Primary care needs to adapt to cope with a future in which there are significantly fewer GPs. According to the Royal College of General Practitioners Blueprint for General Practice, there is currently a shortfall of 3,300 GPs in England; one in three training posts and one in six vacancies are unfilled. Worse still,10,000 (1 in 3) practising GPs are over 55 and likely to retire in the next 5 years.
It is not clear how many GPs will have to be trained to fulfil the government’s ambition, set out in their New Deal for General Practice, to recruit an additional 5,000 GPs by 2020 and provide seven day a week primary care.
According to a survey of trainees last year the possibility of having a ‘portfolio’ career with a mix of jobs, and a superior work-life balance, is among the most popular reasons for choosing to qualify as a GP. A 2015 BMA survey showed that over a third of GP trainees do not want to work full-time in general practice, and 17% of existing GPs want to start working part-time. In the same survey, 21% of trainees and 9% of GPs said they were considering working abroad, and 35% of GPs who had qualified in the last 5 years said they wanted to take on non-GP roles.
For all these reasons, the government’s stated commitment to increase the number of full-time GPs by 5,000 by 2020 is not credible, as Jeremy Hunt is perhaps beginning to accept. Primary care must now be adapted to work effectively with far fewer GPs per thousand patients than in the past.
What follows are some suggestions about how this can be done.
New primary care roles.
Primary care already includes a wide range of health care professions including practice nurses, district nurses, health visitors, occupational and physical therapists, and many more, besides GPs. The government’s New Deal for General Practice also proposes an additional 1,000 physician’s assistants and 4,000 practice nurses, district nurses and pharmacists, including practice based pharmacists. Sustainable primary care should consider the following:
- Physician associates/ health trainers/ community health workers/ community pharmacists – More and more primary care revolves around the care of people with long term conditions who need proactive care and self-management support. They would benefit from having trained members of the community who can act as advocates, educators, mentors and interpreters. We can take inspiration from the Promatoras in Mexico and the US, and community health workers in Brazil. What these new professionals do is more important than what you call them, as Ravi Sharma a GP based-pharmacist, has described.
- Specialist nurses. Specialist nurses for long-term conditions including diabetes, COPD, epilepsy and dementia already perform very valuable roles supporting patients and other members of the primary care team, and we should recruit more of them.
- Legal and financial advisors. A significant part of my role as a GP is to write reports for patients appealing for benefits, housing, immigration and financial matters. The social determinants of health are so strong that we need to ensure that patients have access to the right kind of support in overcoming such problems.
- An essential element in maintaining the quality of primary care is the regular auditing of practice, which is frequently done by clinical members of the primary care team, including trainees. Audits vary enormously in quality and value. Professional auditors employed by CCGs could improve the quality of audits and allow GPs to concentrate on their clinical practice. They could provide accurate, comparable, up-to-date data about workload, prescribing, referral patterns and much more.
- HR, occupational health, and finance-management. Many practices suffer from poor management and many GPs struggle to combine clinical and managerial roles. It would be more efficient for a lot of this work to be carried out at scale for federations of practices with patient-populations of approximately 100,000 or more
Rethinking the gatekeeper role.
In order for hospital specialists to work most efficiently and effectively, the GP still has an important role in helping to select patients who are most likely to benefit. But where diagnosis or management is not in doubt, from abortion and antenatal care to district nursing, palliative care, physiotherapy, and specialist nursing and much more, patients should be able to go directly to someone who can help, without having to make a case for it to a GP.
To make direct access to different kinds of primary care effective, but also as a matter of principle, patients should have online access to their medical records. This can improve the accuracy of the record and will enable patients to show it to every health-professional they meet, and keep it updated.
When a patient first experiences a problem such as stomach ache they may not know whether they need to see a GP, a nurse, a pharmacist, a gastroenterologist, a general, urological, gynaecological or vascular surgeon, a hepatic or renal physician, or none of the above. An expert generalist at the point of first contact can minimise the steps required to solve the problem, and for this reason many GPs are choosing to phone patients before they book appointments so that they can either deal with their concerns immediately or make arrangements for them to be seen by the right person at the right time. GPs are highly skilled at triage and should retain this role. It would be a false economy to delegate triage to less qualified primary care staff..
One of the greatest dangers in general practice is professional isolation. The intensity of their workload now means that many GPs are isolated not only from their hospital colleagues, but also from each other. It is vital that time is made and protected at least weekly, for GPs to discuss the patients that they and their colleagues are concerned about. Almost all the changes envisaged above increase the size of the teams within which GPs work, and effective teams need good lines of communication.
One of the risks of caring for more patients with fewer GPs is the loss of continuity of care and relationship-centred care which is of particular importance to patients with long-term conditions. I fully endorse the proposal that every patient should have their own named GP and organisational efforts must be made to ensure that patients see their own doctor when they need to, especially since it is likely that they will see them less frequently in future.
Training for the needs of the future GP needs to place a greater emphasis on elderly care and multi-morbidity, with more attention to patient-centred care, in particular shared-decision making and self-management support. Training will have to reflect the shift from a GP as an independent practitioner to a multi-disciplinary team player.
Less is more.
There is a world-wide movement of medical professionals, journalists and patients who have realised that a great deal of modern medicine is not effective and that cutting down on waste requires that patients and professionals are given the right information and enough time to make the right decisions about care. We could start by stopping unsolicited health-checks and dementia screening as well investigations like MRI scans for the vast majority of patients with back pain and headaches.
The changes envisaged here call for more space for the other kinds of roles that will be needed in primary care teams. According to a LMC survey, over 40% of GP premises are inadequate to provide essential care and over 60% do not have space to expand. NHS England has secured a £1bn infrastructure fund which will support improvements, but is unlikely to be sufficient. 58% of patients value a GP surgery that is close to home, especially the frail, elderly and disabled and parents with small children, so moving and consolidating smaller surgeries into larger premises must be balanced with the need for local access.
Innovation, evaluation and emulation.
General practice is a hot-bed of innovation, but the innovation is patchy, poorly evaluated, and rarely emulated. The Royal College of GPs should support innovation, evaluation and emulation to ensure that good practice is backed up by good evidence and shared, so that patients and GPs everywhere can benefit.
Fewer GPs and 7-day primary care
GP out of hours, district nursing, community pharmacists and other primary care services already operate seven days a week. Expanding the range of weekend services to include routine GP appointments, clinical diagnostics (blood tests, scans etc.), antenatal care, psychology, and so on, is perfectly possible. Where I work in Hackney, the infrastructure is already in place at the out of hours service to provide urgent GP care, and it could be set up to offer weekend appointments with GPs and other members of the primary care team.. But investment will be required and it would be an illusion to imagine otherwise.
Some of the cost of this investment would be offset by having to pay fewer GPs, but the proposals outlined here are not about saving money. They are about how we can meet the needs of a growing number of patients with a now inevitable decline in the ratio of patients to GPs. This is what any realistic planning has to confront.