Primary Care in the post Five-Year Forward View World
The NHS, its financial position, its sustainability and its services, are at the centre of attention and the subject of copious column inches in both the general and specialist press. Primary care is very much at the heart of the NHS, focussing around the concept that everyone in the population has access to a family doctor through the system of registered patient lists.
GPs are, however, facing a tidal wave of issues: a steadily growing requirement for accountability leading to greater administration and more paperwork, regulation by the CQC, pressure to open 7 days a week and for extended hours, a reducing number of GP candidates, a partner recruitment crisis and a general diminution in financial returns despite the increased hours and increased stress.
It is vital that we do not forget or underestimate the importance of primary care. One of its great strengths is its geographic accessibility and, for the patient, a practice to which they "belong". Many would probably say that their GP is at the core of their access to medical care and that the "free at the point of delivery" concept is fundamental to healthcare in this country.
The importance of primary care is acknowledged in some of the new models of care which have been identified in the Five Year Forward View. Both the Multi Speciality Community Provider (MCP) and the Primary and Acute Care Systems (PACS) anticipate the integral involvement of primary care. The models in the Five Year Forward View are not prescriptive and the MCPs and the PACSs are described in such a way that gives flexibility. Indeed, there has been speculation that in due course the two models could well morph into one.
There are already examples of new structures. Southern Health, a community and mental health trust and one of the MCP vanguards, has announced a model which includes opening a shared branch surgery to deliver 8 am – 8 pm access 7 days a week to support the local GP practices, as well as arrangements with GP practices where there have been recruitment crises. Lakeside Healthcare, also an MCP, is a growing partnership of GP practices with ambitions to expand its combined list to 300,000 patients. In Birmingham and Sutton Coldfield "Our Health Partnership", although not officially one of the vanguard new models of care, is embracing the opportunity to look at new structures, new approaches and new services.
Reading comments in the specialist press about these new models reveals GPs' concerns. Expressions such as "the end of general practice as we know it", "privatisation", and practices "ripe for the picking by the chaps in red braces" abound, and there are concerns that patients won't like it.
It is important that we do not confuse structure with substance. Times have changed since 1948 – bigger population, growing percentages of elderly patients, more chronic illnesses. The reality is that the nation's health and care budget has to do more for more people.
GPs want to retain their clinical autonomy and be able to deliver the best available care for their patients, two objectives which resonate with patients. Today, however, that means a closer relationship between primary and secondary care and breaking down the barriers between health and social care. In turn that means rethinking structures of delivery, for the longer term benefit of the patient.
The transition may not be easy. No-one knows what primary care is going to look like post the Five Year Forward View. However, now is the time for GPs to get involved in shaping the future.
The move towards GP federations in many areas has enabled GPs to take better control of their destiny. As a federation they can present themselves as a unit, for external purposes, whilst retaining their autonomy as far as their patients are concerned. Whilst many want to continue to run practices from premises in their existing localities, there are others for whom the responsibilities of premises and funding are not attractive. They may want the federation to employ them, take on their premises and de-risk their practices to enable them to survive. A federated structure allows flexibility. For those who want to retain their "independence", membership of the federation can provide back office support, remove the administration and allow GPs to focus on clinical services. The federation's ability to employ specialist staff means that all member practices can offer a wider range of services to their patients.
The federation can also be a single entity which can enter into arrangements with NHS Trusts, Foundation Trusts, voluntary organisations and others to deliver a more joined up service for patients.
And what of the concern that patients won't like a new model of care? If patients are receiving good quality clinical care, free at the point of provision, have access to a wider range of services and therefore less visits to hospital for out-patient services, and an ability to book an appointment within a sensible timescale, they are likely to be happy. That may involve some changes to the patient experience – on-line booking of appointments, checking in on a computer screen on arrival at the practice, triage, more nurse practitioners. That does mean patient education particularly by the practice. However, if patients can see that they are getting what they need and are introduced to the changes in an appropriate way, they are more likely to accept them.
GPs don't want to work in a land of corporates but they need to be involved, both for their own benefit and for their patients, in the change process. By embracing change now and helping to shape the offering, they stand a far better chance to remain in control of their own destiny.
Article originally published in One Big Society.