In this time, the proportion of the NHS budget allocated to general practice has shrunk from 10% to 8%, while, last year, primary care spending fell by 1.4% just as secondary care spending rose by the same proportion. Similarly, while the number of consultants has increased by 49% in the past decade, the number of GP partner principals has fallen by 4%.
At present, what we have, then, is a centralised secondary care-led NHS that leaves meagre scraps for primary care; what we need, in line with the health secretary’s rhetoric, is a primary care-led NHS that uses secondary care expertise and technology only when necessary and appropriate. To achieve this, we all need to up our game as clinical commissioners and as providers of services to the frontline.
Clinical commissioning emancipates frontline clinicians to have a say (however indirect) on what services patients receive and, in the interests of the NHS, places the onus on all of us to make the best use of scarce resources. To realise these objectives, however, some rules need to change. Firstly, the tariff system (Payment by Results) is uncompetitive. Where hospitals can attract as much ‘custom’ as possible and be paid ‘per unit’ of care, general practice and primary care have to make do with a fixed sum (approximately £130 a year). This system is largely responsible for the flow of money from primary to secondary care experienced in the past few years. Secondly, separating the primary care and secondary care budgets makes it all the more difficult to transfer resources between the two and support general practice to do more for its patients in the community.
It is important that clinicians and patients – as members of CCGs – hold both the primary care as well as the community and hospital services budget. In line with this, it would also be logical for specialists to be employed by CCGs rather than hospitals, so that they can join forces with local GPs rather than wait to see the 10% of patients who walk through their hospitals’ doors. These suggestions will always attract howls of ‘conflict of interest’, but these can be silenced by clinicians accepting lay majorities on CCG boards and general practice providers (and all NHS providers for that matter) being entirely transparent on how NHS money is spent.
Just as we must change the rules to free clinical commissioners, we must also make it easier for general practice to extend its remit locally. This means local commissioners and GP practices being able to develop a model of ‘GP Plus’ that allows them to care for the elderly in the community, extend their ability to treat long-term disease and play a significant role in creating healthy communities. GP practices will deliver these services as federations or social enterprises, or profit or not for profit limited companies. These models are already in operation around the country. What is important, however, is that, in developing their services and business plans, they and their CCGs are not stalled by the Office of Fair Trading or other red tape around conflicts of interest, when they can show that they are cost-efficiently improving the health and services available to their communities.
General practice will need more people and resources to realise this vision, and the government is committed to supporting this. With this support behind it, we must now step up to the plate and show those features of resilience, adaptability and commitment that have always been the hallmark of progressive general practice. At the same time, we must be prepared to challenge and, where appropriate and by mutual commitment of patients and clinicians, even change the rules that stop us doing the right thing. These may not be the best conditions in which to launch of a new era in general practice, but as commissioners with central support to develop services around general practice, and with our potential to relate to individual patients as well as local patients collectively, we now have more cards in our hand than ever before.
It is no secret that the NHS needs to start delivering more for less. General practice has a significant role to play in this, and we only have to reduce hospital use by 2% (from 80% to 78% of resources) to be in a position to increase resource for general practice by 25% (from 8% to 10%). It is easy to say this is impossible; it is more courageous and better for patients and the NHS to try our best. When general practice has done that in the past, it has invariably succeeded.