Policy Exchange - Report calls for overhaul of ‘outdated’ GP model, rescue package and boost in digital healthcare provision
A new report from the think-tank Policy Exchange details a ‘rescue package’ for general practice to ensure GPs can continue to deliver excellent care to patients in the years ahead. The status quo – the authors say – is unacceptable to the both the GP profession and to patients.
In a foreword to the report, Rt Hon Sajid Javid MP, Secretary of State for Health and Social Care writes:
“From the receptionists to the GPs to the pharmacists, the brilliant people working in primary care have been working harder than ever and in innovative ways. Their huge contribution to the successful COVID-19 vaccine rollout is the clearest example of this and demonstrates the potential of the NHS working ‘as one’. We need to find ways of capturing this culture of close working and shared objectives, and see it replicated across a wider set of priorities, from preventing people becoming unwell in the first place to addressing the long-standing health disparities across our country.
“There is an exciting future for primary care and we need to think deeply about how services are designed and planned – not just within general practice, but across pharmacy and dentistry too. To provide a 21st Century offer to patients, we must give the front-line innovators the right tools to evolve to meet the needs of patients in the future.”
Policy Exchange recommends:
- The overhaul of the current core GP contract to redefine incentives, reduce bureaucracy and free-up GPs to help the patients with the most complex needs;
- A £6 billion ‘rescue package’ to enable improvements to general practice premises, data collection and to enable an orderly transition to new contractual models;
- The ‘levelling-up’ of general practice with a massive boost in high-quality video consultations in areas where there are not enough doctors;
- The introduction of ‘NHS Gateway’, a more coherent entry point to primary care and to reduce dependency upon the 8am call to the GP surgery for appointments;
- A ‘taskforce’ in the new NHS England ‘Transformation Directorate’ to accelerate data security across the NHS and to ensure digital maturity targets are met;
- NHS-trained doctors living overseas to conduct remote sessions through changes to General Medical Council rules; and
- A Digital Health and Care Bill to be introduced to give patients more access and control over their patient data and to expand its use for clinical research in the NHS.
England has fewer GPs per capita than almost all European countries of comparable size, and general practice has remained stubbornly ‘under-doctored’ in deprived areas since the foundation of the NHS. Today however, GPs are tasked with managing a growing number of patients, many of whom have increasingly complex conditions. Pressures on the service pre-date the pandemic – but have only become more acute in the past two years. Patient satisfaction has also decreased in recent months.
The report is launched amid an ongoing row over primary care access. A letter published on 1 March from NHS England to general practitioners called for GPs to offer appointments between 9-5pm on Saturdays. It sparked a backlash from the British Medical Association, who said they were “bitterly disappointed” with the move.
Among the ideas proposed in Policy Exchange’s report, called ‘At Your Service’, are a ‘smart’ new way of booking appointments and checking symptoms called ‘NHS Gateway’ which would see enhancements to the NHS App (which Health Secretary Sajid Javid wants 75% of adults to be using by March 2024) and would help end the 8am scramble to book appointments by telephone (currently 86% of GP appointments booked this way).
COVID-19 has created an increased public acceptance of at-home diagnostics. More than 400 million later flow tests have been delivered in the UK since the start of the pandemic.
Under the new Gateway model, following initial questions about symptoms, the public would have the option to order ‘at home’ blood tests and kits, taking the pressure off busy GP services. Examples include a dipstick test to diagnose uncomplicated urinary tract infections which account for between 3-10 million GP appointments every year. Gateway would also be a portal for NHS-approved health apps to manage mental health and chronic conditions such as musculoskeletal pain (which account for 30 per cent of GP consultations). Patients would also be able to request and manage their appointments, requesting high-quality video consultations with a range of primary care staff, including community pharmacy.
To better integrate GP and hospital care, the authors propose that Gateway links to My Planned Care, a scheme announced earlier this month to personalise information for patients in England on NHS waiting lists. In the longer-term, Gateway should be driven by Artificial Intelligence and machine learning to improve triage and to flag ‘at risk’ patients and highlight public health trends.
The reforms would be accompanied by £6bn one-off injection of financial support for general practice. Approximately £5bn would go towards estate transformation, including buying-out the GP owned estate in England. The remaining £1bn would fund reforms to the Additional Roles Reimbursement Scheme, incentives to boost GP retention, and to fund digital transformation including NHS Gateway.
Commenting, Dr Sean Phillips, a Research Fellow in Policy Exchange’s Health and Social Care Unit and lead author, said:
“There have been growing pressures on general practice for years, but the current situation just isn’t sustainable for GPs or their patients. GPs are doing their best, but dissatisfaction is increasing among patients. We need to find ways to work smarter, rather than just demanding that stretched GPs work harder. Our package of reforms would deliver what patients value most from their GPs: quality of care, convenience, choice and continuity.
“By expanding high-quality digital healthcare, such as video consultation, we can ‘level up’ areas that have fewer GPs and enable GPs to conduct more appointments face-to-face – particularly those with complex needs. Optimising the use of the NHS App can help reduce missed GP appointments which cost the NHS £216 million every year through simple reminders and signpost patients to the place their needs are best met.”
The report examines the way general practice is structured and finds the ‘traditional’ small-scale partnership model to be in terminal decline, with the number of partners falling by 22% since 2016. It recommends moving towards a ‘mixed economy’ of scaled forms of general practice. GPs would be incentivised to either partner with local hospitals (vertical integration) or formally join forces with other practices to provide community and primary care (horizontal integration). The report recommends a phase out of the General Medical Services contract and the ‘global sum’ (which is how GP services are currently commissioned) by the 2030s. Successful, larger-scale independent models would be commissioned by their Integrated Care Board. To minimise disruption, alternative contracting models would be introduced and run in parallel to the 2024/25 five-year framework.
Patients should have greater say over services with, real-time, open-access ‘Trip Advisor-style’ review and feedback platforms informing commissioning decisions and service design.
Robert Ede, Head of the Health and Social Care Unit at Policy Exchange, said:
“We are already witnessing a steady reduction in the proportion of ‘traditional’ partner-led practices. So, we have a decision to make about whether to ride out the decline, or to proactively support an orderly transition. Our proposed reforms build upon, rather than disrupt, the direction of travel, without prescribing a ‘one-size-fits-all’ approach.
“We have a window of opportunity, with the forthcoming GP contract negotiations, to do things differently. This should begin with consulting with the entire GP profession, rather than relying solely on the BMA. The Policy Exchange model would help to bridge the historic divides between primary and secondary care and allow the NHS to put more emphasis on preventing ill health.”
Alongside the foreword from the Health and Social Care Secretary, the report has been welcomed by Dr Harpreet Sood, a GP practising in South London, by Louise Ansari, National Director of Healthwatch England, by Dame Barbara Hakin, former Deputy Chief Executive of NHS England and by Lord Patel, a crossbench peer in the House of Lords and former President of the Royal College of Obstetricians and Gynaecologists. Their endorsements can be found HERE.
Policy Exchange’s report ‘At your service’ can be found HERE, with the full list of 23 recommendations.
Notes to Editors
- 90 percent of all patient contacts with the NHS occur with a GP. That equated to over 360 million appointments in 2021. Nick Bostock, ‘General practice delivered an unprecedented 367m appointments in 2021’, GP Online link
- 86% of patients currently try to book their appointments with general practice via telephone which has created conditions that many will be familiar with: the 8am scramble. Response to Q12. How did you try to book the appointment?, GP Patient Survey, NHS England link
- Just 8% currently use the NHS App to book and manage their appointments. In the instance that patients are unable to secure an appointment on the day they call their practice, 32% don’t seek any further support and will most likely try again another day, creating failure demand. Just 3% follow up with online services provided by the NHS after not securing an appointment, whilst 8% have suggested they will attend A&E, which – in most cases – will be an inappropriate clinical setting to manage their condition. Response to Q17. What did you do when you did not get an appointment?, GP Patient Survey, NHS England link
- Musculoskeletal pain accounts for 30 per cent of GP consultations link
- NHS England undertook a General Practice Premises Review in July 2019 which estimated that the total cost for buying out the GP owned estate in England would be £5-6bn. Link
- In 2019, NHS England reported that “missed GP appointments cost millions”, calculating that 5% — more than 15 million — appointments across primary care were missed every year, of which 7.2 million were GP appointments. That equated to 1.2 million GP hours, with estimated NHS costs of £216 million annually. Missed GP appointments costing NHS millions’, NHS England, 2 January 2019 link
- The General Medical Services (GMS) contract is held by more than 70% of partnerships. It is negotiated annually between NHS Employers and the BMA. GMS defines services GPs must provide and determines payment allocation through a “global sum”, a formula based upon population size.
- The number of GP partners has declined by 22 per cent since 2016 link
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