Models of care: GPs can reshape their role to control workload by 2020

GPs will be working very differently in 2020, says Dr Mark Spencer. At a time of unprecedented pressure, the profession can use this change to reshape its role and manage workload, argues the New NHS Alliance co-chair.

How will GPs be working in 2020 and what will their clinical workload look like? Well, it’s hard to be sure given these uncertain times, but one thing is for certain - that by 2020 we’ll all be working very differently to how we work now.

Whatever comes our way I feel that, alongside all the innovation and new ways of working, we should maintain the strengths and traditions on which general practice is built. This includes long-term continuity of person-centred care, as well as caring for families and having a responsibility for improving health across a community.

Primarily, GPs are clinicians. At present, GPs feel that they are being pulled from pillar to post by expectations that they are all things to all people, all the time. My view as to why so many GPs are retiring early is that they feel that they are not in control of their clinical workload, let alone all the increasing admin and managerial stuff.

Protect GPs' role

By 2020, yes, nurse practitioners and clinical pharmacists will be managing a fair amount of minor illness, and paramedics will be doing some of the home visits. So what is it actually that GPs will be doing, clinically? There will undoubtedly be continued sub-specialisation within general practice, with more GPSI’s in key clinical conditions such as mental health, diabetes, COPD and heart failure but we also need to maintain enough 'generalists' to manage complexity.

One of the less favourable aspects of hospital-based care in recent years has been the loss of the generalist physician. Every consultant seems to be a super-specialist these days. The only true generalist left is the GP and this role needs protecting and enhancing.

Experienced GPs will become scarcer. So, we should concentrate this resource on areas that can't safely be managed by other community-based clinicians.

I would define these core clinical GP functions as:

  • managing uncertainty and assessing clinical risk.
  • taking ultimate responsibility for clinical decisions.
  • making a holistic assessment of patients with complex, co-existing physical and psychological symptoms.

GP workload

GPs are perfectly comfortable with managing clinically difficult and complex patients but, the problems arise when there are too many other demands on their time from patients that could safely be managed by others.

I would look at the varying organisational levels that GPs would be working at:

  • their own practice.
  • neighbourhood of practices (covering 30,000 to 50,000 patients).
  • health economy (collection of neighbourhoods).
  • I would then divide care into urgent care and planned care.

I think that most community-based ‘urgent care’ patients could be managed at a neighbourhood and/or health economy level, freeing up practice time to concentrate on routine access. Furthermore, clinicians other than GPs, such as nurse practitioners, paramedics and clinical pharmacists, acting as the ‘first contact clinician’, can manage most urgent care patients.

Urgent care GPs would then support these clinicians in the role of ‘consultant in primary care’, primarily managing complexity or significant and/or diagnostically difficult illness. I'd also place GPs in health economy urgent care clinical 111 hubs as part of multi-disciplinary teams.

Primary care consultant

In regards to routine planned care, this is where I'd prioritise ‘generalist’ GP time at a practice level, with patients having the options of ‘face to face’, telephone, video or e-mail consultations with the GP of their choice. This would be particularly for patients with ongoing symptoms but no definitive diagnosis. This is where we need GPs to take responsibility for diagnosis and formulating management plans. Once a diagnosis of a long-term condition has been made, then continuity of management can be taken up by nurses etc, either at practice or neighbourhood level.

A multi-disciplinary team, based at neighbourhood level and led by a GP, best manages patients with multiple long-term conditions. Each neighbourhood would also have access to a number of GPSIs in key long-term conditions.

I therefore see the majority of GPs spending some of their time undertaking routine consultations within their own practices, being responsible for making a diagnosis and putting in place a management plan. The remainder of their time would be spent at neighbourhood or health economy level, either acting in a GPSI role, or as a consultant in primary care in an urgent care setting, or leading a multi-disciplinary team for complex patients.

This model not only re-defines what a GP will be doing, but it also re-shapes what GP practices and neighbourhoods do. It puts GPs back in control of their workload and focuses their skills where they will have the biggest impact.

Dr Mark Spencer is a GP at the Mount View Practice, in Fleetwood, Lancashire and co-chair of the New NHS Alliance

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