General practice across the UK is in deep crisis
Here we launch a discussion on general practice, the crisis it faces, NHS England's proposals and we propose a campaign with a charter of demands to restore the best of the general practice model in order to deliver the excellent primary care our population deserves.
Here are extracts of our discussion paper written by Dr Louise Irvine, GP in Deptford, South East London and chair of the Save Lewisham Hospital Campaign - this can be read in full here.
General practice across the UK is in deep crisis. Over the past decade funding for General Practice has fallen in real terms; there are fewer GPs because of reduced recruitment and retention, in part due to impossible workloads and soaring stress levels; and many practices have been forced to close. Patients are unable to get appointments to see a GP for weeks, and are even less likely to see a GP that they know and who knows them personally.
This is tragic because British General Practice, based on the principles of personal, continuing, community-based care, has proved over many decades to be clinically effective, efficient and popular. Not only has it enjoyed high levels of patient satisfaction, with patients consistently expressing their preference for personal continuing care with a GP they know, but there is strong evidence that “continuity of care” saves lives and protects patients from unnecessary and harmful interventions, thus being cost effective as well as clinically safe and effective. Yet, despite the remarkable achievements and popularity of this system of care, Government policy in England over the past decade has actively undermined General Practice and led to the crisis that it currently faces.
Successive government policies in England have underfunded General Practice (funding policy in England inevitably also determines funding for the NHS in the other UK nations) and undermined its core essence, in particular continuity of care, by favouring “access” at the expense of all other values, by promoting a corporate model of GP provision and by promoting “General Practice at scale”. As a means of survival many GPs have opted or felt coerced into merging with giant “super practices” of hundreds of thousands of patients. Others have chosen to be employees of large corporate GP providers, being moved from location to location and developing no deep or long-term connections with patients or communities.
This process began in 2004 with the Labour Government’s changes to the GP contract, allowing non-GP corporate organisations such as United Health, Virgin and Care UK to provide General Practice services, and has accelerated since 2010 by government policy, which selectively encouraged and promoted “General Practice at Scale”.
“Entrepreneurial” GPs have created mega GP organisations such as the Birmingham-based Modality with over 380,000 patients, the Hurley Group with over 100,000 patients and the rapidly growing GP at Hand, with over 40,000 patients and counting. There is no evidence that these mega practices are more clinically effective or acceptable to patients. Rather they are a response to the desperation of many GPs and the opportunism of others.
It is no mystery that this has correlated with a decline in patient satisfaction with General Practice and a decline in the popularity of General Practice as a medical career, contributing to the crisis it now finds itself in.
Primary Care Networks
It is against this background that NHSE has agreed a new GP contract with the profession that claims to address some of the major issues affecting General Practice, especially funding and staffing.
One aspect of this new contract – Primary Care Networks (PCNs) – has attracted a lot of attention. It is important to find out about what primary care networks are and what they are not. (Read our full discussion paper by Dr Louise Irvine here.) The Primary Care Network contract will not affect the core GP contract (known as the GMS or PMS contract) with its registered list of patients. PCNs are very different to the proposed Integrated Care Provider (ICP) model, promoted by NHS England (NHSE), and which KONP vigorously opposes, whereby GPs would give up their practice contract and patient list and merge into a massive organisation covering upto hundreds of thousands of people.
GPs working together in larger groups across a neighbourhood is not a new idea.
Previous versions have all seemed to follow the same pattern of rise and fall, starting with great expectations only to disappear without trace. However, cynicism apart, virtually all GPs will end up signing the PCN contract because it is the only way for practices to get the extra funding they desperately need, and if they don’t sign up they stand to lose money, through loss of funding for extended hours.
Will PCNs be able to rescue General Practice from collapse?
A wider range of practitioners could usefully complement the role of GPs, just as practice nurses do. However they won’t solve the GP workforce crisis. There is already a shortfall of 7000 GPs. There is a need for more GPs, not fewer. Furthermore, given the NHS staffing shortages with over 100,000 vacancies, it is unclear where the proposed non-GP staff (eg physiotherapists) will come from.
In addition, severe cuts to public health, preventive services, social care and community services have undermined the possibilities of improving care in the community. But being unrealistic never prevented previous grandiose NHS schemes. As the Red Queen said to Alice one can believe ‘as many as six impossible things before breakfast’ – one just needs to practise!
But what about the risks?
Not only are PCNs not the solution to the GP workforce crisis, by diverting resources from core General Practice that could be used for the recruitment and retention of GPs, PCNs are adding to the GP staffing problem. Many GPs fear loss of autonomy from PCNs, especially if more and more funding is funnelled through PCNs rather than directly to practices. Some GPs see PCNs as yet another reorganisation taking up precious GP time and wasting resources. The proposal that any savings from reduced A&E usage or hospital admissions would be shared with PCNs is irresponsible and unnecessary.
Improved community care is a good thing in its own right and if it also reduces unnecessary hospital usage then all GPs would recognise that as a good thing – they don’t need financial incentives for that – they just need community care to be properly funded.
PCNs and the Long Term Plan
The statement in the NHS Long Term Plan that PCNs will be the ‘building blocks’ of bigger Integrated Care Systems (ICSs) – systems of health care planning and provision covering populations of up to a million people – is a cause for concern. But PCNs progressively merging into bigger organisations and ending up in ICPs (ACOs) is not an inevitable outcome. Whether a final apocalyptic possible future actually happens or not is dependent on the outcome of political forces, resistance and popular struggle. Nothing is inevitable.
What’s more, it is wrong to suggest, as some have done, that this has already happened. To say we have already lost prevents us from fighting effectively to defend what we still have. Let us campaign to restore Primary Care to a well funded, caring, effective personal service for our population. Let us know what you think of our draft Primary Care Charter.
Read Dr Louise Irvine's article in full here. Read on to learn about our draft charter on primary care.
KONP's Primary Care Charter (DRAFT)
In campaigning to restore Primary Care and GP services in the NHS, these are our demands:
FUND THE GP CURRENT MODEL THAT GIVES CONTINUITY
- Support the traditional model of General Practice based on personal and continuing care.
- FULLY FUND IT: Significantly increased core funding to General Practice
- Significantly increase numbers of GPs and Practice Nurses
- Stop the move to merged corporate super-practices
SUPPORT GPs and OTHER PRIMARY CARE STAFF
- Manageable workloads for all staff
- Support staff wellbeing and prevent dangerous stress
BETTER ACCESS FOR PATIENTS:
- Prompt access to your GP – end long waits for appointments
- Prompt access to your Practice Nurse
- Prompt access to other primary health care staff in the community
- Prioritise easily accessible services within a short distance of home
RIGHT TO SEE YOUR GP – FILL THE VACANCIES:
- The right for patients to have face to face appointments with a GP
MULTI-DISCIPLINARY TEAMS ADDITIONAL TO, NOT REPLACING GPs
- Increased numbers of community staff such as district nurses
- Collaborative multi-disciplinary networks, small enough to be sensitive and responsive to local health issues and accountable to local people.
- Adequate wider services to support primary care in the community including social care, public health and mental health services.
- Strong links with local hospitals and improved communication and collaboration between primary and secondary care.
PATIENT & PUBLIC ENGAGEMENT IN PRIMARY/COMMUNITY CARE
- Opportunities for genuine patient and public involvement in the development of community services
Read Dr Louise Irvine's article in full here
Join Keep Our NHS Public today!
I felt that ambivalence which Dr. Irvine describes when delivering Dr. Bob Gill’s template letter to ‘my GPs’ suggesting they do not sign the contract. It is after all his/their private business. That didn’t matter previously because I had confidence in the NHS, its motives especially. That confidence has now gone and only suspicion and disquiet remain in this secretive, corporate health business we now have.
Thank you Judith. I would add that we have not lost this battle for the NHS – far from it. KONP, our local groups, our supporters and allies are campaigning to keep the NHS public and to renationalise what has been privatised. 92% of NHS clinical services are still in public hands. The huge risks are there: the majority of relatively small community contracts are going to non-NHS organisations (private and voluntary) and huge contracts are threatening to privatise NHS pathology and imaging services. We are fighting these. But we have significant wins too. And … we have just won the battle to keep Charing Cross and Ealing Hospitals open after 7 years. We are discussing now a charter of demands to strengthen primary care. Do join us if you have not already done so.
Thank you, Louise, for your “checklist”. I will present it to Hammersmith Council, which backed the Charing Cross and Ealing Hospitals campaign and which is fighting proposed cuts by H&F CCG to primary care and community services. The only way to stop the A&Es being overwhelmed is by making a career as a GP attractive again. But this Gov would simply not understand anything as simple as this notion! If it doesn’t have £ signs next to it, they can’t understand….