Written evidence submitted by The At Scale Primary Care Networking Group (FGP0238)


About the Respondent


  1. The At Scale Primary Care Networking Group brings together the leaders of an influential group of large-scale primary care providers to share information, resources and ideas to help advance the development of primary care.


  1. The At Scale Primary Care Networking Group includes thought leaders from a number of well-known large-scale practices covering significant patient populations across the country, all with an interest and commitment to innovation which improves patient care.


  1. The Group's leading members include: Intrahealth, Malling Health, Modality Partnership, Operose Health / AT Medics, Symphony Healthcare Services, The Hurley Group and Tower Hamlets GP Care Group.  The combined list size of the group is more than 1.6 million patients.



Key Messages



  1. Primary Care is under immense pressure due to unprecedented levels of demand and wider challenges in acute hospitals and in the workforce.


4.1.             Changing population demographics:  The increasing health needs of an aging population, combined with a younger sicker population in areas of socioeconomic deprivation, and rising levels of multimorbidity across the board has significantly increased the volume and complexity of encounters. These long term trends have been compounded and accelerated by the pandemic.


4.2.             Over-medicalisation:  Advancements in medical sciences have done wonders but have also created a culture of seeking and reliance on medication.


4.3.             Changing public expectations:  Understanding the role of Primary Care as a provider of the needs of the population is often confused with catering to the wants of the patient.  We have observed a change in culture and attitude of our patients. Aggression and complaints are regularly fueled by negative press reports and a lack of visible and timely support from the Government and NHS England.


4.4.             Scope creep:  We are seeing significant “overspill” of work due to issues in other parts of the system – e.g., the shift of almost all chronic disease management out of the hospital outpatient clinic at a time when an increasingly lengthy and complex array of monitoring and treatment options are available for all the major illnesses.  We also routinely receive requests relating to domestic / police investigations, social care and/or housing benefits. We are increasingly the “front door of the state” without the resources to match.


4.5.             Recruitment and retention:  This is no longer just about GP shortages – there are challenges filling posts across all roles.  The profession does not feel valued.  The constant negative press, vilification of GP’s and exponential increase in abusive behaviours faced by staff is a strong deterrent to the recruitment of quality staff.  Existing pension rules and limits are encouraging experienced GPs to do less when we need them to stay and do more.


4.6.             Education and training: GP training is too short given the rising complexity and challenges of the role, whilst training, education and accreditation pathways for key Primary Care staff (e.g., practice nurses, healthcare support workers) and new roles (e.g., physician associates) is often under-funded and poorly defined.


4.7.             Ancillary support:  Reducing the reliance on GPs with alternate roles has been insufficient to compensate for the shortfall of GPs given workforce shortages and mixed messaging from politicians. 


4.8.             Digital exclusion:  The increased using of digital channels to access care has produced benefits but we also need to be mindful of the unintended consequence of excluding patients who do not understand and/or have access to technology.


4.9.             Estates and IT:  Substandard infrastructure continues to hamper service delivery.  Many existing estates are small, dated, not infection control friendly, and/or fails to support the sustainability agenda.  We are still working with desktops and applications that are years out of date.  Our servers and network connections are also slow and unreliable.



  1. Primary Care is an integral part of the NHS but a new care model is needed.


5.1.             Primary Care has a pivotal role in enabling effective population health management, underpinned by system level collaboration in analytics, pathways, workforce and finance.




5.2.             Primary Care is ideally placed to deliver Population Health Management (PHM) being:


a)      The first port of call for any health concerns for patients of all ages (from new babies to elderly people).


b)      Looks at each person as a whole covering physical, psychological, social, spiritual, cultural and economic aspects of care (whole person care approach).


c)       Provides continuity of care which is key to improving outcomes and reduce the burden of demand on other services.


d)      Housing a lifelong medical record from which data can be used to compile population and disease registries for population health management.


It is however not setup and/or resourced appropriately to fulfil this role. 


5.3.             Demand for primary care is now so high that a digital front end for primary care is a necessity, with the ability to stream the access queue into channels that facilitate patients receiving clinical care. This should be used 24/7 and will help not only in-hours GP practice workflow, but also OOH and 111 demands.


5.4.             The population will still require local care in GP practices for face-to-face examination; continuity of care from a known GP for people with complex problems and as trusted environment in which to receive preventive services.


5.5.             Practices need to get better at identifying the kind of care needed by patients depending on their health needs at the time and adjusting the type of care provided accordingly.  Data from primary care can be used to create shared care plans to support community cased care by MDTs supervised by experienced GPs.


5.6.             Scaled primary care needs to allow the ‘back office’ function of care to be removed from clinicians, freeing them up to deliver the care they are trained for and would choose to be doing.  Back office functions include HR, finance, governance, results and document handling.


5.7.             The current GMS contract has been useful for enabling GPs to deliver care, but is now outdated and is increasingly responsible for issues around care and financesWe propose the following changes for consideration:


a)      Keeping some elements of a national contract proving the equivalent of a ‘basic practice allowance’, combined with a local volume contract that is sensitive to local need and takes into account local care pathways, will enable the delivery of high quality primary care of the future. 


b)      Recognise the additional challenges faced by practices in areas of high deprivation through new monies from the levelling up agenda. Restore Practice Deprivation Allowance or similar. 


c)       Interaction with secondary care through advice and guidance usage along with local clinical pathways should redistribute the finances to incentivise primary care and help play a significant role in the success of integrated care systems.


d)      Consider potential changes to primary legislation around minimum list-size and enabling contracts to be held by alternative business models such as limited liability partnerships, mutuals or other employee owned entities.


5.8.             Primary care has estate of variable quality and contracts do not offer an easy way to invest in modernising estate.  Contractually separating the care model from the estate model would allow investment and remove the burden of GPs feeling shackled by this responsibility.  This could be done with state ownership, although there are now scale providers of primary care estate that could also contribute in this arena.


5.9.             The unique role of a GP is being a medical generalist who can manage illness, coordinate multiple services and, at times, hold clinical risk in the community without onward referralGPs can also provide oversight of wider primary care teams but need significant experience and training to do thisThis could be addressed by extending training so that current MRCGP becomes the entrance exam into a further three years of a training post. This would require GP providers to make sure that these younger doctors in training would receive suitable cover, feedback and training in GP practices with possibilities of working in extended roles.  GP providers would pay for these new role GPs in training from a national pool and so would be cost neutral to the system and would have a role in influencing external market locum costs.  The RCGP can then make FRCGP the exit exam to this new extended training program associated with suitable standards.  GMC should register GPs as Consultants in Primary Care.



  1. The functions of general practice can be provided by many different forms of provider.  The important thing is to enable at-scale and sustainable multi-professional team working and system level collaboration.


6.1.             Working at scale can bring significant benefits to patients, the workforce and the broader health system alike:


a)      Resilience: The traditional practice model with a small list size will find it increasingly difficult (if not already) to sustain.  Size provides resilience and stability to the service.


b)      Career Progression:  At-scale working have created more opportunities for training and upskilling, sharing best practice, and personal career development.  It also and creates opportunities to employ multi-professional teams with sufficient resources to organize supervision, training and peer support.


c)       Promoting Innovation:  More leadership headspace and appetite to invest have encouraged innovations.




6.2.             Primary Care Networks (PCNs), as a key structure to enable system level collaboration, can work but it is still very much in the early phase of development.  Continued investment and time will be needed to realise its true potential.  We also recommend:


a)      PCNs be afforded more autonomy in developing their agenda, suited to their patient needs, and provide support through commissioning intelligence, PHM, and a centrally curated playbook of what works.


b)      Make a network of PCN or pan-PCN facilities the next major building programme priority to strengthen out of hospital care, with co-location of PCN Hubs, diagnostics, community trust, hospital specialisms alongside other wider ICS stakeholders.


6.3.             System level collaboration also requires investment and time to be properly nurtured and embedded.  We recommend:


a)      Create a safe space for system leaders to co-design a set of short-term measures that impact immediately at practice level focusing on alleviating workload pressure, without destabilising other parts of the NHS. The profession needs a plan and, ideally, this needs to come from the profession itself (BMA and RCGP).  Make implementing this agreed plan a priority at ICS level by engaging PCN leadership at the top table and make reducing practice workload an explicit requirement of every ICS.


b)      Bring primary and secondary care clinicians together to redesign how and where care should be delivered, given a one system approach within a single budget, for a defined population, in the light of recent technological and data advances.


c)       Bring specialists into the ‘PCN workforce family’ through horizontal and vertical integration of services - Teams without walls. Help hospital specialists understand their responsibilities to the whole community, not just those in outpatients or on their wards. Enable care out of hospital to be delivered by hospital practitioners.



  1. There are no overnight fixes but there are high impact actions that can help build towards a sustainable longer-term solution.


7.1.             Develop a shared understanding of the role of Primary Care and ownership of issues to enable more effective collaboration across the system.


7.2.             Change the current narrative about the role of Primary Care with patients and the public.  Focus all DHSC and NHSE communications teams towards a simple public message of valuing general practice, improved self-care, responsible use of services, engagement with a blended delivery model and the roles of the wider practice team.


7.3.             Reduce administrative burden by removing or simplifying requirements which are often disproportionate to the value and purpose it is intended to achieve (e.g., ARRS, local contracts management, CQC, appraisal processes).


7.4.             Unblock estates and IT infrastructure issues that are negatively impacting service efficiency and effectiveness.


7.5.             Remove existing pension limits (annual allowance) and disincentives (locum access to NHS pensions) to encourage experienced GPs to offer more sessions at a time many have less family commitments and could do so, and more GPs to choose permanent employment.


7.6.             Reset the current GP contract as it is no longer fit for purpose.


7.7.             Invest in at-scale exemplars particularly around innovative use of resources, data and digital to tackle workload, access and inequalities concerns.


7.8.             Invest in training on leadership, quality improvement and management to support GP development throughout their careers.


7.9.             Ensure voice of primary care is embedded in ICSs and ICPs as they emerge and mature.


Dec 2021