The year is 2020. General Practice has changed but is still recognisable. Longer GP appointments are the norm. This is based on patients’ desire to be treated nearer to home and spend longer with their GP, the complexity of GP consultations and some evidence that longer consultations reduce referrals and improve prescribing as well as allowing for health promotion. The tensions between cost, quality care and autonomous practice have become increasingly difficult to resolve and some contentious choices have been made. CCGs have evolved and now primary care, out of hours care and the commissioning of specialised services are within their remit but management costs have been kept lean. Unlike many old PCTs they are much more aggressive at driving out variations in both quality and cost of care, focusing on both low and high referral rates and prescribing costs. They can do this because a significant proportion of GP income is based on a wide range of key performance indicators. Local clinicians are in charge and work with their colleagues to provide effective peer support and, if required, pressure to change behaviour. Financial prudence has become the accepted culture. It is in everybody’s interest to succeed.
Practices have moved to longer GP appointments because it makes both clinical and financial sense. Nurse practitioners, prescribing pharmacists, and physicians assistants have all become increasingly skilled. Care is based on evidence based pathways. Other professions provide care so GPs rarely see acute minor illness or provide monitoring of chronic disease. Instead the role of GP has become that of skilled diagnostician in referral management and complex chronic care decisions . They also support other professions in their day to day work. It has been recognised that clinical review, significant event analysis, audit and patient feedback are key elements of medical practice and not simply add-ons to a busy day. Practices are timetabling this in as it makes business sense to do so.
Working times for GPs have changed for a number of reasons. Firstly patients want access in their lunch times, evenings and weekends.
Secondly better access reduces home and A+E visits and admissions and thirdly because the new GP contract stipulates the minimum number of consultations provided per head of population and it makes sense to spread these throughout the day. Fourthly reducing costs by fewer A+E visits and admissions increases GP profits via agreed payments. Many larger practices open 8am to 8pm five days a week and at peak weekend hours. This is achieved by a co-operative of GPs and nurses staffing the practice at less social hours or a particular practice caring for others patients and receiving payment for this but models vary.
Community clinics including GPSI clinics also operate in the evenings providing good patient access and profitable services to practices.
Providing Out of Hours services as a federation ‘in –house’ is becoming commonplace with a proportion of GPs deciding to provide sessions as these are financially attractive and provide good patient care.
Emergency care practitioners developed as a nursing sub speciality staff many centres with GP support.
Through local solutions there is an accessible single care record making treating patients safer and easier. Continuity of care is still prized by patients but the impact of loss of this has been partially compensated for by improved record keeping and high quality consultation skills.
Many GP practices remain individual businesses but many have joined together into federations. These have become business entities with each practice providing proportional financial input in return for pooled resources such as diagnostics, therapies such as counselling, physiotherapy, dietetics, drug and alcohol support etc and back room functions such as CQC compliance, health and safety requirements and management of community based GPSI services and out of hours care.
Other practices are considering being managed by national organisations in a variety of mutually beneficial arrangements. The sale of goodwill is still not allowed although the rules have become relaxed.
The average full time GP in 2020 working around 50 hours a week is paid equivalently the same as currently. It has been recognised that having a stake in a business is good for improving standards and retention and the concept of different partnership grades has been developed. Limited companies and other vehicles are being increasingly used to allow GPs to plan effectively for tax and pension purposes.
Many GPs spend less time on face to face in- hours primary care consultations than they currently do and work a shift pattern. The rest of their time is spent on teaching and support, administration, clinical governance with commissioning, GPSI and out of hours work as further options. GPs in successful partnerships or those that are providing marketable services as sole traders or in groups are working longer hours but are being paid considerably more than average.
Community tariff payments are set at around 80% of hospital tariffs making this worthwhile. Quality care is rewarded. Measuring output is becoming increasingly sophisticated however there remain significant anomalies.
Practice buildings are being funded flexibly allowing for greater entrepreneurialism. However GPs are investing more of the own money into premises as funding has become less generous. Most GPs work from modern premises, there is more ‘hot desking’ allowing for better use of space .Rooms are much more generic in layout and are smaller.
Commercial enterprises are beginning to tap into the foot fall of GP centres with coffee shops, retail, multi- healthcare and spa facilities being developed in some areas.
Dr Paul Charlson is a portfolio GP based in Yorkshire, a GPSI in Dermatology, Strategic Clinical Director of One Medicare Group and RCGP Commissioning Champion. He is a founder of the newly formed Doctors Think Tank