Written evidence submitted by Policy Exchange (FGP0323)

Policy Exchange is an independent, non-partisan educational charity which seeks new policy ideas to deliver better public services, a stronger society, and a more dynamic economy.

The Health and Social Care Unit at Policy Exchange looks to tackle the most pressing questions facing the NHS and social care sector today and looks to ensure that the needs of consumers are placed at the forefront of the national conversation.

The Committee is exploring this issue at an opportune moment. Our evidence submission opens with a series of key messages which prospect a future model for general practice. This is followed by direct responses to the questions posed by the Committee. We have chosen not to respond to question 6c. Our submission draws upon research which will be published by Policy Exchange on this subject in early 2022.

 

Key Messages

Now is the time to rethink and reform the delivery of general practice in England. Too much of the present discussion is skewed to historic challenges; too little discussion explores the desired end-state. A shift is required from a binary debate over the merits of face-to-face versus remote consultation. This is a debate which has also too often neglected other significant factors for access including the value of timeliness and variations in quality between different types of remote consultation. Instead, the focus of our conversations should be upon the end-state for general practice that is required, including discussion of the purpose general practice should serve in the future (and who should serve it) so that it can meet future demand.

Patient choice will be an important consideration in reforms to general practice, but reforms will need to look at the big picture: any new model should be designed so it meets the needs of a population which is increasingly older, multi-morbid and which will require multiple channels of interaction with the NHS. For this emerging profile of patient, the current model of general practice is neither adequately staffed, nor sufficiently planned. Alongside the growing scale of complex care management are high volumes of one-off episodic care, where speed and ease of access is a priority. This demand could be much more effectively planned and delivered at scale and high-quality digital consultation should become the default consultation method, unless in-person examination is necessary for clinical reasons.

The Government has an important role in defining the type of service that is required and should set out its vision as we look toward the next five-year GP contract term (2024 onwards). This will require candid conversations about trade-offs and ultimately, bold decision-making including challenging those who have a vested interest in the status quo and creating alignment around benefits to all stakeholders of a reformed model.

 

The current model of General Practice is increasingly unsustainable and requires redesign. The current approach to general practice has remained largely unchanged since the NHS was formed. The private provider GP model has been in decline for many years, with a trend from GP partners (who own practices) to salaried GPs increasing year-on-year. A majority of the profession have accepted the need for change. The most recent England LMCs conference called on the British Medical Association to negotiate a new GP contract with 94% of delegates believing the current GMS contract to be ‘outdated and inadequate’.[1]

We are at a crossroads. The partnership model could be ringfenced and supported, but pressures upon it will increase further as the patient and workforce profile changes and demands increase. Moreover, the default model of general practice which remains small-scale and partnership-based will seem increasingly out-of-step with a move to more integrated models of care. Instead, over the next decade, we expect partnerships to be increasingly replaced by a model of general practice in which premises, workforce, data and procurement are planned at a larger scale. This is the direction of travel, but it will not be an overnight transformation; there are many effective individual GP practices and horizontally-scaled models which provide excellent care, and any transition must safeguard what is currently working well.

With the introduction of integrated care systems and a shift to greater collaborative working across the NHS, now is the opportunity to ensure that primary care develops in-step with the health and care system at large.

In any new model of general practice, GPs should remain expert generalists and should continue to provide continuity of care to a defined population, but increasingly, they should play a coordinating role as part of a more diverse team of pharmacists, physios, nutritionists and general practice nurses, who will be the first contact in the system for the majority of consumers seeking health improvement or preventative interventions. New reimbursement arrangements will be required to deliver this transformation, including fundamental changes to the GMS contract.

Substantive reforms which pursue vertical integration (meaning that GPs are salaried and managed at a trust level) may be controversial with some within the GP profession. However, the artificial separation of general practice from hospital-led care has long been viewed as incoherent. Reform has been attempted before and faced resistance, but the evidence and rationale for change has strengthened over time.

 

Workforce planning in general practice should pre-empt and underpin this transformation. Current pressures upon general practice staff are well understood, with fewer staff delivering more consultations than before the pandemic and across many more channels, with greater numbers of GPs leaving the service than currently joining. Efforts to grow multi-disciplinary teams, such as furthering the work of the Additional Roles Reimbursement Scheme (ARRS) should be seen as a priority. Any new model for primary care should create new possibilities for hybrid workforce roles, better meeting variable patient need but it should also be sufficiently flexible to suit the lifestyles and preferences of the future GP profession. The new model should also open routes for other primary care staff to deliver a broader range of services and must enable clinical research (including greater porousness between work in secondary care) to become more commonplace.

High-quality digital health solutions should be increasingly embedded into routine channels of care. Where appropriate, primary care should be digital-first. The government should clarify an intention to make primary care ‘digital first’. The current review of remote GP consultations which was commissioned by NHS England in mid-November 2021 should shed light on current limitations and opportunities, but where the case for their implementation is clear and can assist patients and clinicians, deliver cost savings and enhance clinical pathways, they should be championed in general practice.[2] General practice should look to provide the blueprint for how the highest-quality digital technologies can be scaled throughout the NHS.

 

Question 1: What are the main barriers to accessing general practice and how can these be tackled?

a)      To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

The publication of the government’s Winter Access Plan in mid-October 2021 introduced several welcome measures, including[3]:

It should be stated however that the plan does not set out how systemic challenges in general practice will be addressed in the longer term. We believe it is vital that the Government sets out a reformed vision for general practice over the next twelve months.

 

b)     What are the impacts when patients are unable to access general practice using their preferred method?

 

 

c)      What role does having a named GP—and being able to see that GP—play in providing patients with the continuity of care they need?

Continuity of care is a key part of general practice, but it is about integrated data, consistent patient information and effective teamwork in general practice as much as attachment to a named GP. The idea of a ‘family doctor’ and a desire for a continuity of care is embedded into our expectations of the NHS. There is a strong evidence base for the value of continuity of care in both clinical outcomes, reduced inpatient visits and overall satisfaction (for both patients and practitioners alike), but continuity of care is not delivered through interaction ‘in-person’ with a single, named GP. You can ‘see your GP’ via a high-quality video consultation for instance.

Whilst often minimised in the public discussion, continuity of care is best achieved by ensuring that information available to staff about patients is consistent and up to date, meaning everyone deals with a ‘single version of the truth’, reducing the need for patients to recount information.

 

Question 2: What are the main challenges facing general practice in the next 5 years?

Resource-based challenges in general practice are well understood.

The organisational/structural challenges facing general practice and how they can best be tackled are less clear, however.

 

Question 3: How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

There is a long-standing regional disparity in the provision of GPs and the quality of services across England. It has long been understood that the practices in areas of the greatest deprivation remain relatively underfunded, whilst they often possess fewer GPs per person. There is one GP per 2,761 people in Hull, compared to one per 1,688 in Oxfordshire.[8] As a result, there are significant divides across the country (both between regions and groups) in access to high-performing services.

To tackle this, we recommend:

 

Question 4: What part should general practice play in the prevention agenda?

General practice should have a strengthened role in the prevention agenda and in planning place-based approaches to population health. GPs already contribute significantly to preventing the exacerbation of diseases, but should play an expanded role in the future. With 90% of the public’s healthcare interactions occurring in general practice, the holistic care that GPs currently provide as trusted providers of individual and continuing care mean they have a unique insight into population health and should therefore play an important role in defining population health measures at neighbourhood and place level. A shift to a scaled form of general practice, equipped with improved data reporting should be coupled with a boosted role for general practitioners to have a ‘seat at the table’ within ICS structures to plan and determine population health approaches. An expanded and multi-disciplinary general practice workforce can also assist in more effectively managing preventative care ‘upstream’. An example would be to enable nurses to take on some of a GPs case load in diabetes care and to actively use the best quality digital solutions in their effective management. An appropriate compromise will need to be found which balances an improved approach to triage, whilst maintaining the dispersal of cases which allow GPs to retain the case diversity which often attracts them into the profession.

General practitioners should increasingly utilise and ‘prescribe’ high-quality digital health tools with their patients to support health promotion and prevention. NHS England should ensure appropriate maintenance of a database for use by both the public and practioners which profiles and recommends the highest-quality apps and connected devices for use in general practice, such as Healthy.io’s ‘Dip UTI’, a home testing kit for Urinary Tract Infections which has been shown to reduce UTI-related GP appointments.[12] Nationally, increased investment should be made to enhance the NHS App to support this agenda through signposting to wider services, including those already delivered by the voluntary sector.

 

Question 5: What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

There are opportunities to strengthen general practice through addressing failure demand in primary care. The Government should examine ‘failure demand’ – which entails the examination of unnecessary work arising from current system deficiencies, through delay and duplication – in general practice.  Expertise from both within the NHS and the commercial sector should be brought together to examine this and proposals should be made to reduce failure demand which bears cost, clinical outcomes and patient satisfaction in mind. Demand patterns coming into primary care should be examined, and proposals made for the optimum channel and organisational level at which these are best served.

Any new model of general practice should be designed around the future GP workforce. NHS England should work with the Royal College of General Practitioners and medical schools to consider measures to make general practice an increasingly attractive route for students as well as examining how the recruitment of multi-disciplinary teams can be boosted.  An examination of how career development pathways could be enhanced, how roles can become increasingly regarded as possessing parity with roles in hospital settings, as well as exploring methods to boost GP-led clinical research in primary care should be explored.  Moreover, new approaches to recruit skilled international staff should be considered, including exploring whether there are possibilities to increase the number of remote physicians, nurses and allied health professionals through amendments to current GMC rules.

 

Question 6: How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

a)      Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

The private provider GP model has been in decline for many years, with a trend from GP partners (who own practices) to salaried GPs increasing year-on-year.[13] This corresponds with the changing workforce profile of general practice, with a tendency for younger recruits less willing to shoulder the financial risk associated with becoming a partner, opting instead for flexible locum roles or salaried positions, a greater number of women (who now make up the majority of the general practice workforce), many of whom are looking to balance work with child-caring responsibilities and are seeking greater flexibility in their working hours.[14]

At large, there has been a decline in the overall attractiveness of general practice as a career pathway. A recent study of medical students at the University of Oxford – whilst a limited sample – produced some telling results and defined three factors which ‘put off’ students from general practice: a low perceived value of community-based working and low status of general practice, second, observations of the wider pressures under which GPs currently work and their detractions; finally, a lack of exposure to academic role models and primary care-based research opportunities.[15] 

The sum of these challenges has meant that the current model of general practice seems increasingly unsustainable in the long term. To respond to these challenges, a suite of new models for general practice have emerged over the past decade which include ‘GP Federations’ – two or more independent practices, pooling profits to support shared activities; ‘Super Partnerships’ – two or more practices merged but often possessing their own GP contract; ‘Practice Networks’ – with common objectives, but operated independently.

Each of these models seeks to deliver efficiencies by planning and pooling resources at greater scale. They broadly correspond to a model of horizontal integration, whereby practices maintain significant autonomy, but there is an alternative form of vertical integration which has gained greater prominence in recent years. Examples have emerged in recent years in Birmingham, Wolverhampton and more recently, West Suffolk.[16] The model sees the full integration of local general practices with the trust, linking primary, secondary and community care into a single structure, allowing practices to retain GP contracts with NHS England, but with GPs directly employed by the trust, who assume responsibility for staffing, premises and finance. In this structure, practices have been able to integrate and share data to track patients more effectively through the system.[17]

An evaluation of one model’s outcomes in December 2020 found that in several locations across the country since 2015, the model would have ensured practices remained open that would otherwise close, given it provides a more stable financial platform than individual practices run as separate businesses.[18] Moreover, evidence from that study also showed that the model produced a 10% reduction in in-patient visits to the A&E department.[19]

The evidence base that a scaled form of general practice leads to improved clinical outcomes and cost savings in the medium to long-term remains inconclusive. However, the advantages that come with economies of scale, more effectively managing data at a population level and enabling employees to work on more flexible contracting arrangements is likely to see the model become more widespread in the years to come. Perhaps the greatest advantage to this arrangement however is its ability to ensure that general practice becomes less fragmented and more closely aligned with the work of ICSs.

 

b)     Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

The current design of general practice is too heavily skewed toward gatekeeping patients to acute care settings but should be increasingly enabled to provide more proactive and preventative care. To deliver an effectively scaled model of general practice (more effectively coordinated) which has digital health at its heart (and thereby more personalised) and focuses upon prevention, the GMS contract and incentive structures require reform.

The Digital First Online Consultation and Video Consultation (DFOCVC) framework for instance which seeks to provide a streamlined route for supplying and purchasing assured online consultation and video consultation systems should be revised so that quality is built more effectively into the framework and so the measurement of user satisfaction plays a more significant role in solution appraisal.

 

c)      To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

Many initiatives are already in place which seek to develop multi-disciplinary teams to deliver primary care more effectively. At a national level the work of the Additional Roles Reimbursement Scheme (ARRS) has sought to diversify the skills mix present across primary care at large, but this type of working in general practice is not yet commonplace across the countryPresently, systems are currently looking to appraise current initiatives, such as the multi-disciplinary projects being trialled by the Surrey Downs Integrated Care Partnership.[20] There is scope to expand existing initiatives however.  The Community Pharmacist Consultation Service (CPCS) which seeks to refer a greater number of patients to community pharmacy from emergency departments and urgent treatment centres has reported lower referral rates than anticipated, whilst there is scope for greater take-up of the GP referral service.[21] At large, more evidence is required to demonstrate that there is a causal relation between new partnership structures and additional capacity.

Dec 2021

10


 


[1] https://www.pulsetoday.co.uk/news/breaking-news/94-of-lmc-leaders-believe-current-gp-contract-outdated-and-inadequate/

[2] https://www.hsj.co.uk/primary-care/nhs-england-reviewing-remote-gp-appointments/7031315.article

[3] https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/10/BW999-our-plan-for-improving-access-and-supporting-general-practice-oct-21.pdf

[4] http://president.rcem.ac.uk/index.php/2021/08/06/whats-behind-the-increase-in-demand-in-emergency-departments/

[5] https://pubmed.ncbi.nlm.nih.gov/29474392/

[6] https://ifs.org.uk/publications/15871

[7] https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice

[8] https://www.independent.co.uk/news/health/uk-gps-doctors-patients-nhs-b1936101.html; https://bjgpopen.org/content/5/5/BJGPO.2021.0066

[9] https://www.bma.org.uk/news-and-opinion/access-to-care-bridging-the-digital-divide

[10] https://www.northtynesideccg.nhs.uk/livi-complementary-gp-video-consultation-service-pilot-evaluation/

[11] https://gprecruitment.hee.nhs.uk/recruitment/ters/england

[12] https://pharmaphorum.com/news/healthy-io-extends-smartphone-uti-kit-roll-out-in-uk/

[13] https://www.nuffieldtrust.org.uk/news-item/what-does-the-gp-workforce-look-like-now

[14] https://www.bmj.com/content/372/bmj.m4966.full

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6030758/

[16] https://www.wsh.nhs.uk/News-room/news-posts/Forward-thinking-GP-surgery-links-with-local-hospital-to-improve-patient-care.aspx

[17] https://wolverhampton.moderngov.co.uk/documents/s28135/Appendix%201%20Wolverhampton%20Local%20Digital%20Roadmap.pdf

[18] https://www.hsj.co.uk/workforce/how-hospitals-could-step-in-to-help-manage-gp-practices/7029069.article

[19] https://bjgp.org/content/70/699/e705/

[20] https://nhsproviders.org/providers-deliver-collaborating-for-better-care/surrey-downs-integrated-care-partnership 

[21] https://pharmaceutical-journal.com/article/news/consultation-service-refers-350000-patients-to-pharmacists-since-launch-says-nhs-england