Is list based general practice under threat?
In this blog I address a topic very dear to my heart. I was a GP at The Castlefields practice, Runcorn for 36 years, my choice working in a socially deprived area with the added piquancy of a predominantly Scouse patient population who had moved from Liverpool for New Town opportunities. I loved it and would happily repeat if young again.
The NHS Plan commitment to the individual GP practice is unclear to many readers, begging the question is the current model worth preserving? Whenever there is an NHS reform such questions come to the fore, but now understandably with more force. The current context is a large dip in public satisfaction when for years it was always leading, increased workload beyond pre Covid levels and a recruitment problem magnified by relative reduced funding within the NHS.
The present practice based service has my unwavering support matched by service and academic luminaries; ‘soul of a proper, community orientated, health-preserving care system’ (Donald Berwick). The late Prof Barbara Starfield ‘That aspect of a health service that assures person focussed care over time to a defined population……coordination of care such that all facets of care (wherever received) are integrated. Primary Care. New York: Oxford University Press; 1998’. USA based academics extolling the virtues of UK general practice. And from the UK; House of Commons; Health and Social Care Committee, ‘The future of general practice’ 2022; ‘’general practice is the beating heart of the NHS and when it fails the NHS fails. There is clear international and UK research showing that seeing the same GP over a long period of time leads to fewer hospital visits, lower mortality and less cost for the NHS. There can sometimes be a trade-off between access and continuity, and we believe that the balance has shifted too far towards access at the expense of continuity. Seeing your GP should not be like phoning a call centre or booking an Uber driver who you will never see again: relationship-based care is essential for patient safety and patient experience. It is also much more motivating for doctors.’ And from the public; A major new research project has found that the public wants the government to focus more on improving primary and community care than hospitals and is willing to pay more taxes to improve NHS services’ (Health Foundation May 2024).
From the Plan, ‘However, truly revitalised general practice will depend on more fundamental reform. Having served us well for decades, the status quo of small, independent practices is struggling to deal with 21st century levels of population ageing and rising need. Without economies of scale, many dedicated GPs are finding it difficult to cope with rising workloads. Far too often, that means work is causing chronic stress and mental illness among hardworking professionals. Many GPs are voting with their feet: 74% of fully qualified GPs were partners in 2015, compared to just 55% today. Where the traditional GP partnership model is working well it should continue, but we will also create an alternative for GPs. We will encourage GPs to work over larger geographies by leading new neighbourhood providers’’.
The description of the problems is ‘spot on’ but the wording, unintended or not, portending the demise of the individual practice concerns many GPs. To retain list based general practice is fundamental to my own vision which we delivered in the general practice of which I was a partner- to primarily continue to develop and extend primary care provision consequentially reshape aspects of hospital-based provision, and importantly, take a population responsibility for the health of its registered public. Only the autonomy of being an independent contractor ensured the implementation of that vision. We only received patchy support from the local NHS despite the vision germinating my originating the Primary Care Home concept. To ‘nationalise’ general practice will likely damage the continuation of its heritage, well referenced in the attendant quotes. And its key hallmarks-Localism – being an integral part of local social capital and for some significant practices, being regarded as an anchor organisation. For many ‘left behind ‘communities, the larger NHS organisations as with many others have become distant and unreachable. These deprived communities are at the heart of current policy, informed by the work of The Independent Commission on Neighbourhoods. It’s not GPs alone who are key to local health, but the practice as an organisation providing local access to other care professionals. A home! More Starfield ‘Evidence shows that primary care helps prevent illness and death,’ Milbank Q 2005 Sep;83(3):457–502. The distinguishing unique feature of UK general practice is its population responsibility, and indeed the only provider in the NHS with such responsibility. Prof Kamila Hawthorne, the very recently 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.” Reinforcing the importance of a local population being offered personal continuity of care. Not an impersonal service at a distance. If that was on offer in the past, many of us would not have become GPs.
And to address the very real current problems facing general practice by ridding itself as should the entire NHS, of binary thinking. Adaptive leadership is urgently and universally required. For general practice concomitantly as I’ve long advocated, being little and local yet large and strategically influential. The local practice must be maintained with clinical and service accountable autonomy but may well be best served being part of a larger organisation as indeed is increasingly and successfully the case. I trust this is what the Plan aspires to.
I will only briefly address future general practice contracts as there is much to unpick from the two contract models of the Plan. What will be the relationship with the GMS contract? And to reward the GP practice innovators will there be the option of a local mediated contract-revivifying the PMS contract? The traditional contract stultifies the energised. And finally, will the proposed integrated health organisation (IHO) be totally budgeted so all providers will be jointly incentivised to deliver on optimal quality and cost-effectiveness? I am currently working in a group exploring these issues so maybe more later.
Professor David Colin-Thomé is chair of PCC, a not-for-profit social enterprise supporting primary care, the development of neighbourhoods and collaborative leadership, contact enquiries@pcc-cic.org.uk or visit www.pcc-cic.org.uk for more information.