General practice seems to be at a major crossroads. There is a widely recognised GP crisis, with unfilled posts, resignations from partnerships, early retirements, retention issues and patients waiting weeks to see a GP in many areas.
The proposed new plans for primary care networks (PCNs) – the draft network DES service specifications - released just before Christmas have certainly thrown fuel on the flames, causing a national outrage amongst grass roots GPs, LMCs and PCN leaders.
The GPC has rejected the plans outright, meanwhile the RCGP has also called for a complete rethink and a fresh start. Given this unprecedented resistance to the proposals, it seems we may be back to the drawing board again.
It is incumbent on NHS England to agree a suitable and workable set of plans before the end of March 2020 that will help relieve the demands and pressures facing general practice. The backlash to the proposed contract changes provides an opportunity now to pause, think, reflect and consult – and come up with alternative proposals that will improve patient care, be realistic to implement and be cost effective for the NHS.
Here are a few practical suggestions ‘from the coal face’ that I think NHS England should consider. These are based on my own local experience and from listening to and reading opinions from colleagues nationwide.
Allow for local innovation
Allow for local innovation and stop the ‘mushroom management’. Recognise that PCNs are fledgling organisations. The complexities of working in teams with other GP practices to provide local population-based health cannot be underestimated. When PCNs were introduced (without consultation) one of NHS England’s stated aims was for PCNs to look ‘at what the population needs and select areas to work together on a service improvement project'.
Do not re-invent the wheel
Look at any schemes that are thriving and proved to be successful within existing PCNs and offer a selection of these nationally as part of the DES. Example we have seen locally include an in-hours ‘home visiting service’ (this could work within a PCN or a cluster of PCNs), near-patient testing for (streptococcal) sore throats to signpost minor illness to a pharmacist and reduce antibiotic prescribing and in-house first contact mental health workers. Most primary care teams are dynamic and innovative and will thrive when given patient-centred opportunities that also relieve workload.
Allow local flexibility
Give PCNs local flexibility and choice for workforce planning. An MSK practitioner or social prescriber may benefit one PCN, while another network might need a mental health worker, paramedic, or extra pharmacist. The staff employed should match the needs identified. The current rules seem too prescriptive. Many PCNs have been unable to use their available staff funding budgets for this reason.
Look for the gaps in the QOF and close the loop via the PCNs
One example would be formal screening for pre-diabetes in high-risk groups, referring patients into the NHS Diabetes Prevention Programme and maintaining a pre-diabetes register with annual monitoring. This is evidence-based and highly cost effective. Another example would be safe monitoring of high-risk medication (DMARDs, NOACs, ACEs, ARBs, diuretics and NSAIDs) to ensure that a formal audit process and safety checks are in place nationally.
Invest in essential equipment
For example allow a budget per patient per annum for a range of essential equipment that would benefit patients care. Items might include an AED, emergency bag for visiting paramedics, ambulatory BP/ECG monitors to reduce cardiology referrals, dermatoscopes to reduce dermatology referrals, near-patient testing kits and paediatric pulse sats monitors to name a few. Once again the emphasis would be on flexibility for each PCN to use the funds available based on local needs (and without increased bureaucracy).
Resource and value administrative support
Recruiting and training staff – who are then expected to work across a number of practices – takes time and energy. Networks clearly require extra funding to support HR, administration and training needs. Funds can be reasonably redeployed within the DES for this purpose.
Allow for local population-based health education
Think about promoting group educational classes as part of the DES (for example pulmonary rehab, weight management, smoking cessation, diabetes care, cardiac prehab)
Resource staff training via PCN
Financially support and encourage group training and teaching via the PCN (for example for mandatory training such as basic life support and adult & child safeguarding)
We have to do this for our PDPs each year and NHS England should do so too. Only introduce new plans that are Specific, Measurable, Achievable, Relevant, and Time-based (one could argue that not much of the draft specifications fell into this acronym). Ensure that box ticking, data collection and bureaucracy is reduced, not increased.
Stop the quicksand approach
Please negotiate and agree that there will be no further unilaterally imposed changes for the next four years (to complete the initial 5 year PCN plan) to allow these new organisations to settle in and start to offer local personalised population healthcare.
As stated in a previous article many of the issues currently facing general practice have relatively simple solutions, however implementing them requires sustained political will and focus.
- Dr Simon Hodes (@DrSimonHodes) has worked as a GP partner in the same Watford practice since 2001 and is also a GP trainer, appraiser and LMC rep. The views expressed above are his own.