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The ‘cottage industry’ model worked well, but won’t last



In a new report, we argue that the ageing population, the changing burden of disease and rising patient and public expectations demand new models of care if the NHS is going to rise to the challenges that lie ahead. Primary care must be at the heart of these new models with much greater consistency in the standards of care provided and closer integration with other services.

Full use should be made of all the skills in the primary care team and the role of patients as care providers must be recognised and supported. The way in which patients access services must also change with greater use of telephone and email where appropriate and the deployment of telehealth and telecare to enable the home to become the hub of care.

At the heart of our vision for the future is a model of primary care in which practices work together and with other providers to deliver more care in the community. This would reduce the overreliance on hospitals by providing access to high quality services delivered by GPs working hand in hand with community health service and social care staff. These services would be available 24/7 when needed to avoid hospitals becoming the default providers of care.

More radically still, collaboration between practices in federations, as first advocated by the RCGP in 2007, would make it much easier for some hospital services to be provided in the community. Examples include many diagnostic tests and specialist consultations that do not require the expensive technologies that are currently located in acute hospitals. Community based specialist care is particularly appropriate for the treatment of conditions like diabetes and COPD where referral to hospital is needed for a small minority of patients. 

One of the benefits of federations is that they would allow primary care to progress beyond the traditional cottage industry model of small practices and operate at the scale needed to facilitate a fundamental shift in where services are provided. Federations have the potential to enable practices to retain their identity and knowledge of the population they serve, as well as the advantages associated with small businesses, while also creating a platform for the provision of services they would find difficult to provide on their own. In some cases, practices may choose to come together to create larger units but this should be optional rather than compulsory.

If practices rise to the challenges we have outlined and seize the opportunities available to them, then they can pioneer the new models of care that are sorely needed. On the other hand, if they rest on their laurels and fail to read the warning signs, they may find themselves under threat both from within the NHS and from new providers wishing to enter the market. Primary care has proved remarkably resilient but as financial advisers are keen to warn, past performance may not be a reliable guide to the future.

In our report, we give examples of innovations in care that show the way forward. One of the most telling is Group Health Cooperative in Seattle where some family doctors now have around a dozen appointments a day each of around thirty minutes. This is possible because of the extensive use of telephone and email consultations and the role played by nurses and other staff alongside doctors.

In Seattle, family doctors concentrate on caring for patients with complex needs who require face to face consultations and cannot be dealt with by other members of the health care team. These are often the older patients with co-morbidities who make up an increasing part of the workload of GPs in the NHS. Doctors are able to focus their time and expertise on these patients precisely because of the effective deployment of communication technologies and the emphasis on team work.

General practice has demonstrated its willingness to adapt to changing needs throughout the history of the NHS and its responsiveness and flexibility will be tested to the limits in the challenging times that lie ahead. The trick will be to combine the best of the current model with the benefits that can only be realised when practices collaborate on the scale required to bring about major shifts in care.

Professsor Chris Ham is chief executive of The Kings Fund

Now read Dr Michelle Drage’s response to the report, ‘”Cottage industry”? Bigger is not always better in general practice’.