Investing in general practice – if not now, when?
Anticipating another glossy NHS strategy as the 10-year-plan looms, Dr Katie Musgrave asks: If this isn’t the time to properly invest in general practice, then when is?
At the NHS Confederation conference earlier this month, NHSE primary care director Amanda Doyle said the 10-year-plan for the NHS will be ‘GP-centric’ – while stressing this would not include a significant redistribution of funding from secondary care to primary care. In the same week, The Times reported on Government plans to drastically shift care from hospitals into the community, in an attempt to create a ‘neighbourhood health service’. Make it make sense.
Previously, Wes Streeting has expressed his intention to move care from acute trusts into the community. Lord Darzi’s much-feted review of the health service advised this was necessary to improve the sustainability and functioning of the NHS. He warned the NHS was in ‘serious trouble’ and specifically advised to increase the share of the NHS budget spent in the community; emphasising ‘too many people end up in hospital, because too little is spent in the community’.
Last year, a report by the King’s Fund suggested the lack of primary care investment was ‘one of the most significant policy failures of the past 30 years’, saying the NHS in England ‘must be radically refocussed’ to put primary care at its core. But does the fact a hospital consultant reviews outpatients in a GP surgery, significantly change the emphasis of the care delivered? Would a visiting ophthalmologist to a high street optician, transform the nature of the care provided?
Lord Darzi’s report stressed that a significant shift towards supporting primary care could dramatically reduce the downstream costs of expensive hospital care. An experienced GP, with an adequately resourced team of district nurses, might for example negate the need for a hospital admission at the end of life. The current cost of avoidable, but sadly futile, hospital admissions across the UK must be astronomical. Yet, aside from visiting geriatricians or palliative care consultants, and diabetes expertise, the plan to invest in the community by paying hospital specialists to relocate for part of their week rings somewhat hollow.
When Amanda Doyle claims there will not be a significant shift of funding to primary care, it suggests that Labour and the leadership of the NHS have fundamentally misunderstood the crux of Lord Darzi’s report, and have therefore devised an incoherent strategy. I am left questioning at what point do they intend to make the shift (especially when bearing the general practice underemployment crisis in mind). If not now, when?
From the direction of travel in the NHS, it seems that health leaders are either oblivious to the downstream consequences of the situation in general practice, or they are receiving seriously poor advice. As more and more work has been funnelled towards GP surgeries, with real-terms funding cuts, and moves to scale up services (in a misguided quest for economies of scale); the situation for UK general practice gets worse by the day.
The 2016 General Practice Forward View, which lay out a five-year plan for the profession, was a failure. There haven’t been improvements. When it is published, the 10-year-plan will almost certainly lack insight into patient and staff behaviour and motivators. It will further fragment care by focusing on scaling up services and dividing acute from chronic care.
Can no one see what matters? Patients need timely access to a GP, rather than a plethora of insufficiently-qualified-or-experienced clinicians. GPs need to be protected from inappropriate workload demands. Working conditions need urgently to be improved. Practices need sufficient funding to employ enough staff to safely provide services. And why the push to merge and scale up? Where is the evidence that this improves patient outcomes, or promotes staff retention and satisfaction?
We have a government and leaders at NHS England who repeatedly give lip service to the importance of shifting care from hospitals into the community, and claim to have plans that are people-centred and prioritise continuity; yet they refuse to invest in the community, and are pushing to scale up services and fragment care. The strategy is incoherent, and ultimately will be ineffective.
Dr Katie Musgrave is a GP in Devon
