GPs may soon see urgent same-day appointments being dealt with by ‘single, urgent care teams’ across larger populations following proposals put forward in a major NHS England-commissioned review.
Dr Claire Fuller, who is the chief executive of an Integrated Care System (ICS) in Surrey and a GP herself, published her report today on integrating primary care with other NHS services.
Her main recommendations came around ‘enabl[ing] primary care in every neighbourhood to create single urgent care teams and to offer their patients the care appropriate to them when they pop into their practice, contact the team or book an online appointment’.
This would require a shift in national policy towards 111, she said, and organising a ‘single integrated urgent care pathway’.
Dr Fuller said: ‘Left as it is, primary care as we know it will become unsustainable in a relatively short period of time.’
She also laid out plans to develop ‘innovative employment models such as joint appointments and rotational models’ to counter the GP workforce crisis, and change the way GP premises are owned and managed.
The report said that primary care ‘urgent care teams’ must ‘connect up the wider urgent care system’, including ‘currently separate and siloed services’ such as general practice in-hours and extended hours, urgent treatment centres, out-of-hours, home visiting and 111 call handling and clinical assessment.
They must ‘organise them as a single integrated urgent care pathway in the community that is reliable, streamlined and easier for patients to navigate’, it added.
NHS 111 ‘can often result in duplication of effort for patients, carers and clinicians’, the stocktake heard, as there is currently no ‘clear and consistent way of counting and measuring same-day urgent access or unplanned waits for routine appointments’.
The report suggested NHS England should develop a way to do this, in connection with its ‘wider work with systems in bringing together a set of key primary care standards’.
It also set out ways ICSs can be ‘flexible and nimble in managing the broader workforce’ to provide some ‘quick wins’ to tackle workforce pressures.
It said: ‘Systems should also support the development and rollout of innovative employment models such as joint appointments and rotational models that promote collaboration rather than competition between employers, particularly where skills are scarce.
‘To support improved workforce planning, the electronic staff record or a similar integrated workforce solution should be used throughout primary care to inform demand and capacity planning and enable team-based job planning and rostering to become the norm.’
On GP premises, the report said the Department of Health and Social Care (DHSC) and NHS England should give ‘additional, expert capacity and capability to help offer solutions to the most intractable estates issues’.
It said that the ‘GP owner-occupier model includes perverse incentives which can make cross-system collaboration more difficult’.
The report recommended that ICSs ‘develop a system-wide estates plan to support fit-for-purpose buildings for neighbourhood and place teams delivering integrated primary care, taking a “one public estate” approach and maximising the use of community assets and spaces’.
And in ‘last partner standing’ scenarios, ICSs might consider transferring estates ‘ownership to public or commercial system partners’ when GP partnerships propose handing back their contracts, it said.
NHS England and the DHSC should review ‘what flexibilities and permissions should be afforded to systems’ to allow ‘shaping and influencing of the physical primary care estate’, as well as reviewing the Premises Cost Directions, the report said.
The DHSC should also make sure primary care estate is a key part of the next iteration of the Health Infrastructure Plan, it added.
The report also said:
- The ‘primary driver of primary care improvement and development of neighbourhood teams in the years ahead’ should be ‘system leadership’
- ‘Every effort should be made to create as much local flexibility around discretionary funding as possible’, beyond DDRB and pay uplifts after 2023/24
RCGP chair Professor Martin Marshall said ‘further detail’ is needed about the ‘proposals around streamlining urgent access’.
He said: ‘Any new metrics will need to be thought through carefully so they have a positive impact on patient care and avoid any duplication or perverse incentives across the system.’
However, he added that the report is ‘appropriately ambitious given the scale of the crisis in general practice’ and that the ‘explicit support of the new chief executives of the ICSs for the report is positive’.
‘ICS leaders have a significant responsibility to ensure that general practice and primary care receive the support and resources that they need to be the foundation of a reformed NHS,’ he said.
BMA England GP committee chair Dr Farah Jameel said it is ‘refreshing to see Dr Fuller’s honesty about the scale’ of the workforce and workload challenges facing GP practices and the report’s ‘bold suggestions on how to begin to address this’.
She said: ‘This stocktake clearly lays out a desired direction of travel for care in our communities, setting a vision for what good looks like in primary care – while recognising the challenges and need for movement from Government and NHS England to fix the issues around workforce, estates and digital infrastructure.
‘Ministers and policymakers must now take heed – listening to, supporting and working with GPs and their colleagues to ensure they can provide the standard of care that all patients deserve. As ever, general practice stands ready to play its part and will continue to deliver for its communities.’
Dr Jameel also welcomed the report’s findings that GP ‘autonomy is far more valuable in improving outcomes for patients than top-down directives and micro-management’.
ICSs are due to become statutory organisations in July, and will replace clinical commissioning groups.
GP Dr Claire Fuller was tasked by NHS England to look at the ‘next steps’ for how PCNs will work in ICSs via a ‘stock-take’ in November.
READERS' COMMENTS [15]
Please note, only GPs are permitted to add comments to articles
Who pays for the urgent care and how much – is the question.
Or we could just fund the most efficient primary care system in the world properly, rather than allow it to collapse and try to replace it with less efficient systems.
Has anyone considered the effect on GP training?
If all diagnostic activity is taken off GPs and dealt with by unqualified persons practicing medicine without GMC registration, leaving only Chronic Disease Management for real GPs, then the quality of available experience for GP trainees, and the current VTS system will breakdown completely.
But then, it won’t matter if we can’t train GPs in diagnosis and acute care, since they will not be needed anyway, and they can go overseas to live and work after qualifying at med school, while unqualified people manage all the remaining trivial requests and hospital discharge mess-ups.
“This would require a shift in national policy towards 111, she said, and organising a ‘single integrated urgent care pathway’.”
Living on another planet. 111 is and always has been pants. As is most urgent care and OOH. Because there is no ownership and continuity of patient care.
Further centralising care with this BS, effectively NHSE again hoping to directly employ/control us and phase out independent contractors, takes away our autonomy and with it our efficiency and decent care.
Rock on NHSE. I won’t be working for your little centralised, directly employed service.
Time for a career change asap. They seem pretty determined to get us into line/directly employed.
For practices with mostly on-the day appointments whether urgent or chronic reviews that would be almost entirety of their work…
Alternatively we will have patients opting to wait for “their” doctor in chronic disease routine review appointments rather than getting serious & acute issues correctly managed on the day by someone else.
Do you think the Pensioner Daily Mail reading fascists will like this idea NHSE come on tell them see what they think.
At the same time a select committee, no doubt influenced by Jeremy Hunt pronouncement, is extolling the virtue of ‘patient lists’ and seeing the same doctor!
A substantial number of ‘on the day’ work comes from complex patients, sometimes poor hospital discharge, and ongoing mental health stuff.
While seeing the same doctor isn’t always possible, seeing someone from the same GP team usually is, and yes, GPs in a practice do discuss patients and call on wider teams.
What a load of management-speak nonsense gets spouted every day while inadequate funding, inadequate NHS estates charging exorbitant service charges contribute to starving practices of resources while all the while private companies operating digital remote for easy stuff are being encouraged.
The Saj’s salaried service under ICS and ever increasing working ‘at scale’ contradict the call to restore continuity
Turn out the lights indeed.
Everything that makes General practice an effective and efficient service is systematically being eroded by NHSE.
With all due respect, dear Dr Fuller ,my opinion reception of this kind of report and writing are:
(1) It always raises more questions than answers , as in some colleagues’ comments under this article . For instance , who pays for these ‘single , urgent care teams ‘ ?Are you going to write follow-up reports at different stages in the near future to reflect more specific , realistic and tangible answers? Please remember time is running out as general practices are facing a clear and present danger from an existential threat .
(2) While I understand that this kind of report is open to all for reading ( from top to frontline in the system and the general public, the way of writing is an art of balancing between political ambiguity and realistic clarity. Under the circumstances, the latter is more essential for the urgency of finding solutions and trajectories to save GPs and hence , help our patients needing well-justified treatments sooner than later .
The choice of words in parts of this report appears to be falling into the old habits of adopting ambiguous political jargons and rhetorics . We need clarity and specificity for these words you used , for example , ‘single Integrared urgent care pathway’, ‘ system leadership’ , ‘quick wins’ etc . These words have been ‘recycled’ numerous times in previous , similar reports .
Personally, I think Sue Gray’s report published two days ago appeared to have got this ‘balance’ right .
Forgive me if offence is taken as my English perhaps is not so good . But I always refer back to George Orwell’s famous Six Questions:
1. What am I trying to say?
2.What words will express it?
3.What image or idiom will make it clearer ?
4.Is this image fresh enough to have an effect?
5.Could I put it more shortly ?
6. Have I said anything that is avoidably ugly?
And also ,’’Never use a foreign phrase, a scientific word, or a jargon word if you can think of an everyday English equivalent.’’
After all , my belief is 21st century politics should be driven by transparency, honesty and last by not the least , humility by leaders .
(3)Notwithstanding my ‘harsh’ criticism, I am grateful for your honesty and passion in certain parts in this report . Perhaps , you should be even more assertive on some issues using the word ‘must’ than ‘should’ in addressing DHSC ,NHS England and our government, for instance on the issue of GP premises :
‘……the Department of Health and Social Care (DHSC) and NHS England should give ‘additional, expert capacity and capability to help offer solutions to the most intractable estates issues’.
‘NHS England and the DHSC should review ‘what flexibilities and permissions should be afforded to systems’ to allow ‘shaping and influencing of the physical primary care estate’, as well as reviewing the Premises Cost Directions’
Finally , I appreciate your effort and good intentions to write this relatively ‘closer to earth’ report . Once again , my apology of a rather cynical and critical comment . But I also believe in what Mr Orwell’s famous words in his original preface of Animal Farm ( part of that was omitted initially when he failed to find a publisher willing to take on this legendary book due to his strong criticism of Russian government i.e. USSR ) :
ʼ If the intellectual liberty which without a doubt has been one of the distinguishing marks of western civilisation means anything at all, it means that everyone shall have the right to say and to print what he believes to be the truth, provided only that it does not harm the rest of the community in some quite unmistakable way.’
Liberty is one I believe …….
Vinci Ho
GMC no 3483114
so in my 20 Yr career, shared obstetric care , chronic disease management home visits and now apparently acute care is to be removed from my job description. So what exactly does GP mean ??
They have already sucked out 90% of the job satisfaction and then wonder why there is a retention crisis . The more fragmented and complicated ( and expensive) the system becomes, the worse the care becomes . Patients dont want to be seen in hubs , they will still want to be seen at their own surgeries so doubling the work load .
111, hubs , ucc etc etc have lead to an increasing decline in care and an exodus from the profession.
Fund primary care , staff general practice with Genersl Practitiiners and maintain appropriate , timely and coherent secondary care referal pathways . KISS.(keep it simple stupid) and the NHS may survive .Keep over complicating ,fragmenting and demoralising and it is gone.
“‘urgent care teams’ must ‘connect up the wider urgent care system’, including ‘currently separate and siloed services’ such as general practice in-hours and extended hours, urgent treatment centres, out-of-hours, home visiting and 111 call handling and clinical assessment.”
Not sure I get this… create a new separate service from day-to-day general practice in order to reduce fragmentation???
So the GP-Partner model is perverse !
I cant see consultants paying out of their own pockets to prop up hospitals, but that is what we Partners do because NHSE and PCSE have ‘;#’;4d up our payments for the 3rd year running (weve subsidised the health service to a 6figure sum!)
And, I cant see how moving doctors away from the efficient 9-6 surgeries to the inefficient evening and weekends is helping anybody. The sunshine coast was looking attractive til it closed for overseas Drs
Dylan Summers
Brilliant!
After more than 20 years in practice, I have many reports and recommendations on how a reorganisation will solve the problems. I suspect I will still be waiting even after this one.
This is definitely going a little off topic, but I do agree that 111 can sometimes duplicate work.
Also, I wonder if there is space for urgent care to become an official speciality in its own right, or as an official subspecialty within RCGP, or an a merged subspeciality between RCGP and RCEM.
I wonder what other peoples thought might be on this?