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Should general practice accept its share of NHS cuts?

The entire NHS faces cuts and GPs cannot expect to be spared. Rather than being protectionist, we must show we can deliver value for money, says Dr Johnny Marshall. But the RCGP's Professor Steve Field argues a strong, well-funded general practice is essential to deliver care closer to patients while keeping costs down across the NHS

The entire NHS faces cuts and GPs cannot expect to be spared. Rather than being protectionist, we must show we can deliver value for money, says Dr Johnny Marshall. But the RCGP's Professor Steve Field argues a strong, well-funded general practice is essential to deliver care closer to patients while keeping costs down across the NHS



Saying general practice cannot expect to be protected from the economic crisis may sound like a turkey voting for Christmas. But ignoring that reality requires an ostrich-like burial of one's head in the sand. The main political parties are competing over how much less they are going to spend. To suggest primary care should be exempt because we are the solution to NHS inefficiencies fails to recognise how we are perceived in the corridors of power. More than ever we need to demonstrate our value.

I believe we are the solution, but we need to prove it. The combined political wisdom is that core funding for primary care will fall in real terms. Rather than wasting energy fighting the inevitable, we should change how we provide care. Access to high-quality general practice is something everybody deserves. With the NHS now focused on delivering quality, innovation, prevention and productivity, the unwarranted variation within medicine - and primary care in particular - is coming under increasing scrutiny. Rather than taking a protectionist view of the way we are now, we should be hastening the change from an illness service - reacting to the needs of individual patients - to one that proactively manages the health of our population.

The future direction for health services requires a greater emphasis on prevention, with more care being delivered out of hospital and shorter stays in acute settings. This will require a new focus on the proactive management of individuals with long-term conditions to reduce the need for acute care. If this is to be achieved through the development of primary care, we need to demonstrate that general practice is able to work smarter and to provide the value for money taxpayers demand. Those in the corridors of power are questioning whether hospitals are better placed to take on this work than we are.

As NHS commissioners become increasingly effective in recognising value for money, general practice needs to become increasingly productive through new ways of working that are matched to population need, requiring an increasing skill mix. We need to transform a primary healthcare system that arguably encourages dependence into one that supports greater prevention and self-care, and that releases GPs to focus on core skills of generalism in management of comorbidity and uncertainty, working in partnership with patients.

Such a response will earn us a reputation within the NHS as being the solution to the economic challenge, rather than confirming the not-infrequent perception that we are the problem. It will require greater integration across health sectors and with social care, more informed performance-management of individuals and more informed decision-making on the basis of robust cost-benefit analysis. We need to earn the trust of patients and taxpayers alike if we are going to earn the right to lead in changing the NHS for good.

One of the largest barriers to this change is the increasingly transactional nature of the primary care contracting mechanisms - with only GP provision of extended hours recognised as eligible for funding, and performance measured against existing patterns of service delivery, such as the number of GP appointments provided. To overcome this the necessary contracting flexibilities need to be in place and those commissioning primary care services must have the relevant competencies, capacity and accountability for the task.

There is likely to be no shortage of alternative providers competing to deliver high-quality care and better patient experience. If we are going to be trusted with delivering more healthcare in the community, and to attract investment in the future, then we need to raise our game and demonstrate added value for money.

Dr Johnny Marshall is chair of the NAPC and a GP



After years of investment, talk among the main political parties is once again turning to cuts in the health service, with everyone expected to do their bit to save money. But I would argue that GPs are already the greatest promoters of efficiency in the NHS and that strong primary care, properly resourced, is the key to saving the NHS money. By providing more services in the community where patients want them and preventing unnecessary referrals to hospital, we are already demonstrating our cost-effectiveness, and further cuts would be unnecessary and inappropriate.

Wherever you live in the UK, healthcare has improved over the past decade as a result of the large and much-needed increase in NHS funding. Waiting lists have dramatically reduced and general practice has risen to the challenge of the new contract by providing better care for our patients closer to home. But the NHS faces a future where funding will be reduced and increases in productivity will be required, alongside continued improvements in quality. How can that be achieved?

I am convinced the solution lies with general practice. As GPs, we must rise to the challenge and provide the answers. I like the quote from Barack Obama: 'Change will not come if we wait for some other person or some other time.' This is a time for strong GP leadership at all levels.

And a strong primary care saves money. The millions spent on management consultancy costs by the Department of Health is a scandal. To think what general practice could do with that money. Around 90% of all healthcare in the UK is delivered at primary level and it's highly cost-effective - GP care for an entire year costs less than a single night in hospital. Preventing illness and keeping patients out of hospital means a healthier society and less pressure on the NHS. It's a service valued by patients too - the latest GP Patient Survey showed 91% of patients were satisfied with the care they received. The recent swine flu pandemic has shown the commitment of GPs who have worked incredibly hard under great pressure to treat patients and reassure the public.

The RCGP has produced detailed plans on how GP practices can work together as federations to deliver a wider range of services, closer to patients' homes. Most health services - including mental health, X-rays and scans - could be dealt with in the community by healthcare professionals who patients know and trust and only in hospital when absolutely necessary. Moving care closer to the patient will reduce NHS costs and improve speed of diagnosis. Federations could use existing buildings - rather than building new ones - and money saved would be invested in better services.

Importantly, this model preserves continuity of care, which is so important. Patients want to see a family doctor they know, who treats them as an individual not as a number. And it is a grassroots approach, working from the ground up in local communities rather than being imposed from the top down.

Regardless of which political party forms the government in the next election and which version of the NHS we work in, GPs will need to stand up and lead at local, regional and national levels. They need to be involved in commissioning but must also to lead provision of care through practices as part of federations. And over the next few years, GPs will need to lead the move towards better integration with managers and our specialist colleagues.

General practice is the jewel in the crown of the NHS and the solution to the big health challenges of the next 10 years. As Obama said: 'If you're walking down the right path and you're willing to keep walking, eventually you'll make progress.'

Professor Steve Field is chair of the RCGP and a GP in Birmingham

Should general practice accept its share of NHS cuts? yes no

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