General Practice is a bit of an oddity. While an integral and fundamental part of the NHS it has never been a service directly provided by the NHS, but instead provided through GPs as independent contractors. Yet it is widely regarded as the bedrock of our health care system and partly responsible for its efficiency.
This is because it is list based so everyone has a GP, and the practice is responsible for preventive and proactive care as well as acute care. General Practice is the first point of contact with health services for the vast majority of health problems. In fact 80% of health care encounters are in general practice. 70% of the population sees their GP in one year and 90% in five years. So general practice is where the vast majority of the population receive their basic health care. Most health problems are managed completely within general practice and only one in twenty consultations lead to referral. GPs and practice teams look after people of all ages and life stages from childhood to old age; they deal with immediate problems as well as long term conditions; they manage mental health as well as physical health problems; they are responsible for a lot of preventive health and making early diagnosis of serious illnesses like cancer and referring promptly and appropriately; they are aware of the many social problems facing their patients from poor housing to poverty, discrimination, lack of rights and access to benefits for disabled people, unhealthy working conditions and much more.
General Practice is also greatly valued by patients. It’s what most people experience of the NHS. People rightly get worried and angry when it fails to meet their needs. Good quality general practice is highly valued by people. They value continuity of care with doctors and nurses they know and who know them. There is a plethora of research that shows the value of continuity of care in reducing ill health and saving lives, and enabling cost effective health systems to function.
General Practice is now in a state of crisis. This has been many years in the making. In my 30 years experience as a GP this is truly the worst time for General Practice.
I’ve been a GP for 30 years and for 25 years of those I have been a partner in a GP practice in Deptford, Lewisham, south east London. My practice is in a very ethnically and socially mixed area. I’ve loved working as a GP and I was lucky enough to have my training in General Practice in the 80s which was in many ways a golden age for the development of the philosophy and practice of general practice, with new ideas evolving, such as patient centred care; the primary health care team; and holistic care covering the biopyschosocial dimensions of a person’s problem. The concept developed of the patient as expert and of the consultation as a meeting between experts; so did the idea that GPs had a vital role in prevention and management of long term conditions as well as the acute problems patients present to us. There was a growing understanding of the social and psychological dimensions of health and illness and the importance of the GP understanding the kinds of pressures our patients were facing within wider society. At that time the general hospital physician gradually started being phased out: more and more care was being transferred from hospitals to general practice especially for long term conditions like diabetes, and the idea grew that general practitioners were specialist medical generalists, based in the community and not in hospitals.
The idea of the primary health care team developed – recognising that GPs can’t and shouldn’t do everything by themselves. We saw the birth of the nursing specialty of Practice Nursing and since then practice nurses’ role has flourished to the point where nurses are responsible for a huge proportion of care of our patients, especially with long term conditions.
A powerful argument was raised that GPs needed more time with the patient. The 5 minute appointments that still existed were seen as a total anachronism. But even the 10 minute appointments that were coming in were clearly far short of what was needed. General practice, with a growing confidence, a growing body of academic evidence showing the value of the model of British primary care, an increasingly popular choice for young doctors, and a growing and important scope of practice should have been in a good position to get the resources needed to develop further, including more GPs, more time for consultations and more resources to develop the wider primary health care team.
Alas that was not to be. General Practice remained consistently underfunded and reached a crisis in 2004. There was an injection of extra funding from the Labour government with a new contract and that did help a bit for a couple of years, but the funding got frozen and so inflation did its erosive damage. Since 2010 it is estimated that General Practice has lost about a billion pounds a year. The workload has increased but the resources have not kept up. Since 2010 there has been a 30% increase in consultant numbers but the number of GPs has fallen.
England’s NHS has lost nearly 600 full-time equivalent GPs over the past 12 months.
An analysis by the Nuffield Trust think tank for the BBC shows the number of GPs per 100,000 people has fallen from nearly 65 in 2014 to 60 last year.
GPs are seeing twice as many patients a day compared with 30 years ago.
Consultations are often significantly more complex.(1)
GPs are finding their workload stressful and exhausting and many are voting with their feet and either not joining general practice after training, or leaving early. Those that remain find themselves in even more difficult conditions and sometimes this is unbearable.
Almost 140 surgeries closed last year alone – more closures than in any previous year and almost eight times the number seen in 2013,
It brings the total number of closed GP surgeries to 583 since 2013.
In conjunction with the Nuffield Trust and The King’s Fund, the Health Foundation also found the overall NHS workforce shortfall could increase to 160,000 by 2023/24, which includes a shortfall of 7,000 GPs. Currently, trusts have an estimated staff shortage of more 100,000 FTE workers.(2)
Last year, a survey published by The King’s Fund found that only 37% of GP trainees planned to become partners – while just one in five planned to stay working in full-time clinical general practice a year after qualifying. (3)
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. Service provision is suffering. Immunisation rates have dropped and one reason is the lack of availability of nurse appointments. Surveys show that while people still value their GP they are getting angry and upset and losing confidence in General Practice because they can’t get appointments and they can’t get to see the same GP twice, and when they do, they feel there is not enough time.
Why does this matter?
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 (4), 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 over the past decade has actively undermined General Practice and has 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 essence, in particular continuity of care, by favouring “access” to anyone at the expense of all other values, by promoting a corporate model of GP provision and by promoting “General Practice at Scale”. Many GPs have given up and handed back their contracts. 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.
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.
Some GPs welcome PCNs because they feel they will direct extra resources into and help reinvigorate General Practice; others are more sceptical – summed up by one GP whose views I sought:
‘Another nail in the family physician coffin’
Another GP expressed the ambivalence many others feel:
‘My first gut feeling about PCNs was positive. I think there is lots of potential to work together with neighbours so I generally welcome any push for GPs to work together, but this is tempered by my own cynicism about the direction of travel more generally – that everything I see coming from the Department of Health at a high level seems to be wilfully ignorant of the kind of relationship-based care that is the cornerstone of general practice, both in terms of popularity and efficiency.’
What is the Primary Care Network contract?
Under the PCN contract, practices agree to link up with other local practices in groups of 30-50,000 to form a Primary Care Network. The Primary Care Network (PCN) contract is an extension to the basic GP contract and is known as a Directed Enhanced Service (DES). DESs have existed for many years and are used by NHS England as a contractual mechanism to get GPs to do things over and above their core contract requirements. GPs had until 30 June 2019 to sign the PCN contract.
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.
Practices will keep their individual contracts and continue to be paid the vast bulk of their funding directly through that contract, for providing core primary care to their registered list of patients.
This is a very important point as there has been some misleading messaging being put about that PCNs entail practices merging their whole lists into the PCNs and no longer functioning as individual practices. This idea of practices merging into a bigger organisation was proposed in the Integrated Care Provider (ICP) model, promoted by NHS England (NHSE), whereby GPs would give up their practice contract and patient list and merge into a massive organisation covering up to hundreds of thousands of people. KONP vigorously campaigned against the ICP contract alongside We Own It. The ICP contract model is also opposed by the GP profession.
BMA GPC chair Dr Richard Vautrey said:
‘We have made our serious concern about the impact of ICPs known repeatedly and we continue to do so. These proposals (ICPs) would undermine the positive potential that working together within primary care networks, based on the existing GMS or PMS contact, could bring. There is no need for practices to give up their contract to be able to develop sensible collaboration with local NHS services and put in place improved community-based services as a result.’
PCNs are seen by many GPs as a way of protecting themselves from pressures to be subsumed into larger organisations such as super-practices or ICPs, enabling them to retain the benefits of smaller scale practice size at the same time as supporting them to work with neighbouring practices to provide a wider range of services.
The PCN ideas of greater collaboration between practices, multi-disciplinary team working around the patient – especially the most complex and vulnerable – and a wider range of practitioners to provide patient care, have always been valued by GPs and the idea of some extra funding going into this is being seen by many as a good thing. They hope it will help to rebuild and enhance the primary care teams that used to exist, when other types of practitioners such as District Nurses and Health Visitors worked closely with GP practices (before a previous wave of policies broke up those teams!)
But PCNs can’t and won’t solve the problems of General Practice and surveys of GPs show they have little confidence in the ability of PCNs to solve the problems of General Practice
They won’t solve the shortage of GPs, which is predicted to be 7000 by 2023/24. A wider range of practitioners will not be able to replace GPs because of the nature of GP work. As primary medical care becomes more complex, and more and more work that was previously done by hospitals, such as the care of people with long term conditions, is transferred to General Practice there is a need for more GPs, not fewer. Even if some of the new practitioners relieve some of the GP workload, that will make very little difference to the overall shortage of GPs.
Furthermore, given the NHS staffing shortages with over 100,000 vacancies, predicted to be 140,000 by 2023/24, it is unclear where the proposed non-GP staff (physiotherapists etc.) will come from. It is likely any such staff will be taken from the already reduced NHS staff pool i.e. poached from hospitals or seconded from existing community providers.
Severe cuts to public health, preventive services, social care and community services have undermined the possibilities of improving care in the community. Add to that the on-going impact of austerity, poverty and inequality and it seems unlikely PCNs will have much impact on health inequalities, given that they have no power over those wider issues.
And what about the risks?
Diverting further resource away from GP frontline care
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 and practice nurses, PCNs are adding to the GP staffing problem.
Many GPs fear loss of autonomy from PCNs, especially if in future even more funding is funnelled through PCNs rather than directly to practices, thus allowing for more centralised control and depriving practices of the resources to determine their own ways of doing things.
Some GPs see PCNs as yet another reorganisation taking up precious GP time and wasting resources. Each PCN will take up the time of a GP in the Clinical Director role for one day a week. Across the country, this would be the equivalent of about 270 GPs taken from front line care. That is in addition to GPs continuing to be involved in other structures such as Clinical Commissioning Groups and GP Federations.
Irresponsible inducements for GPs not to refer to hospital
The proposal that any savings from reduced A&E usage or hospital admissions would be shared with PCNs is irresponsible and unnecessary. Similar schemes in the past have proved futile and only served to sow distrust in patients towards their GPs – patients could no longer be sure their GP was acting in their best interests.
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 definite cause for concern. This is especially so if Integrated Care Systems go on to spawn Integrated Care Providers (ICPs), otherwise known as Accountable Care Organisations (ACOs), with all the attendant risks of privatisation, rationing of care and loss of public accountability that KONP has already highlighted.
So what can we do?
The risks identified in PCNs – of them being a stepping-stone to Integrated Care Providers and Accountable Care Organisations – are not inevitable and are amenable to political resistance.
PCNs do not affect the basic structure of general practice with its registered patient lists and general medical services (GMS) contract. There is no automatic conveyor belt between PCNs and some bigger, potentially privatised conglomerate such as an ICP. Whether such a thing happens will be 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 – that practices signing up to PCNs entails them signing away their patient lists to a prototype of an ACO and the end of General Practice, as we know it. To suggest that is to say we have already lost the fight when we have not – not by a long way. And to say we have already lost prevents us from fighting effectively to defend what we still have.
We need to be aware of the kind of steps that could lead towards this outcome, such as GPs feeling pressured to give up their patient lists and join in with Integrated Care Providers. That is the main sign we should look out for. The pressure for this will be in the guise of integration and collaboration and we should argue that these are possible without having to create ICPs. We should oppose the government’s drive towards GP at Scale, which is an excuse to stop supporting small and medium practices and to preferentially favour large and corporate practices. This includes ending all support for the Babylon app-based model of general practice.
We should be calling for more funding for General Practice, as well as all other branches of health care. We should also be calling for the reversal of social care cuts. We need investment in doctor, nurse and allied health professional training and in particular, an increase in GP training places.
On the wider political level we need to be campaigning for an end to austerity. Poverty and inequality have massive impacts on the mental and physical health of our patients and on General Practice workload and challenges. Patients for whom difficult social conditions are compounding their mental and physical health problems present a demoralising level of complexity for GPs, given the destruction of local community support services, the hostile benefits system and the underlying problems such as poor housing. GPs can feel helpless and hopeless and it is very demoralising.
We must have a government that ends austerity and invests in all social services including the NHS. Within that we need a significant increased investment in general practice and community and social care; much more than the £4.5bn promised, due to the many years of funding restriction and cuts.
We need a radical solution that recognises general practice as a generalist community based specialism – a branch of medicine with its own special qualities and characteristics. This means looking at our evidence base and forming policy around what works. We know continuity of care works, so lets start there. We know care is more complex: that problems present in bio psychosocial ways, so let’s have practitioners trained in managing those, with sufficient time to spend with patients and knowledge of the community in which they are embedded. We know that care requires more than just the GP, so let’s invest in the primary and community health care team. And, yes, we should have integration and collaboration, but that is impossible in a market based system defined by commercial contracts, so we should be fighting to take the market out of the NHS and renationalise it.
Within that, we may need to look at the model of care. Does independent contractor status still work or should we look at a salaried model?
There is much to debate about what the ideal model of General Practice might be; with some on the left calling for a salaried service while others arguing that what has developed over the decades is, in all practical senses, an NHS service. But it is clear that currently a salaried GP service that preserves what is good about traditional General Practice is not on the cards and what is facing us now is the replacement of traditional General Practice with something much worse: more corporate, more remote from patients, less caring and less effective.
The main challenges to General Practice now are to stop it sliding into deeper crisis, securing adequate funding, increased GP training places, increased funding for wider health care teams, in particular practice nurses, and opposition to further pressure towards large corporate models and, in particular, into the proposed ICPs. Within the context of the current pressures towards ICPs we need to defend the traditional practice-list based system of General Practice. Whether in an imagined future NHS we would still have that is a moot point. At present a mixture of traditional general practice and better collaborative working in neighbourhoods is the best defence against that. That is why many GPs have hesitantly supported PCNs.
Dr Louise Irvine
Louise is a GP in Deptford and a member of DFNHS. She is Co-Chair of Health Campaigns Together; Chair of the Save Lewisham Hospital Campaign; and Secretary of Doctors in Unite (formerly the medical Practitioners Union). She stood as a candidate for the National Health Action Party in Jeremy Hunt’s constituency in the general elections of 2015 and again in 2017, when she came second with 20% of the vote.
- Palmer W (2019) ‘Is the number of GPs falling across the UK?’ Nuffield Trust blog, 08 May. https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk#the-scale-of-the-problem