There is a really good case for bringing together high-quality general practice and some secondary providers as a merger with mutual, two-way benefit. But this is no quick fix.
Ideas about how to best support and integrate general practice are a growing feature of the health policy landscape. The creation of an NHS England stock-take about primary care, led by Dr Claire Fuller, follows hot on the heels of the integration white paper and a Parliamentary inquiry into primary care. One suggestion is that the health secretary is considering creating a permissive approach to practices being run by NHS trusts.
Many in general practice have made clear their scepticism at this prospect. Yet all accept that the status quo cannot hold. As small enterprises workforce gaps hit hard. Taking on lifetime partnership property commitments may not be attractive to some entering the profession.
If doing nothing is not an option, doing something has to be thought through. The breach of trust lingers from past governmental promises of thousands of new GPs.
The unacknowledged reality is that many Trusts are already employing or taking contracting responsibility for general practice. Northumbria, Yeovil, Sandwell, Wolverhampton and East London FT are examples of the former. Others have partnership arrangements which seek to galvanise real change in how services are delivered, with the Hurley, Modality and Operose among those who have taken on services offered by hospitals. Quietly, these steps have been going on over several years. Guy’s Hospital employed GPs before the start of this century: I helped set it up!
So if this is being done now, the question becomes how-best: a discussion about scaling it up. This could get clouded by three missteps:
- Scaling up often implies one size fits all. There are not infinite ways to gain benefit from integration, but it is improbable that a single approach will help all settings or patient populations. PCNs themselves serve to illustrate the potential achieved by some, but the poor-fit for others. Different collaborative models, like federations on Teeside, or incorporation in Leicester, may be better placed to work. It is to be hoped that the Fuller stocktake is explicit about local flexibility – what counts is what works.
- What problem are we trying to solve? Pressure on primary care is longstanding yet data on appointment backlogs is not published, so the legitimate concerns of those unable to get an appointment are an unsized iceberg. The typical media narrative reverts to how to take pressure off Emergency Departments. It is implied that more capacity in general practice would reduce A&E demand. But there is little evidence that primary care access alone is a material driver of attendance to hospital. If the aim was to turn GPs off the idea of Trust employment, then being deployed as a make-weight in an acute hospital salvage deal is a poor sell.
- And finally do Trusts have the skills to collaborate well? This is a question of both competency and trust. Trusts can bring estate management skills, IT deployment expertise, HR and finance skills. But the key skill is making transactions work but without losing purpose.
Why this matters, and how could it happen?
The focus needs to be on shaping services around those with multiple long-term conditions. Repeat attenders at emergency departments need a joined-up approach between local professionals, as well as the skills of the third sector, as Wolverhampton has shown. All types of Trusts offer many of the gains required; in some places mental health integration may offer more than a hospital.
Listening to the Trusts who have been down the path of primary care collaboration, what comes across is the time these relationships take to build. With a backdrop of lingering suspicion, clinical collaboration has to be genuine and strong to overcome concerns. Boards are still faced with distinct sectoral regulatory regimes within the CQC, separated funding streams, and duplication of functions. If the policy is to now scale up it needs a recognition that those inhibitors have to be changed.
Primary care has leaders used to changing working practices. Trusts have financial muscle and management bandwidth, with research and educational infrastructure to make careers more rewarding. Blending these talents has much appeal. This renewed attention on how to deliver models of at-scale primary care may break down barriers.
Done well then, this should be an option for some. Asking ‘what would help’, rather than an institutional takeover. Practices and PCNs opting in should not be viewed as undermining primary care, but as innovators wanting to fulfil the overdue promise of population health. Sufficient sites are doing this now that a national longitudinal evaluation is needed before dismissing the chance to enable more.
Toby Lewis served as an NHS chief executive who has worked in both primary and secondary care. He merged a large Trust with a 100k patient GP grouping in 2019. He is an advisor to NHS Providers.