Ben Gowland, Director, Ockham Healthcare
That there is a crisis in general practice is not in doubt. The impact of escalating demand and unmanageable workload is having a devastating effect, with GPs leaving the profession in significant numbers either through early retirement, or for a career change. The extent of the crisis means something has to give. And it has.
In Chesterfield a number of practices are now the responsibility of the local hospital, which now runs them through the Royal Primary Care banner. In Yeovil, the Symphony Healthcare Services model, where GP practices are run by a company wholly owned by the hospital, is attracting more local practices. While in Manchester, the local LMC chair suggests that the primary reason GP practices in Manchester are signing up to the new multispecialty provider (MCP) contract is because they see it as a way out of their current pressures.
So who will be the saviour of general practice? Does the answer lie in the hands of Jeremy Hunt and the Government? He certainly seems to think so. The problems in general practice have certainly not been ignored, in part due to the threat of mass resignations that coincided with the strike action of the junior doctors. In April this year NHS England published the General Practice Forward View (GPFV) with a sprawling list of initiatives designed to increase the overall investment in general practice by a recurrent £2.4bn by 2020/21.
The main strategy seems to be a promise of more money. But the problem with money is that it gets swallowed up - half of the promised money funds year on year contract rises of less than 5% that barely keep up with inflation of GP expenses (GP indemnity costs continue to rise exponentially). And for the other half, strings are inevitably attached. NHS England wants 12 hours a day, 7 days a week opening in general practice. The GPs to cover current working hours do not exist, and despite the promise of 5,000 more, the colleges are still predicting a shortfall of 10,000 GPs in five years’ time. However welcome, the GPFV money is only half the answer to the GP crisis.
To outside observers the problems facing general practice may seem quite straightforward. The nearly 8,000 small businesses, many of whom are finding their current business model unsustainable, need to consolidate into a smaller number of larger organisations – federations or alliances are the accepted terms. The “answer” in the commercial world after all is nearly always to save costs by operating at scale.
But is this business model risk-free? Reports emerged earlier this year about a federation in Doncaster going into administration after running into financial difficulties when it was unsuccessful in retaining contracts it had previously been awarded. The local LMC warned other practices, thinking of federating and delivering services at scale, that they needed to be aware of the liabilities they might be taking on.
Operating at scale can help practices. But it is not a solution in itself. It creates the potential for delivering efficiencies and new ways of working, but these benefits are not automatic. They are not delivered simply because the practice is now operating at a greater scale. If merger is not accompanied by doing things differently or doing different things, it just means the same problems will exist over a larger area.
So is the answer a takeover by the local NHS acute provider as is the case in Chesterfield or Yeovil? In some cases it may be, but while some brave souls may believe they can make the changes to general practice it has been unable to make itself, it is hard to see a mass movement to take over a service so badly underfunded and understaffed, especially at a time when provider organisations are facing severe deficits and staff shortages themselves.
Like many intransigent or ‘wicked’ problems – there is no easy answer. A single strategy cannot meet the needs of the widely differing circumstances facing each GP practice, or each local area. There are potential solutions, like operating at scale and partnering with other NHS organisations and they can be made to work, in the right circumstances. But the starting point for change must be the GPs themselves. Only GPs truly understand their patients, their business, and their challenges.
We need to invest in clinical leaders in primary care, in experienced change managers, and in creating time for GPs and practices to discover their own solutions. As one GP said to me recently, “I just need headroom from the constant pressure to find a way out of the mess that I’m in”. It’s a vicious circle – and somehow, GPs need to be able to get off the merry-go-round long enough to do the kind of thinking and development work that’s necessary. The “answers” for general practice are out there, but they will only have an impact if we actively support GPs to put them into practice.