General practice seems to be considered by politicians and the media as both the cause of and solution to the current crisis in demand for urgent and emergency care.
At the same time, the primary care community is recognising that the current business model of general practice is under threat due to increased demand by patients, growing regulatory workload and, for some this year, significantly less income.
From discussions with GPs and policy makers, there appears to be some consensus that the current ‘small scale’ organisational model of general practice has served us well for the last 60 years or so, but health care needs have now outgrown it and larger scale models of provision are likely to be required.
Additionally, there is a pressing need to ensure that general practice is an attractive career option, if we are not to witness our high quality primary care workforce crumble over the next few years.
Clinicians and other staff report being able to develop their role and career through increased specialisation in a manner that would not be possible in a small practice
We therefore need to work out how to keep what is valued highly by patients about ‘small scale’ practice, such as continuity of care and identity with a local practice. At the same time, work needs to be done to examine organisational models that ensure the sustainability of the general practice business model, facilitate scope for extended primary care provision and development, support integrated care, and create attractive career paths for clinicians.
Last week we brought together GPs from around the country, who have been working to develop new ‘at scale’ approaches to general practice provision. These GPs have changed their business model, developing new organisational governance and structures and expanding the range of services provided to their patients.
These included outpatients services, enhanced diagnostics, urgent care services and community based dementia care. The new organisational models being used by these GPs include: GP federations, ‘super partnerships’ establishing large integrated care organisations within a local health economy, and a small partnership model achieving scale by holding multiple practice and service contracts across deprived areas of London.
These innovations demonstrate a number of benefits. Firstly, the potential for general practice to act as care co-ordinators enabling integration between GPs, community services and specialists within the practice setting.
Secondly, the use of single, integrated IT systems across care settings to improve co-ordination of care and flexible workforce delivery models.
Thirdly, strong primary care medical leadership that has greater provider influence locally, and fourthly, improving business sustainability through diversification of income streams, relying less on the core contract and achieving some economies of scale.
Clinicians and other staff report being able to develop their role and career through increased specialisation in a manner that would not be possible in a small practice.
The big question however is this: are innovations like these replicable across the country and in both urban and rural settings?
I believe that this is possible, although the history and context of general practice in each area will determine the precise approach to be taken. The seminar identified ‘essential ingredients’ that were common to all examples:
- strong, local GP leadership driving a shared vision of the future model for primary care in their area – working with, but not led by, GP commissioners;
- a well-developed strategic business plan for the GP partnership incorporating service, organisational and workforce development plans and supported by short and long term financial investment models;
- investment by GP partners in the procurement of additional skills and capacity not typically found in practice management – these included organisational development expertise, commercial and legal support, property advice and accountancy;
- an attitude to risk that enabled innovation to flourish, such as investing up front to deliver new services despite relatively short contract terms.
In our highly regarded NHS general practice system we have the foundation in place for care co-ordination based on the registered list that we do not exploit to full advantage. This can deliver a more efficient and cost- effective service with improved patient satisfaction than the current fragmented system.
Larger scale provider models provide more flexibility to manage current challenges such as access and improved urgent care management. But to make this a reality, GPs as providers, not commissioners, need to have vision and determination for the future and sustainability of general practice.
They will need support from CCGs, NHS England and Royal Colleges, but the development of innovative approaches to delivering primary care-based services will fall to GP leaders and their teams.
Parker H (2013) ‘Transforming general practice: GP providers thinking big’. Nuffield Trust comment, 23 May 2013. https://www.nuffieldtrust.org.uk/news-item/transforming-general-practice-gp-providers-thinking-big