The consultation, part of the wider NHS Call to Action, launched by chief executive Sir David Nicholson last month, asks primary care staff and patients for their views on how general practice can transform in response to ‘increasingly unsustainable pressures’.
The review, headed by NHS England’s deputy medical director, GP Dr Mike Bewick, identifies the aging population, growing comorbidities, increasing patient expectations, workforce pressures, persistent inequalities in access and quality, and increasing financial pressure, as the challenges general practice must face.
Dr Bewick told GP he was ‘looking for innovative ideas and ways of working to adapt to that challenge’.
‘This is really a call to action in terms of getting people to think about what they want their system to look like in future years. We are not trying to tell people they have to reorganise, although there will inevitably be some kind of reconstitution of how the services work.’
The consultation documents ask healthcare professionals and patients their views on proposals covering every aspect of general practice organisation.
- Using the GP contract to create stronger focus on whole-system outcomes
- Defining high quality general practice and its responsibilities and accountabilities through the GP contract.
- Tackle poor performance and bring in new providers to stimulate innovations and improve capacity
- Going further in publishing an increasing range of comparative public information
- Create space for clinically led innovation
- Develop QOF, preserving its essential features but creating more flexibility and reducing the feel of a tick-box culture
- A joint concordat with partners to reaffirm and refresh the core features of general practice.
- General practice at the heart of integrated out-of-hospital services.
- Stronger incentives for inter-practice collaboration.
- The potential future role for PMS and APMS contracts in stimulating innovative approaches, or addressing local challenges.
- Stimulating new, innovative provider models .
- Potential for primary care plus contracts, built on co-commissioning between NHS England, CCGs, and local authorities.
- Improve workforce recruitment and retention.
- Named clinicians responsible for coordinating patients’ care.
- Strengthening GP accountability for out-of-hours.
- More convenient routine access, and more responsiveness to access preferences.
- How far should resources be shifted from acute care to general practice?
The consultation launch was welcomed by the RCGP as a ‘much needed and long overdue’ opportunity to look at general practice’.
The BMA responded more cautiously, emphasising that GPs were suffering from rising workload and falling resources.
Dr Bewick said the consultation would look at how funding was released from secondary care as primary care is asked to pick up more work. But, he said, there had to be incentives for secondary care to decommission services as well, so some savings had to be reinvested in hospitals.
‘That will be a grown up debate between CCGs, primary care and area team about how you commission services across the piece.’
He said there were savings to be made across the system that could be reinvested.
Dr Bewick acknowledged that one of the problems addressed by the consultation - the ‘persistent inequality in access and quality of primary care’ - was caused partly by funding.
‘The inverse care law still applies’, he said. I don’t think I know any clinicians who believe where you have poor outcomes, be it in mortality statistics in secondary care, or be it in access in primary care, that they are actually equal across the patches. And most would equate that to a lack of funding in out of hospital care.’
The review aims to get CCGs and NHS England area teams together, looking at whether ‘alternative provision or increased provision or capacity’ were necessary, which could help address problems of inequality, said Dr Bewick.
While flexibility exists in the GP contracts to achieve ‘whole-system outcomes’, Dr Bewick said there was no reason why other models could not be used.
American-style accountable care organisations could be used to deliver primary care, ‘where you are asked to deliver a set of services, you receive a budget for that, and you are judged on the outcomes’.
On the consultation’s QOF proposal, to reduce the ‘feel of a tick-box culture’, Dr Bewick said this would not be a debate about changing the QOF. It was about sharing best practice on how to implement the QOF.
‘I don't think we want to throw the baby out with the bathwater. It genuinely was a transformational change, introducing public health into primary care. There is a danger of it becoming all-consuming. But the best practices are not particularly concerned about that because they use the whole of their practice teams to do it, not just the doctor in the consultation.’
‘I don't think there is any intention in the short term to change QOF, as it stands’, he added.
RCGP chairwoman, Professor Clare Gerada said: ‘It is very encouraging to see that the strengths of general practice and its position at the centre of the NHS are so readily acknowledged and that GPs, other clinicians and patients in their communities will have such a strong influence in the engagement process and the results it produces’, she said.
GPC deputy chairman, Dr Richard Vautrey said: ‘The call to action contains a number of positive starting points that the BMA will be happy to discuss further with NHS England.’
He said declining resources were putting practices under severe strain, and the imposed contract changes had cut average practice funding while giving GPs more admin work.
‘We need to recognise that rising workload will require increased funding for general practice as well as a commitment from the government to empower GPs, patients and other healthcare professionals to use their experience to help shape services in the future’, he said.