General practice on the brink: what should reform look like?

There is a will in both central government and the NHS to tackle the multiple problems that general practice faces. Any attempt to get it back on to a stable footing must address public frustrations while being honest about available capacity, workload and workforce pressures.

So what would reform look like? In this blog, we outline seven components of the design and delivery of core general practice services that need to be built into any policy reform.

1. General practice must be able to cover four fundamental functions 

As my colleague Charlotte described in the previous blog, policy focused on rapid access has distracted attention from the wider roles and core values of prevention, holistic care and continuity that underpin general practice. Any reform must tackle this by ensuring that GP practices can cover the following (adapted from Reeves and Byng, 2017):

• routine and preventative work (such as immunisations and screening) that does not need a patient to quickly access a GP, and can be done by any trained, competent person
• rapid assessment of acute illness that may be severe, and occur both in people otherwise living full, active, healthy lives and those with ongoing health problems (such as diabetes)
• coordination with other services (such as care homes and hospices) for people with complex problems like frailty or those at the end of their lives
• continuity of care for people with new or complex symptoms that need to be interpreted using knowledge about the wider context of their lives (for example, family, social and socioeconomic).

Patients’ needs for these services change over time. A usually healthy adult with occasional sore throats who develops severe tummy pain may need a period of continuity, and then, if treatment works, only intermittent acute and preventive care. GP services need to be able to identify and respond to these changes.

2. Arrangements for contacting a practice must allow all patients to access care on an equal footing

When a patient needs a GP appointment, the way they contact their surgery must be flexible to their needs and circumstances. Practices that insist on telephone or online access are inaccessible to some patients and a more tailored approach is needed. This should include access through digital services (online consultations) for people able to use these, options to contact the surgery in person or by phone for people without digital access, or using email for selected patients with special needs. Practice staff – particularly receptionists – must proactively identify patients who cannot use digital services and inform them about alternative access routes.

3. There needs to be a new approach to organising quick access to appointments for acute illness

The shortage of GPs and pressure for access described in Charlotte’s blog is skewing GP appointments toward on-the-day access, leaving insufficient capacity for continuity for patients with ongoing problems. Our case studies illustrate ways of organising rapid access at a scale that can support skill-mixed teams of clinicians supervised by GPs for patients with one-off acute illnesses and wider social determinants of poor health, while retaining the ability to offer continuity if complex and ongoing problems develop. This may need to be shared across several practices and, as such, will only work if established with intensive support for organisational development and meticulous attention to quality and safety (see next blog). And at a scale where patients needing continuity can be identified and steered towards their usual GP.

4. Non-medical clinicians should be embedded in multi-professional teams with GP supervision

Non-medical clinicians like pharmacists, dieticians and physiotherapists are essential to expanding the capacity of general practice – both for acute access and for ongoing care. But too many of these roles have been introduced in isolation with inadequate supervision and support, resulting in loss of output and poor staff retention. Any reforms must ensure that these professionals are embedded in teams supported by GPs, linked to each patient’s usual GP team through a shared medical record, and with opportunities for training and supervision.  

5. There needs to be much better use of data to inform how different patients should be cared for

GP practices hold a treasure trove of clinical and administrative data that currently support various activities around long-term conditions (through disease registers for population health management), prescribing, quality improvement and practice administration. But this data could be used in more sophisticated ways to identify patients whose risk of serious illness is increasing, and to target continuity of care more personally tailored to their needs. Investment to develop this kind of data analysis is a core part of this vision.

6. Policy-makers should avoid specifying the organisational model for delivering general practice

Discussion over reform of general practice often gets bogged down in debate over whether the traditional partnership model has run its time. But this is missing the point: different areas should be free to develop different types of GP organisation to provide the functions described in point 1. Policy should support this and avoid specifying particular organisational types (such as networks or chains), as long as a provider can deliver these functions ensuring equity of access and to agreed standards. This would park the question marks over the partnership model – at least for the time being.

7. There needs to be widespread improvement in the use of digital technologies

Any policy reform needs to ensure improved use of digital technologies – for clinical encounters (including to promote health and wellbeing), to provide advice for minor illness, to undertake selected assessments, to provide long-term condition monitoring, and deliver back-office functions. Enhanced digital skills in both patients and practice staff should be supported and promoted.

The Fuller stocktake, due soon, will set out a vision for primary care at the level of neighbourhood, place and integrated care system. It is likely to focus on neighbourhood networks bringing together a diverse group of clinicians, supported by digital services and shared across several GP practices. But unless general practice can be stabilised, this vision is going to be hard to realise. The components described above would bring a future for general practice that is broad in function, true to its core values around continuity and holistic care, and able to play a full part in local NHS services.