Existing GP model 'no longer fit for purpose', says Lords report

The small business model of general practice is 'no longer fit for purpose' according to a House of Lords report that calls on NHS England and the DH to consider 'direct employment' of GPs.

The report by a Lords committee set up to evaluate the long-term sustainability of the NHS warned that the existing model of general practice is 'inhibiting change'.

It highlighted problems with chronic underfunding of general practice, problems with recruitment and retention and soaring workload, and found 'broad support' for moves towards GP practices working at scale to deliver 'extended services through federations'.

The findings come just days after a landmark NHS England report set out plans to incentivise every GP practice in England to join 'local care networks' covering up to 50,000 patients.

Reacting to the report, both the RCGP and BMA said that GPs were open to new ways of working but warned that there was no 'one-size-fits-all' solution for general practice across the country. The RCGP said that despite the partnership model struggling in parts of England, it should not be scrapped.

General practice at scale

Despite the Lords report's finding that there is 'broad support' for GP practices working at scale, a recent GPonline poll suggests most GPs oppose plans to move them into hubs serving larger populations.

However, the Lords report says: 'The traditional small business model of general practice is no longer fit for purpose and is inhibiting change. NHS England, with the help of the DH and the profession, should conduct a review to examine alternative models and their contractual implications. The review should assess the merits of engaging more GPs through direct employment, which would reflect arrangements elsewhere in the NHS.'

The report also strongly recommends that 'a tax-funded, free-at-the-point-of-use NHS should remain in place as the most appropriate model for delivery of sustainable health services both now and in the future'.

It warns that the reduction in the share of GDP spent on the NHS in the current decade 'cannot continue beyond 2020' without undermining services, and warns that 'to protect the sustainability of the NHS the government needs to set out plans to increase health funding to match growing and foreseeable financial pressures more realistically'. Health spending beyond 2020 should rise 'at least in line with the growth of GDP.'

The report also criticises 'short-sighted' cuts to public health funding, and calls for an independent review of the impact of NHS pay freezes. It urges a longer-term approach to NHS funding, and a bid to secure cross-party consensus.

The government should 'acknowledge the shortcomings of current workforce planning', the report adds, with a strengthened role for Health Education England in creating sustainable workforce plans and better protection of funding.

NHS funding

RCGP chair Professor Helen Stokes-Lampard said the college welcomed the Lords committee's advice that NHS funding should rise at least in line with GDP.

She added: 'GPs and our teams are open to new ways of working to cope with the changing needs of our patients and the growing demand this brings. But there is no one-size-fits-all approach and GP practices must be able to choose the best ways of working to offer services that local populations want and need.

'The independent contractor model of general practice service delivery brings important benefits and must be nurtured and maintained as an option going forward. It has been a trailblazer for innovation in general practice and created the excellent service that patients rely on and value, as well as providing great value for money to the NHS. This continues today with many GP partnerships taking the lead in developing new models of care.

'The college recognises that the partnership model in some areas is struggling – principally as a result of years of underfunding, and recruitment difficulties – but this is not a reason to give up on it.

'We were encouraged last week that NHS England’s updated Five Year Forward View plan reaffirms its commitment to delivering the GP Forward View, which pledges £2.4bn extra a year for general practice and 5,000 more full-time equivalent GPs by 2020. This must be the government’s priority – not a top-down reorganisation of our service that will only serve to destabilise general practice, the wider NHS, and the care we deliver to our patients in the community.'

GP workforce

BMA chair Dr Mark Porter said: 'This report highlights what we have been saying – that the NHS desperately needs a long-term strategy to deal with the funding and staffing problems threatening the delivery of high-quality care.

'The committee is right to identify the serious and ongoing problems in recruiting and retaining NHS staff, and the morale damage of years of ongoing pay restraint. Only last week, doctors got yet another real-terms cut in pay despite working harder than ever before. At a time when GPs are unable to keep up with the number of patients coming through the surgery door and hospital doctors are working under impossible conditions, our government should heed the committee’s recommendation and allocate the investment needed to match the promises made.

'It is important that general practice continues to evolve to meet the changing demands of patients, especially those who need more intensive, complex and flexible care in the community. Many GP practices are, with the BMA’s support and leadership, exploring new ways of working, including forming federations or networks to pool resources and plan care for their local populations. A "one size fits all" model won’t do this. General practice’s great strength is its flexibility, and smaller practices can work just as well as larger units in providing services that their patients want. The biggest threat to smaller practices is not their organisational form, but the pressure that all parts of the NHS are under from rising demand, unnecessary bureaucracy, stagnating budgets and staff shortages.'

Photo: Ian Bottle

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