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The 'one stop shop' GP revolution

Plans to cut secondary care could mean practices have to take on a wider range of responsibilities, finds Alex Matthews-King 

NHS chiefs across England have been drawing up secret plans for months. Prepared in shadowy committee rooms, their contents have been shielded from public view.

The plans will mean practices take on a whole raft of new responsibilities. Yet GPs have largely been excluded from the process. NHS England has refused to publish any draft reports, and rejected all requests under the Freedom of Information Act to share them – including several from Pulse.

Why the extreme secrecy? Drenched in management-speak, the so-called ‘Sustainability and Transformation Plans’ (STPs) are likely to be the most contentious change in the health service since the Lansley reforms in 2012. These blueprints for the future of the NHS include downgrading or closing hospitals, consolidating general practice and shifting more care into the community.

Announced this time last year, they are part of a ‘financial reset’ for the health service and have split England into 44 ‘footprints’. The intervening months have seen regional teams, CCGs, trusts and local authorities working together to draw up the plans, with the aim of ensuring the NHS can deliver the ‘right care, in the right place, with optimal value’.

But along the way, they have omitted to involve the main group of professionals whose buy-in will be required to make the plans work: GPs.

Pulse warned in August of LMC leaders saying they were being ‘excluded’ from discussions over the vital new plans. A recent survey of consultants and GPs carried out by the BMA revealed 59% had not even heard of STPs.

A recent King’s Fund report found some regions used CCGs as a ‘proxy for GP involvement’. Hugh Alderwick, a senior policy adviser at the think tank, says: ‘Gaining meaningful involvement in the plans from anybody was difficult within the time available. So within the NHS the groups least involved were GPs, clinicians, and frontline staff.’1

But some details have leaked out, and they have big implications for GPs.

GPs in Nottinghamshire may have to shoulder an increasing burden of patient care, following the merger of two acute care trusts, and more than half of community hospital beds in East Devon could be closed.

In north London, 500 hospital beds face the axe and managers want all practices to have list sizes of more than 10,000, as part of moves to create primary care ‘hubs’ covering 30,000 patients.

Patients would prefer problems to be solved in general practice

Health scretary Jeremy Hunt

jeremy hunt press association SUO 330x330px

jeremy hunt press association SUO 330x330px

And health secretary Jeremy Hunt has begun preparing the ground for a ‘dramatic expansion’ in the role of GP practices, as secondary care is cut. At last month’s National Association of Primary Care Best Practice 2016 conference, he said he wanted to make GP practices ‘one-stop shops’, with many more pathways of care beginning and ending in primary care.

Mr Hunt said the NHS has to ‘get back to basics and think how many issues and problems could be solved with a visit to a general practice’ rather than ‘sending someone to the back of another queue’.

He added: ‘I think patients would much prefer it if a lot of those problems were sorted out inside general practice. You will be hearing more about what I am calling “the GP one-stop programme”, looking at areas like diabetes, end-stage renal, and many others.

‘We are going to go through, situation by situation, condition by condition, and ask what barriers we can remove centrally to allow more of this work to happen in general practice.’

He admitted that this meant asking GPs to ‘do more work’ but said that they would be ‘paid for doing that’ and argued it would also ‘make life more rewarding’.

NHS England says this work would be based on the existing ‘new models of care’ running in some areas of the country.

A spokesperson tells Pulse: ‘There are opportunities to integrate consultant outpatient services and the support offered by GPs, particularly for long-term conditions such as diabetes, rheumatology and heart problems. This is happening in places such as Tower Hamlets, Portsmouth and Northumbria, and we now want to expand this dramatically.’

Success

In these areas, practices have been hosting Saturday clinics alongside outpatient specialists, specialty consultants and technicians to improve management of patients with respiratory conditions, or been given access to nasendoscopes, CT, MRI and some simple radiology for ENT patients.

Practices in East Hampshire have been operating successful ‘carousel clinics’ on Saturdays, with respiratory specialists coming in to treat patients with asthma, COPD and breathlessness.

Speaking to Pulse, NHS England chief executive Simon Stevens says groups of practices could take on responsibility for ‘cardiology, diabetology – all the -ologies’.

Mr Stevens says the aim is to replace the current system, where ‘patients are sent off with a referral and the next contact comes when the GP receives a letter from the consultant’s medical secretary weeks or months later’.

Many GPs will agree with these aims. Deputy chair Dr Richard Vautrey says: ‘Practices would welcome stronger links with their local specialist colleagues and sharing management in a way that reduced patients’ need to attend hospital.’

However, with brutal cuts planned to secondary care via the STPs, the danger is funding will not follow the extra work. Dr Vautrey says the changes cannot ‘just shift more unfunded work on to the already overburdened shoulders of GPs, and the resources to sustain such community-based services must be fully provided’.

If this does not happen, Mr Hunt’s ‘one stop shop’ idea for GP practices will be dead in the water.

Q&A: The secretive plans that will determine the future of the NHS

What are ‘sustainability and transformation plans’?

They are plans for the future of health and care services in England, aimed at building on the Five Year Forward View and restoring financial balance. NHS England has divided the country into 44 ‘footprint’ areas, with area teams, acute trusts, CCGs and local authorities collaborating to produce the plans.

What are the plans suggesting?

With few published, it has been impossible to get a full national picture. However, those that have been issued offer radical recommendations: managers are proposing to close more than half of community hospital beds in East Devon; the Dorset plan says its 98 GP practices at 135 sites will ‘overstretch’ local ‘workforce and finances’ and suggests a reduction; in north London, managers want no practices with list sizes of less than 10,000.

Why is little known about them?

NHS England and the footprint areas have strived to conceal the STPs – the King’s Fund think tank even found NHS England had trained managers in how to prevent the plans’ release under the Freedom of Information Act.1 But some areas have rebelled against this secrecy, and other plans have been leaked to the media.

How will GPs be affected?

Many STPs set out secondary care cuts, with GP practices increasing in size to pick up the slack. This feeds into the Government’s ‘one-stop shop’ strategy, whereby practices will offer specialised renal, respiratory, ENT and diabetes care, and more. However, managers in Hampshire and Isle of Wight want to cut GP workload by almost a third.

What happens next?

Publication of STPs will continue in the months ahead. NHS England says they will be consulted on, but the Local Government Association, among others, fears consultation will simply be on ‘pre-determined solutions’.

Reference

  1. Alderwick H et al, 2016. Sustainability and Transformation Plans in the NHS.

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Readers' comments (12)

  • STP ; serenity ,tranquility ,peace. An amphetamine based hallucinogen developed by Alex Shulgin. Somebody in NHSE has been taking it and had a vision of GP's with spare capacity to take on these fantasies. Get Real FFS

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  • Not enough GP's .
    Not enough people wanting to train as GP's
    Not enough trainers.

    Do the math.

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  • So Simon Stevens and Hunt, both non clinical professionals are going to go through the ologies one by one to decide which can be managed in GP practices by a remote clinician?
    This is a clear example of how expertise has been downgraded in decision making and is very dangerous indeed.
    Everyone with any knowledge about it said that Lansleys reforms would be a disaster. They still ploughed on. Can't see any hands held up or responsibility taken for that.
    Rather than stepping back and wondering what went wrong they are just ploughing forward into anoth balls up. Ultimately it doesn't matter if you are running Sainsbury's. It kind of does matter (more) if you are running healthcare.
    Get out and work privately. You can work to your own moral and professional ethical standards and not to the current distorted ones.

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  • Dear GPs we've had word with Bob and Sue both of whom have end stage renal failure. They would much prefer it if they could have their dialysis at the GP practice down the road because its right near the local supermarket and they can combine it with there weekly shop. Anywho's all the renal consultants have gone in to the private sector, the registrars are working perpetual nights and weekends on general medical oncall to deliver 7/7 access and we've let everyone else at your local renal unit go as part of efficiency savings. Here is an instruction manual for the dialysis machines and an oxford handbook of renal medicine for a low low price of £39.99 (per GP). Good luck and please as ever keep these patients out of hospital. Lots of love from your faceless STP footprint

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  • I am a 54 year old GP with 25 years in practice . I'm not even going to wait for index linking . I want to get out right now. If it sounds like panic -it is . I'm not alone in this feeling .

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  • Sustainable Hospital Interdepartmental Triage Experiment.
    SHITE

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  • STPs no problem. Bring it on. But I am gone because I cannot do anymore.
    I am already Dermatology, Neurology, Psychiatry [ not quite an ology, don't tell ], Orthopaedics etc here [ Waiting times are over 2 years].
    Hey comrades, let us not worry too much, as we only do 90% on 7 & of the budget, and these budgies want us to more!!!
    Good luck to the ones who stay.

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  • I agree with 5 41-I have written my resignation letter from the partnership. I am only 50. This Job is already much too much.
    This is an experiment, and you do not want your name and reputation associated with it. I worked hard for my qualification, and have continued to work hard to do the best for my patients, but impossible is impossible. We need to draw a line in the sand now .

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  • 5:41 - Respect!
    I was only 42 before I’d had enough and, seeing the direction of travel, got out. Never looked back. Very sad to see that it’s only got worse since then - apart from a very brief earnings uplift around 2004.
    This is just nonsense. If we get consultants to do this work it’s terminally inefficient; and to train enough GPwSIs would be unfeasible even if we had enough GPs to train up.
    Complete bonkers. No commercial organisation would even consider it. Without charging appropriately, that is.
    Bring back John Chisholm et al.

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  • We all know it's not going to work. In fact it may not even happen due to the shortage of GPs. However the likes of Hunt and Stevens need to be seen to be doing something.

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