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Let’s use hubs to take the load off practices

Dr Michelle Drage

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The NHS and in particular general practice is at breaking point. We all know why, the unholy trinity of increasing demand, decreasing resources and a decreasing workforce. Although most of us want to work in the current pattern that we are familiar with and feel gives maximum benefit to our patients, unless something drastically changes we may be forced to change. If so, we need to consider the role of the general practitioner and how best to utilise this precious resource.

GPs currently see all types of patient with all types of problems. National data collections suggest that almost one in four GP appointments are potentially avoidable but what about the remaining three out of every four consultations? Do you need to see a GP with a minimum of 10 years of training for every problem? Evidence shows that outcomes for people with long-term conditions are improved by continuity of care and seeing the same GP, but what about people without long-term conditions who have acute and probably self-limiting illness? Significant numbers of GP appointments are being held on a daily basis for people with conditions that they feel are urgent but, from a medical point of view, largely are not. A typical ‘duty doctor’ session will involve seeing patients with upper respiratory track infections, urinary tract infections, musculoskeletal injuries, sore throat, ear ache, diarrhoea and vomiting etc. Could these patients be managed in an alternative fashion and if so would this cause any detriment to their long-term health?

This would free up time to enable the GP practices to see the patients who require continuity of care

For a number of years GPs worked in co-operatives to provide out of hours’ care so that individual practitioners where not on call 24-7, the profession deemed this acceptable practice that does not harm patient care. Recently in some areas GP hubs have been formed to provide for routine GP care outside of core practice hours, the hubs have full access to patient notes but the patient is not being seen by their ‘normal’ GP.

A discussion now taking place in the profession is ‘could these hubs offer care in core practice hours and if so how would this best be utilised?’ The idea being that these hubs are used for appointments booked on the day for patients who deem themselves to have an urgent problem. The hubs could be staffed by physician’s associates/advanced nurse practitioners/pharmacists etc. with a GP supervising and supporting a team of these clinical colleagues. This would then free up time to enable the GP practices to see the patients from their list who require continuity of care and longer term management of their health conditions. Such a system would require good quality triaging to ensure that patients were appropriately directed to either their practice or the hub. This would be to ensure that problems that may need a two week wait referral, be suggestive or significant illness (e.g. depression)  are seen at the GP practice rather than the hub.

Opponents to such schemes will highlight the importance of continuity of care and the potential of each consultation in providing health education, building the doctor-patient relationship and exposing hidden agendas. The counter argument to this is that although these are all important factors to take into consideration, we have already lost a lot of the continuity of care in practice with the increased role of the practice clinical team and part-time working, we have a workforce crisis and that unless we take positive action to address the flood of demand, in the very near future we will be unable to support our patients with significant health needs.

Dr Michelle Drage is chief executive of Londonwide LMCs

This blog is part of our ‘Great GP Debate’ season. If you would like to write a blog on how you see the future of general practice, then please email the Editor at

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Readers' comments (12)

  • Vinci Ho

    See exactly where you come from. The principle is sound but it is a matter of logistics and implementation, some form of triaging by designated but well trained staff?
    More importantly, as like many are criticising the feasibility of STPs, it is about the government's willingness to invest upfront with 'new' money( claimed back by long term improvements in theory ) in new structures like the hubs you are talking about. That should be in line with the so called Neo-Keynesian approach for economy . But this tunnel visioned Tory government insists economy always comes before health and social care.Hence , 'new' money is never new and is to be squeezed out of already in life-support NHS (as well as social care) finances......

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  • Vinci Ho

    And for the sake of argument, second law of thermodynamics applies......

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  • If the problem is smoothing out peaks and troughs in demand a hub makes sense, for example when organising emergency vascular surgical rotas and services.
    In general practice this isn't the problem however. The problem is insufficient capacity every single day.
    Thus a hub is an inefficient way of increasing capacity.
    The money to provide 1000 hub appointments could provide 1500 or more appointments with a practice that knows the patient.
    As no commissioners trust GPs with more money, only more work and responsibility, 1000 appointments is better than 0. It's still not a great use of money, in the same way that WIC appointments cost 60% more than GP appointments yet the former is a nurse with no information on the patient and whose differential for most complaints is 'UTI'.

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  • "The problem is insufficient capacity every single day" - certainly the case for many practices.

    But more important is the massive increase in demand. Hubs will not address this underlying problem. If you open more lanes on the motorway they will eventually get filled up unless you do something about the number of cars on the road...

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  • Cobblers

    So Saldoc 10:32 you advocating euthanasia then? (TIC)

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  • The infrastructure for gp services is much less than for roads. Patient payments would chase the flip the conversation from fearing demand to meeting it.

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  • Demand has to be limited as increasing access just leads to further demand as we have found in our practice. Copayment is the only answer. This has two advantages. Firstly it allows practices to get more money to pay for the extra activity. Secondly it acts as a mild deterrent for demand.

    It works everywhere else in the world. Why should the NHS be any different? What. Makes us different?

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  • Hubs staffed by non-GP clinicians will not divert demand from practices. Once patients realise that they cannot get what they want i.e medical certificates, referrals, a proper medical opinion etc. they will not re-attend there. After a few years, we will be talking about the hubs in the same way as walk-in-centres. Any demand that is diverted will simply be the minor illness that would normally not take too long anyway. Patients will also be asked to go back to their own GP and "ask for a referral", thereby creating more work.

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  • In countries where there are charges to see a Doctor/GP patients with minor illnesses see pharmacists and other cheaper health providers.These patients do not need to see a highly trained GP.It is a gross waste of recourses and training.I agree however that we need measures to reduce demand. This demand is not justified by Medical need.

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  • Cobblers 1206 , look at what happened with the 5p plastic bag charge - usage dropped by 90%. I am advocating that we need measures to reduce inappropriate demand (1 in 4 GP appointments according to recent research).

    Either copayment or the state covering eg 3 GP appointments per year and any extras/home visits with a fee unless palliative or bedbound. We will habe stable income and be able to offer longer appointments. We may even be able to recruit and retain more staff.

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