NHS England chief executive Simon Stevens told the House of Commons health select committee last month that he had a vision of how primary care in Birmingham might be delivered in future.
He envisaged two large groupings of GPs - the Vitality Partnership (see box below) and one other - that would employ geriatricians and other physicians. Some of the city's GP practices would choose to remain unaffiliated.
A hospital trust in the city might then be told it could provide general medical services across the Birmingham CrossCity CCG area, where there is a bulge of GPs approaching retirement.
Mr Stevens admitted he had not discussed this in any great detail with people on the ground in Birmingham, but this is the sort of radical, locally driven overhaul of primary care services that NHS England's Five Year Forward View blueprint for the health service outlines.
Jointly published with the CQC, Monitor, the NHS Trust Development Authority, Public Health England and Health Education England, the document sets out new ways of working that the centralised health bodies hope will flourish organically around the country, with different geographical patches tailoring the models to their unique set of circumstances. On the face of it, there is much for GPs to like.
New deal for GPs
The document talks of a 'new deal' for GPs, with core funding 'stabilised' over the next two years, a much higher proportion of the NHS budget spent on GP services, more funding for primary care infrastructure, incentives to encourage GPs to work in under-doctored areas and CCGs being given more power to shift work out of hospitals.
The report says: 'It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospital, between physical and mental health, between health and social care, between prevention and treatment.'
It outlines new models that it expects to spring up, with the common thread being integration, either horizontal or vertical. Multispecialty community providers might target services at registered patients with complex needs, and it could be made easier for extended group practices to form as federations, networks or single organisations.
These might employ consultants or take them on as partners. They could run local community hospitals, expand diagnostic services and eventually manage the budget for their registered patients, the document says.
Primary and acute care systems could form as single organisations to provide NHS list-based GP, hospital, mental health and community services. Acute trusts could open GP surgeries in areas struggling to recruit GPs.
But a key part of the plan is to develop prototypes and then let health economies choose the most suitable for adoption.
In Birmingham, LMC chief executive Dr Robert Morley says there are already two large-scale GP organisations in his city. One is the Vitality Partnership, the other, the Midlands Medical Partnership, comprising 33 GPs across 10 surgeries with more than 60,000 patients.
The Midlands Medical Partnership aims to 'improve and develop all that is excellent about traditional GP services'.
'Really the only way to protect the GP-led model of primary care is for larger groupings of GPs to work together and we need to look for business models that can deliver that,' says Dr Morley.
'The move towards larger organisations is inevitable because of the way the NHS is going and the small cottage industry model is becoming increasingly unsustainable.'
But Mr Stevens' suggestion that hospital trusts could take on primary care services in his city is anathema to Dr Morley: 'The worst possible scenario for general practice would be foundation trusts providing GP services. It would signal the end of general practice as we know it and destroy its ethos.'
GPC deputy chairman Dr Richard Vautrey backs many of the report's proposals and wants politicians to 'act urgently' to deliver them. But he says: 'I would be very concerned if hospital trusts in cities started taking over general practice.
'The reason some practices are increasingly unviable is that they are seriously underfunded, struggle to recruit new GPs and work in very poor premises.
'Many areas have found solutions to these problems and it is one of the reasons the average practice list size is steadily rising. It may be that such practices working more closely together with others in their area can provide a viable model, but there will still need to be long-term, sustainable funding provided.'
Dr Vautrey says the report notes the risks of vertical integration - it says precautions must ensure acute trusts running GP services do not simply use them as 'feeders' to push work to hospitals.
The RCGP also likes much of the report, but fears vertical integration could undermine general practice. Chairwoman Dr Maureen Baker says: 'Models under which GPs are made employees of hospitals - and therefore can no longer independently advocate for their patients - should only be considered if there is very good evidence for doing so.'
In Northumbria, the local foundation trust is not looking to employ GPs yet, but is developing 'Northumbria Primary Care', to provide support and back office functions for GPs in the area.
The proposals are still being drawn up and Northumbria Healthcare Foundation Trust would not comment in detail until the arrangement had been signed off. But the idea is that support to GPs will be provided on a tiered basis, so GPs can control the level of support they need.
Northumberland LMC secretary Dr Jane Lothian, who is GP clinical director at the foundation trust, says her trust is bridging gaps between primary and acute care.
It has designed pathways and held joint clinical education sessions for hospital consultants and GPs to bolster relationships.
Dr Lothian says that unlike parts of the country that have greeted the report with 'some alarm', GPs in Northumberland were 'not surprised' by its content.
'We have a tradition of looking at other ways of working, and we are already working towards much of what it suggests,' she says.
Drivers behind the report apply just as much in rural areas as they do in the cities, she adds. 'I see no reason why this should be the sole preserve of metropolitan areas.'
|Case study - The Vitality Partnership|
The Vitality Partnership, based in Birmingham and Sandwell, in the West Midlands, describes itself as the first 'GP super-practice'. It began five years ago when two GP practices merged with the aim of developing integrated services in primary care.
It is still a single GP partnership, but now operates from 13 locations and holds a list of 65,000 patients.
The partnership employs hospital consultants to deliver services such as rheumatology and dermatology, alongside GPs with special interests, and operates its own X-ray service.
It created a 'health hub', which will eventually act as a single point of access for patients from any practice in the partnership.
So far, the hub can be accessed by telephone or online by patients from two practices, but the intention is for it to open for person-to-person GP consultations in the future.
As part of the technological development, practices within the partnership now guarantee that patients can speak to a GP or nurse within an hour of contacting the practice by telephone, via the internet, or through an app.
If the doctor or nurse thinks the patient needs a personal consultation, they will be given an appointment that day.
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