General practice on the brink: what’s needed to implement change?

There have been countless strategies, toolkits and other resources over the years to drive change in general practice, improve access and work at scale, but progress has been generally slow and patchy. The Covid-19 pandemic has driven rapid and sweeping changes in digital access, but less in the way of access clinics organised at scale. If general practice is to reverse the decline in public satisfaction, retain talented people and avoid attack by frustrated patients, journalists and politicians, then reform and a broader swathe of changes need to be implemented at pace.

In this blog, we argue that policy-makers and those leading implementation need to take account of five main factors.

Engagement of GPs and getting the narrative for change right

While some GPs are already offering services in the ways we’ve described in our previous blog and case studies, many GPs do not yet buy into the vision, focusing more on ways to limit workload than innovation in relation to access. Recent experience of working at scale in primary care networks (PCNs) with countless meetings and top-down management will do little to boost confidence in PCNs, and GPs need time and positive experiences to build trust in their potential for delivering safe care.

The narrative must focus on the potential to control workload and improve patient experience through collaboration, digital technology and multi-professional teamwork, while also sustaining the core values of general practice. But it must also address the issues that worry GPs most, including clinical safety for patients, retaining autonomy and control in their own practices, and what will happen to their income. And it must acknowledge the importance of changing patient expectations about always seeing the GP and the promise of sufficient resources to support change (see below).

Phasing and deprioritising some areas where reform is needed

NHS planning and improvement initiatives often expect too much too quickly, with too many objectives to be addressed. Along with delivering core services, the Fuller stocktake will set out the part that GPs are expected to play in integrated care systems and to support health and wellness in local communities.

But these ambitions are only really plausible if core GP services are stable, sustainable and acceptable to patients. In his early work on digital transformation, NHS England’s Director of Transformation Tim Ferris referred to a “cacophony of initiatives” – highlighting the need to prioritise selected goals and defer some actions to focus on priorities. Politicians, policy-makers and ICS leaders must be willing to defer some changes while focusing on creating sustainable GP services.

Resources and support for transformation

Given the expectations of general practice in ICS transformation plans, the changes we suggested in the previous blog must proceed at pace. This will only happen if there is adequate, proactive support for practices and PCNs to redesign and implement new arrangements for access. They will need significant change management and organisational development support, data analysts, administrators and educators to train people into new roles. They will also need time off for service redesign and action learning. This will come at a significant cost, with further funds needed to pay for patient and public involvement. Change is unlikely to happen without this kind of investment.

Resolving infrastructure problems and other barriers

Long-standing frustrations about the infrastructure in general practice must be addressed, including opening up links (called APIs) that allow innovative digital services to ‘dock’ with GP computers; improving telephony systems and access to high-speed broadband; training in digital skills for staff and patients; and estates that can house large-scale access services. 

The step change we call for in data integration and analysis needs changes to data governance rules, and more efforts to build public confidence that data can be safely shared to support better care. These have been promised for years, have been very slow to emerge and are essential to support the transformation we describe.

User involvement and a public narrative around change

Finally, we argue for a public communication campaign to explain that, with new multi-professional teams in general practice, patients may not always see a GP. This needs honesty that, even with efforts to increase GP capacity and to better target GP care according to need, there is likely to be pressure on services for some time. Linked to this, we need public debate about what are reasonable expectations of the service during and after the period of transformation.

And policy-makers will need to think carefully about effective levers for change, avoiding multiple micro-incentives that leave GPs running like rats on a wheel in pursuit of payment, without headspace to think how to work differently. There are certainly questions to be asked about the suitability of the current GP contract for shaping 21^st century general practice. But finding ways to specify more clearly the functions and standards to be delivered is likely to be more effective at driving change than throwing it out completely.

Even with this approach to implementation, there are some wicked problems that will need to be tackled. At-scale networks that include GPs who argued decades ago and now need to work closely together. Variability in people’s ability to cope with small changes, let alone this kind of fundamental shift. And it will also be vital to manage the clinical risks that arise during periods of change and to protect patients and doctors from their effects. All critically important issues that can’t be ignored. 

The challenge is huge. The requirement is for clear thinking, well-articulated purpose and well-funded support. And leadership by those GPs who are already providing access in new ways to persuade those who are not that it is in their best interests and those of their patients to do so.