, I highlighted the work of European academics who have demonstrated a clear need to ‘invest to save’ to secure the benefits of an effective first point of medical contact: improved health outcomes, reduced avoidable admissions to hospital, and improved self-management of long-term conditions.

But this investment will only be given – and will only get results – if it comes alongside sound plans for the medium and long term.

That conference pulled together Australians, New Zealanders, Canadian, Dutch, British, Hong Kong, and many other delegates. It delivered a strong message that primary care providers need to think afresh about the services they offer patients and the population.

All were united in a belief that primary care is at a tipping point where the old models of service delivery (e.g. 10 minute appointments for all, reliance on face to face consultations), dearly loved ownership forms (e.g. the partner-provider), and sacred cows (e.g. fee for service and no patient registration in Australia) have to be challenged and changed.

The factor driving this consensus was that traditional primary care is rarely of a scale, complexity or capacity to deliver and co-ordinate care for frail older people and other vulnerable groups.

In work we undertook with The King’s Fund last year, we proposed a set of ‘design principles’ to be used locally when thinking afresh about the primary care provision. These included tailoring appointment length to the need of patients; enabling 24/7 access to senior medical advice and triage; assuring high quality primary care for people living in care homes, and having rapid access to diagnostics within primary care.

So is primary care on the edge? The short answer is yes: the struggle to meet rising demand with falling funding is very real. But that does not mean that the solution is to hand over more money for general practice to keep doing more of the same.

Instead, leaders and professional groups in the sector need to be bold in articulating how services will be organised and delivered for the coming 10-20 years. This must include how GPs and their colleagues will manage the care of frail people with complex needs, as well as offering 24/7 access to advice and diagnosis.

It must mean learning to support (and be supported by) the RCP’s hospital of the future, maximise the use of technology to provide different forms of access and care, and find new ways of working closely with the wider health and social care team.

The Nuffield Trust is launching a new programme of research and development to support this ambition. Is English general practice ready to step up to the plate?