Pulse’s new campaign posits a better vision of the profession for GPs and patients. Jaimie Kaffash examines the principles behind this
For too long, others have decided what patients want and what GPs should do – ministers, the reactionary press and high-profile columnists.
GPs – those closest to their patients – are often caught on the defensive, forced to explain themselves, and portrayed as averse to progress, whether that be seven-day working, online consultations or face-to-face appointments.
GPs are losing the PR war. So Pulse decided to redress the balance through its Building a Better General Practice campaign. Instead of giving negative (though justified) messages about the state of the profession, we would offer a positive vision, devised by GPs.
We would identify the unique skills of general practice, looking at how they could be best used and in what kind of system, via a series of panel meetings and surveys (see Methodology).
And the results were clear. More than anyone else, GPs know what makes for good general practice. It involves utilising the unique skill of GPs – managing undifferentiated illnesses – as heads of multidisciplinary teams. It involves timely support from secondary care, which would actually relieve the pressure on hospitals. It involves minimal regulation to ensure GPs are practising safely and competently and providing necessary care for patients.
Most importantly, this is all underpinned by simply trusting in GPs and giving them the autonomy they need to act in their patients’ best interests.
The role of the GP
The most fundamental question concerned the key role of the GP and the unique skills they should be maximising.
The panel and survey respondents were in accord that GPs’ core skill is managing undifferentiated illness – as one panel member put it: ‘Differentiating the two sore throats, one cancer and the other a simple sore throat.’ This is unique to GPs – specialists are not trained to do it, nor is it safe for less qualified healthcare professionals.
However, increasing workload has made this harder. But adapting the role so GPs lead a multidisciplinary team – perhaps akin to a consultant in family medicine – would lean into their unique skills, according to both the panel and survey respondents.
One panel member commented: ‘When people fall into the gaps between the protocols or overlapping… that’s where we should get involved.’ But as it stands, GPs are doing work better suited to less qualified team members. The panel estimated that 80% of work is chronic disease management that could be provided elsewhere, potentially by allied health professionals, with GP input only when necessary.
This would also partly depend on GPs being allowed to choose their MDTs; in England, NHS England specifies many of the additional roles it funds PCNs to fill.
While survey respondents agreed that prevention, scheduled and unscheduled care, continuity and stopping overmedicalisation are all intrinsic parts of general practice, they also felt GPs shouldn’t continue to do all of these. Prevention, for example, could be led by other team members, while continuity could entail a patient seeing the same GP for a particular problem until it is resolved – ‘serial monogamy’, as one panelist’s practice terms it.
General practice’s wider role
With these principles agreed, we moved on to the second stage – general practice’s role in the wider system, and what services it could provide.
Perhaps surprisingly, there was agreement that general practice should in principle provide any clinical service that it could safely offer. This isn’t far off the route NHS England is taking, with its promotion of integration – with the key difference that GPs say any integrated bodies should be GP led, with money flowing through to general practice.
Interestingly, while the statement ‘general practice should be co-located with secondary care wherever possible’ was overwhelmingly rejected, the statement ‘co-location with other services would be fine if it meant premises were improved and upgraded on a regular basis’ was strongly supported with an average score of 4.34/5 (see Methodology).
One survey respondent summed up the relationship with secondary care, saying: ‘The main stumbling block on any given day is ease of access to secondary care advice.’ There was huge consensus that this support, plus rapid access to clear information on local guidelines, pathways and services during patient consultations, was essential. Alongside this, GP referrals need to be trusted, and rejected only in exceptional circumstances – ‘we need to banish the pro forma gremlins’ said one panelist.
In building our new vision for general practice, the contractual model is of course central. During the discussions, the group immediately said this could not be as simple as a choice between a ‘partnership model’ and a ‘salaried model’. In 1948, general practice was a pure partnership model, which many agreed worked. Yet, especially in recent years, it has become a hybrid model with both partners and salaried staff.
The panel noted that partnership is no longer very different to being salaried. ‘The extent to which I’ve been micromanaged and had to do mandatory training, it started to feel like a salaried service’, said one GP.
But survey respondents were in favour of general practice being based on small, autonomous businesses – with this option scoring an average of 3.2 out of 5. They were lukewarm on the idea of receiving a salary with business responsibilities removed (2.63), and rejected the concept of being run like hospitals, headed by a GP medical director (2.16) or as big businesses with a mainly salaried workforce. Interestingly, GPs under the age of 44 were more likely to support a partnership-style model.
The panel speculated that GPs are in favour of a business model of general practice because in theory it offers autonomy. ‘The reason we reject that hospital model is seeing consultant colleagues feel really undervalued,’ said one panelist. But currently GPs feel undervalued – treated not as professionals but, in the words of one panel member, as ‘naughty schoolchildren who have to be controlled, regulated and told what to do’.
Funding and payments
With a rejection of the salaried model, the funding and payment system for general practice becomes crucial.
Suggestions of co-payment and insurance systems have historically proved divisive mainly due to their potential to widen health inequalities. Yet general practice has faced years of underfunding, especially since 2010, as the Coalition Government’s austerity has taken effect.
There was no consensus around the source of funding for general practice. The option of the state providing all the funding was narrowly the most popular (3.22), with an insurance system being the least favoured (2.80). Co-payment and a hybrid model of insurance plus state funding each scored an average of 3.14.
There has been a big push for general practice to be paid per activity rather than on a capitation basis. The most popular option (4.10) among survey respondents was a hybrid model, with a base payment for the number of patients on a list and the remaining funding based on levels of routine and enhanced service.
And readers also seemed to favour a more prescriptive contract, but with more money provided through core funding (such as the global sum in England) and less incentivised payment.
For our panel, the priority was a simplified system, with greater clarity on why practices receive certain payments. As one GP put it, ‘the quickest way to send a young GP packing to Australia is try to explain the payment system’.
Our final topic was regulation. Survey respondents largely agreed (3.84) that ‘the only purpose of regulation for general practice is to ensure it is providing safe healthcare to patients, and give patients confidence it is safe’.
The panel – and many GPs – agree that regulation currently goes far beyond this, especially in England, with CQC ratings, GMC guidance and others to contend with. The controversial CQC standards seem to lack an evidence base and tend to lead to overregulation.
Appraisal and revalidation were also criticised. The panel said there is little evidence they improve patient safety, yet they take a lot of time away from clinical care. GPs, like all professionals, want to continue their professional development and learning. But the tick-box culture actually reduces professionalism and is infantilising, the panel said.
Creating a better general practice
So what does all this mean in practice? Well, first, there is a system that’s similar to our set of principles, brought in by the 2018 GP contract in Scotland. But that hasn’t cured all the issues (see below).
But even in England, this model is not beyond the realms of possibility. Simple changes could quickly give GPs more autonomy: a patient-facing campaign telling them the role of the GP; freedom to choose MDT members without NHS England stipulations; an actual plan for direct lines from general practice to secondary care; a state commitment to make an offer for all premises, to make partnerships more attractive; and removal of the QOF.
Such changes do require politicians and health managers to eschew populist policies, and help GPs show patients that allowing them to focus on their skills, and reduce bureaucracy, will help in the long term. Without such changes, the future of general practice looks bleak.
What happens next?
Over the next few months, Pulse will contact decision makers with our principles for general practice, including the four health secretaries in the UK, the heads of the NHS in all four nations, the BMA and the RCGP. We will publish their responses in the subsequent print issues of Pulse, and online. Our editorial line will reflect these principles.
‘Scotland has defined the GP role and we’re getting there slowly’
Many of the principles agreed featured in the 2018 Scottish GP contract. Here, Dr Andrew Buist, chair of BMA Scotland’s General Practice Committee, reviews progress.
‘We see the GP’s role as the expert medical generalist in the community, focusing on undifferentiated presentations (multi LTCs), complex care and providing leadership to a multidisciplinary team that takes on some of the tasks previously done by GPs. Those are the key things we have agreed with the Scottish Government that GPs will concentrate their time on.
‘Of course, the system tries to get us to do new and different things and the pandemic has made all of that a lot worse, with hospitals operating below normal. As patients wait longer for routine hospital care, pretty much all they can do is come back to the GP.
‘Some things have progressed well. Others have been slower – for example, hiring pharmacy technicians, when we spend 10% of our day on things they should do, like medicines management.
‘We are getting there, we realise it is the right thing to do, but workforce supply has been a rate-limiting factor.’
Our panel members
Dr Nonso Anekwe, First Five GP in London; Dr Rehaan Ansari, ST3 GP in Lincoln, GP partner in APMS practice; Dr Katie Bramall-Stainer, chair, UK LMCs Conference; Karin Bruce, practice director, Jubilee Healthcare; Dr Richard Fieldhouse, chair, National Association of Sessional GPs; Dr Poppy Freeman, founder, Covid-19 Primary Care Resource website; Professor Clare Gerada, president, RCGP; Dr Keith Hopcroft, Pulse clinical adviser; Dr John Hughes, chair, GP Survival; Dr JR Mitchell, locum and clinical claims advisor to the MDU; Dr Devina Maru, national medical director’s clinical fellow; Dr Sharon Raymond, director, Covid Crisis Rescue Foundation; Dr Kamal Sidhu, chair, British Association of Physicians of Indian Origin GP Forum.