Why partnerships are not dead, according to GP leading major government review

The GP leading a government-backed review into how to revive the GP partnership model talks exclusively to GPonline about the 'mammoth task' ahead of him.

Dr Nigel Watson (Photo: JH Lancy)
Dr Nigel Watson (Photo: JH Lancy)

'Life would be a bit boring if you didn't accept challenges,' says Wessex LMCs chief executive Dr Nigel Watson.

Nonetheless, the GP hand-picked to lead a government-backed review into how to reinvigorate the GP partnership model admits that he has taken on a 'mammoth task'.

The latest GP workforce statistics show that he will have to stop - and ideally reverse - what has become an exodus from partnership roles in recent years. More than 2,200 partners have been lost to general practice in England since September 2015 - a massive 9% drop.

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Dr Watson's approach, however, is straight from the consulting room. 'Tell me a problem and I will find you a solution. Right from being a GP with a patient in my practice, that is part of my personality.'

The review chair insists he has no preconceptions, but accepts he is 'also not starting with a blank sheet of paper'. That's probably a good thing, given that the review is aiming to produce an interim report by early autumn and final recommendations by the end of December 2018.

The New Forest GP has chaired a vanguard project trialling new models of care, has been involved in the GPC's commissioning subcommittee for a decade, and has been working within one of the country's largest LMCs 'for longer than that, trying to support GPs and make general practice a better place to work'.

He says: 'I have come to the conclusion that the partnership model has not reached the end of its life - there is more we can do. But practices need to be working together to deliver more at scale.'

General practice at scale

Developments such as integrated care organisations show the NHS is ‘moving away from an activity-based system’ to focus on whole populations. Strong GP partnerships ‘delivering high quality in our practices, but taking ownership of what happens across the population’, through primary care networks, are likely to be the future, he suggests.

Dr Watson is convinced that 'lots of things are aligning at this time' that could boost the chances of the review making a difference.

'The secretary of state is arguing we need more investment in the NHS,' he points out. 'There is an argument that we need to stop just pouring money into hospitals, we also have the [state-backed] indemnity discussion and changes to the GP contract in Scotland.'

Reviews of the GP contract funding formula, premises, QOF and other issues are also ongoing in England - and the DDRB could yet recommend a significant pay uplift this month.

Partnership crisis

But the problems fuelling the partnership crisis are broad. Full-time equivalent GP numbers have dropped sharply since the health secretary set out plans to increase the workforce by 5,000 by 2020/21.

'General practice won't survive if we can't recruit enough GPs,’ says Dr Watson. 'It can’t carry on with a reduced workforce. Even those that want to go into partnership don’t necessarily want things as they are at the moment.

'To retain older doctors and attract younger ones, we have to make it a job worth doing – but many say workload is uncontrolled, they are working 14- to 16-hour days trying to get the work done.'

Problems with the relentless workload were highlighted by a recent GPonline poll that found most GPs take no breaks during a clinical session, and many struggle to do so in a full working day. 'It comes down to workload and capacity,' says Dr Watson.

'As independent contractors we can design our day how we want,' he says. 'But you have to get through a certain amount of work - if you don’t have numbers of people to deliver it, it falls back on partners. In the past we had a lunch break, now we work through the day – if you take time off you just work later.'

GP funding

Funding is clearly a huge issue that the partnership review will have to consider. Profit per partner fell around 25% in real terms in the 10 years after the QOF was introduced in 2005/6 as investment in general practice slumped.

'We’d be foolish to think that a sum of money coming in would solve all the problems,' Dr Watson warns. But he adds that general practice 'has a smaller share of the NHS budget than 10 years ago, and needs more resources'.

The review chair says: ‘With financial restraint, to get more resources into general practice we have to work with government and others to find out how we can do it and do it effectively.’

Unlimited liability for partners is another factor - the significant personal financial risk doctors take on when they become GP partners, says Dr Watson.

Even new models of care backed by the government have faced barriers to success, he adds. The primary care home model, which now covers about one in eight people in England, has 'had little investment'. 'If you are going to incentivise transformation, you need resources to be put into it. And vanguards struggled to get community services to work in an integrated way with general practice.'

Outside factors

Factors outside general practice are also clearly having an impact on its sustainability. Cuts to social care, district nursing and other community health services have all helped drive up pressure on GPs. 'Those things do have an impact - everyone pushes work away and it lands on general practice.'

'We have to be careful the review doesn’t become so broad it tries to sort out everything in the NHS. But clearly there will have to be statements about resources being made available and other things that need to be done.'

Initially the review will 'look fairly widely', before narrowing its focus, says Dr Watson. He plans to visit areas across England to understand different ways of working, identifying what is working well.

Although involvement and support of the RCGP, GPC, NHS England and the DHSC is important to the review's chances of success, he is determined that its recommendations should reflect views from the front line, not just those of the 'great and good'.

Dr Watson is working with the chairs of the RCGP and GPC on an overview of what the review will consider; a wider reference group will be consulted on establishing 'what the issues and potential solutions will be'; and a working group of GPs and others will be consulted regularly. The review will also invite comments and use social media to drive engagement.

'The number one goal is that we produce a list of recommendations the government can get behind that will make a real difference to general practice, and reinvigorate it. Make it a place people want to work in - get more doctors wanting to be GPs.'

Those recommendations 'have to include things that make an immediate impact', Dr Watson says - alongside recommendations for the longer term.

Lessons from NHS history show that a one-size-fits-all approach is unlikely to work, he adds - pointing to the roll-out of Darzi centres across England under the last Labour government as an example of a good idea becoming 'lost in a rigid national policy'.

Dr Watson says he is ‘honoured’ to have been asked by the government to lead the review, with support from the RCGP, the GPC and NHS England. ‘A bit of me is fearful, but it is an opportunity to find solutions to the problems we face. I am keen to work with others to deliver real changes that will be supported by the frontline and help general practice as it evolves over time. But to have any validity, it has to have an impact for front-line GPs in practices.’

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