Dr Michael Holmes, RCGP Clinical Lead for the Supporting Federations Programme, looks at what is next for general practice.
The overall perception of general practice appears to be that we are faced by significant challenges. Challenges that may ultimately change the way we deliver care. The workload we face has increased dramatically since the introduction of the nGMS contract in 2004. The growth in the number of consultations provided, and the amount of correspondence and results we process, has been striking.
Additionally, the lack of growth in GP numbers, our ageing population and an increasing desire for instant access to healthcare professionals, along with squeezed NHS budgets, are all providing the basis for a seismic shift towards 21st century general practice.
This shift is already underway. The Royal College of General Practitioners has partnered with the Nuffield Trust to examine General Practice At Scale,1 and has seen an increasing desire to work at scale at practice level. We see that 73% of practices are either working at or thinking about working at scale. Numerous models are emerging, from large super-partnerships (of varying structure), to a myriad of corporate entities each aiming to bring financial and system efficiency to the way general practice is provided.
We see a focus on access with the introduction of longer or more diverse opening hours. This is often achieved through shared responsibility and the use of technology to shift the demand out of the surgery. This allows patients to interact with their general practice at a time, place and in a way that suits them, whilst maximising the use of GP time.
We are also seeing a workforce evolution, clinically and nonclinically. Greater diversity of types of clinician and mode of clinical care is beginning to emerge with the introduction of Advanced Practitioners from a variety of professional backgrounds. They are starting to work hand in hand with GPs to see patients at the frontline in a safe and well-governanced way.
This is being supported by the professionalisation of back office functionality, delivered at scale with increasing efficiency. To maintain the core qualities of general practice we are seeing the preservation of local delivery units, manned by diverse clinical teams with support, both clinical and non-clinical, from co-ordinated at scale organisations.
The remainder of the health sector is also under pressure with many similar issues. There is a move to deliver care more efficiently with a patient-centred ethos and greater integration between health and social care sectors – sectors that have been commissioned separately, governed by different contracts and have grown further apart over recent years. The shared challenges are equally providing opportunities to rebalance these inter-sector relationships. The Five Year Forward View has suggested new ways of working – new care models, including multi-speciality community providers (MCPs) and primary and acute care systems (PACS), which have been evolving within NHS England’s Vanguard programme.
Sustainability and transformation plans (STPs) are being developed for publication later in the year, and in many areas are likely to suggest the formation of accountable care organisations as a means to financial and system stability.
The General Practice Forward View has promised support to general practice but to date the details remain unclear and much uncertainty remains about how funding and resources will materialise at practice level.
Working at scale
It feels like we are at a critical point in general practice – to stand still is simply not an option. Working together at scale seems to be the direction of travel and the mechanism to financial efficiency and sustainable clinical delivery. Sadly, we are seeing many practices facing closure – recent data suggests as many as 600 by 2020.2
GPs are sensing the need to be proactive and there is gathering momentum towards working at scale. However there is more to this than just at scale working between practices – collaboration is required at system level too. Larger practices and organisations must now begin to work in partnership, formally or informally, with other health and social care sectors to deliver seamless cost-effective care for patients. Examples of this are beginning to emerge, and hopefully the learning from these early pioneers will be disseminated so that risks can be minimised and benefits enhanced.
Listening to colleagues the difficulties we face now are palpable and the direction of travel feels like a path we have not been down before – although history tells us that practices have been gradually getting larger since the very early days of the NHS.
However as I speak to people around the country I am beginning to feel a sense of hope – magnified in those already dipping their toe into the waters of at scale practice. At a recent event, I heard the current landscape described by GPs as a “once in a career opportunity” – whilst it feels daunting and shrouded with uncertainty I am beginning to believe that it is true.