The state of the NHS continues to dominate the nation’s front papers and in recent weeks primary care has emerged as the new flashpoint. More and more people are now finding it harder to book an appointment, particularly outside working hours or at weekends. Poor access to general practitioners has been folded into the narrative of a winter crisis in A&E. Patients are reportedly queuing up outside A&E as that is less frustrating that trying to get hold of a GP at short notice. What started as a debate on getting an appointment has become a far reaching national conversation on the state of primary care. For the first time the Care Quality Commission has lifted the bonnet and shone the light on the variation in performance in general practice. As the regulator highlighted, one in six GP practices up and down the country are at “risk of offering patients poor care”.
Both government and opposition have set out proposals in recent month to address public concerns – whether by guaranteeing an appointment in 48 hours or seven days a week. Yet the response from doctors was to rattle the begging bowl. Better access comes at a price. Leaders from inside the profession have claimed that the system is now at “under threat of extinction” due lack of investment and tidal wave of demand. Recent stories have highlighted particular crunch points. Some smaller practices face bankruptcy due to changes in the funding formula. With fewer medical graduates opting for a career in general practice and with a majority of doctors over 50 planning to leave the profession in five years a workforce crisis is brewing.
Times are indeed tight in primary care. Certainly, compared to the hospital sector, primary care has bared the brunt of the spending squeeze, with expenditure falling by 3.8 per cent in the last year. But as many commentators were quick to observe, English GPs are among the best paid in the world. Surely it is within their means to keep surgeries running a few hours longer. According to Stephen Pollard, GPs have played the “‘give us more money or the patient gets it” card far too often”. Cooler heads in the debate have pointed out that GP salaries should not be conflated with spending on primary care services.
Whatever the case for spending more on primary care the case for radical reform of primary care is overwhelming. The model of care that prevails resembles a “cottage industry” in a “post-industrial age”. To ensure seven days access, high quality, team based holistic care primary care will needed to be delivered at scale, not in the independent corner shops that have changed little since 1948.
Technology and stratification will be the key enablers of change. New models of primary care will have to embrace the digital age to transform delivery. The Health Secretary has talked of the need for online access to patient records and drew the comparison with banking and airlines that have moved services online. Allowing patients to interact with healthcare professionals and access expert advice online could potentially channel hundreds of people away from needing a face to face appointment. Stratifying populations according to need will also allow GPs to manage demand. Primary care is still based on the heroic general practitioners trying to be all things to all people. However the needs of young working age people are quite different from elderly people with chronic illness. Primary care providers need to offer services that reflect different needs, potentially opting to specialise for one group or another.
While many patients experience of primary care can still be characterised as being sat in a surgery waiting room followed by a ten minute consultation, for a lucky minority remote access in now a reality. The Hurley Group of surgeries in London is one example where patients can now access “e-consultation” through the group website for common symptoms and syndromes, as well as make appointments or view records online. Cleary Government would want all patients to be able to benefit from such modern services. Giving patients a real choice of GP provider, as Policy Exchange called for in 2009, can allow practices at the forefront of reform, such as the Hurley Group, thrive and extend their reach. Similarly, lifting the ban on the sale of GP goodwill will allow successful providers to takeover poor performing practices. Yet while opening up primary care providers to a bit of market profession could transform services the profession has remained fiercely resistant to expanding choice. Given rising public frustrations with poor access now is the time to put patients in control of primary care.
Thomas Cawston is head of health policy at Policy Exchange