A GP manifesto

In an election year we urgently need a GP manifesto as general practice in its present form could be facing an existential threat. Do we need a new model or is the GP partnership fit for the future? The answer importantly depends on what is the expectation of a GP service, and whose expectation should be paramount? The current context being for the year up to October 2023, 358 million general practice appointments were delivered, which is 50.9 million more than October 2019. The increase is equal to 44 extra appointments for every practice, every working day, with more than 70% of those taking place within two weeks of booking. All whilst a diminution of the GP budget to 8% of the already straightened NHS budget, worsening since 2016. General Practice Forward View NHS England 2016 (the most recent comprehensive GP review) – ‘General practice is undeniably the bedrock of NHS care providing over 300 million patient consultations each year, compared to 23 million A&E visits and has one of the highest public satisfaction ratings of any public service. So if general practice fails, the NHS fails. Yet a year’s worth of GP care per patient costs less than two A&E visits, and we spend less on general practice than on hospital outpatients. For the past decade funding for hospitals has been growing around twice as fast as for family doctors.’

People of a managerial or secondary care background often talk of needing GP ‘at scale’ and their model resonates with a ‘factory’ model of relatively impersonal care and driving activity to provide ready access to the service. Some in general practice also are supportive of such a modus operandi. And the Labour Party shadow secretary for health added to the debate, or foretold an existential threat, by questioning the general practice partnership model and certainly casting doubt about the governance of its funding arrangements. In fairness he has pulled back from that view, but we can only watch this space given Labour are likely to be the next government. My view there is little wrong with the current model if patient satisfaction is high, but of course there has been a huge fall in satisfaction with the NHS at large including general practice. The latter, after unbroken popularity, now superseded for satisfaction by outpatient care which of course is a rationed service, whereas the near calamitous falls in satisfaction in other services is mainly due to lack of access. So with focused funding increases, the service which provides nearly 60% of NHS appointments is likely to recover its former high satisfaction.

Should a new GP model be solely focused on speedy access? I venture that general practice can offer its patients and the NHS so much more as it has demonstrated over the years. I quote Prof Kamila Hawthorne, the chair of the Royal College of GPs “The partnership model of general practice delivers exceptional benefits for the NHS. It allows GP teams to innovate and tailor care and services to their local patient populations. It is extremely good value for money for the NHS because it relies on the goodwill of GP partners going above and beyond.” Further, Wilson T, Roland M, Ham C. J R Soc Med 2006 – ‘We identify three areas in which British general practice performs well, leading both international policy analysts and the public to their favourable conclusions: equity, quality, efficiency and three important characteristics that contribute to its success: coordination, continuity and comprehensiveness’ and more holistically Prof Donald Berwick, ‘soul of a proper, community orientated, health-preserving care system.’

It is apparent that UK general practice has a lot to be proud of so what drives the nay sayers? Many GP practices since the covid pandemic have struggled to survive and sought to divest of the ownership of their practices. There are also those who wish a predominantly utilitarian access function approach and, in conjunction with a lack of an empathetic national policy voice and support, there is an existential threat to an NHS success story.

So with an election in the air, what should a GP manifesto look like?

• General practice being a policy priority with specific increased focused resources in the manner of current policy in Ireland.
• The continuation of the patient list-based self-managed partnership model with maintained individual practice budgeting unless practices wish to positively cede that responsibility
• Incentives and/or budget enhancement /devolved budgets at individual practice level to deliver on a more comprehensive offer to its patient community. My own vision which we delivered in the general practice of which I was a partner, was to primarily continue to develop and extend primary care provision and by so doing reshape aspects of hospital-based provision and to take a population responsibility for the health of its public. An approach which culminated in my describing the primary care home which led, after development, to primary care networks (PCN). My contention is without the accountable autonomy of traditional general practice, my ambition would almost certainly have been curtailed. A potential downside of ceding practice ownership.
• Facilitate and support practice based community involvement, examples of which already exist. Can that approach be spread among willing volunteers? Finance support on a case-by-case basis.
• The role of the PCN.
  The NHS England (2023) document lists the putative benefits of PCNs. An exemplary list but lacking a key necessity for a weary and worn-down general practice service, a leadership role that is energising and enthusing. A similar role is necessary within their partner providers whether GP or wider. I stress partners as PCNs must not presume a hierarchical role even though it is sadly inherent in the current NHS culture. Partners are equal even though carrying out different functions. Leadership and its corollary followership should be pervasive. A primary care policy must include training and development on styles of leadership, and where better to start than at PCN level, the very embodiment of an optimal primary system. Practice level for localness, PCN level to provide support to constituent practices where required, supra practice services and importantly of a population size to give primary care a presence at senior levels of the NHS and beyond. An exemplar of adaptive thinking is the concept of concomitantly both ‘little and ‘big’. Adaptive to replace the controlling culture of NHS management. If we are serious about a renaissance of the NHS, we must major on relationship building to create enthusiasm, energy, and indeed excitement. In the world of healthcare, it is astounding how little we major on relationships, preferring to major on contracts compliance. Of course contracts are necessary but not to set the abiding culture. Complexity such as paradoxes, dichotomies and downright disagreement are optimally managed locally.
• This blog so far has focused on organisations albeit small ones, but equally necessary are new ways of thinking and working at the individual clinician/ patient/ citizen level. The doyen of a primary care focused political leader– Kenneth Robinson – who produced the epochal 1966 GP contract, described a good GP having ‘a liking for people and a flair for diagnosis’. Liking is challenging, but the early Royal College of GPs led on patient/GP interface, maybe it’s time for a refresh. The meeting of two experts in the consultation shouldn’t be fanciful, the patient is the expert about how they think and feel. This is particularly relevant in management of long-term conditions and co-morbidity where most of the care resides with the patient/citizen, exactly the reason why Ireland has prioritised primary care. On a more fundamental level, does the current NHS nationalisation model preclude an involved customer. I believe so, as does the think tank Radix to which I belong. There is life beyond the simplistic nationalisation/privatisation dichotomy, but not for now.
• General practice sits at the interface between the NHS and their local community, and their community development opportunity has been well described in the long-ago Peckham Project and more recently Bromley by Bow and at scale Fleetwood. What I found interesting was how many of the early primary care home sites who described their experience as enjoyment, emancipation, fulfilment, self -realisation and fun, got involved in community initiatives. Give professionals enabling opportunities and the ideas flow. Central diktat stultifies.

The time is ripe in an election year for GPs to influence policy via achievements, ideas, and voice. Autonomous accountability with an accompanying evidence base. An offer that shouldn’t be refused.

Professor David Colin-Thomé, chair of PCC