The Fund believes that the future of general practice rests on a combination of investment and reform. Investment is needed to reverse the decline in the share of the NHS budget going into general practice. Reform is needed to improve the working lives of GPs and the experience of patients.
The priorities for investment include recruiting more staff to work in general practice and modernising premises. The priorities for reform include using the skills of all members of the primary care team and embracing the opportunities offered by information technologies.
Benefits of working at scale in federations and networks are considerable
The importance of the practice and registered list as the organising principle of primary care should never be underestimated. At the same time, the potential benefits of working at scale in federations and networks are considerable. These benefits include offering access to patients outside normal working hours by taking shared responsibility for seven-day working and providing a wider range of services than most practices are able to deliver on their own.
The decision of practices in many parts of the country to work together shows that the case for federations and networks is increasingly understood and accepted by GPs. The emergence of super practices like Vitality in Birmingham, chosen by the prime minister as the location for his first speech on the NHS since the general election, is further evidence that the cottage industry model of general practice is on the wane.
To be sure, there are risks in these developments, including loss of continuity for patients, and reduced autonomy for GPs in a more organised model of family medicine. It is particularly important that the discretionary effort GPs have traditionally put into running practices they own is not lost, although growth in the number of salaried doctors has, for some time, created a divide between GP partners and providers.
The bigger prize on offer from new ways of organising general practice is for GPs to lead the development of integrated out-of-hospital services. Our analysis of emerging models of primary care in England underpinned the argument we advanced last year for family care networks to be developed. These networks would be led by GPs and encompass a range of community services, out-of-hours primary care, and some specialist services usually provided in hospitals, as has been proposed in the NHS Five Year Forward View.
Contract negotiations between the government and the BMA provide an opportunity
We proposed that a new contract should be available to GPs wishing to develop family care networks. The contract would offer funding for a much wider range of services than usually provided by practices and would be linked to the delivery of outcomes including access to care, patient experience, and clinical quality. Next year’s contract negotiations between the government and the BMA provide an opportunity to put this in place alongside existing contracts.
New models of integrated out-of-hospital services are best led by the federations, networks and super practices, but if GPs choose not to work in this way then the new contract should be available to other providers including NHS trusts working in partnership with GPs. The leadership expertise available in NHS trusts will enable GPs to manage budgets and services on a much bigger scale than they are used to and also to access the resources needed to invest in technology and premises.
Family care networks could also help improve the working lives of GPs by offering a range of flexible working arrangements. This is critical if general practice is to be an attractive choice for newly qualified doctors and to offer job satisfaction for GPs later in their careers. The experience of Group Health in the United States, which redesigned how its primary care teams work to tackle burnout among family doctors, is a practical example of how this can be done.
The ingredients in Group Health included use of email and telephone consultations and of the full range of skills in the primary care team, including medical assistants and pharmacists. These changes were possible because of the expertise available to family doctors and their colleagues within the organised framework of care available in Group Health. Just as important, they entailed using resources differently, not just doing more of the same.
The ideas put forward here are most likely to gain traction if they are embraced by doctors themselves, extending the advocacy by the RCGP of GP federations since 2008. The alternative is an unedifying stand-off between the government and the BMA in which the needs of patients take a back seat. Now more than ever the medical profession needs to demonstrate leadership and to embrace reforms which are good for doctors and for patients.
* Professor Ham is chief executive of the King's Fund and this blog was first posted on its site.
Read King's Fund report: Commissioning and funding general practice
See King's Fund resources on primary care