There must be some hard thinking going on within NHS England (NHSE) because its flagship plan to resuscitate general practice – which is in a critical condition – is now in serious jeopardy.
NHSE’s vision for the future of primary care looks something like this: there will still be GPs but, relative to our ever-increasing workload, there will be fewer of us. The circle will be squared by expanding the current teams. As well as practice nurses, there will be paramedics whizzing about doing home visits. Clinical pharmacists will review patients’ medications, while physician assistants will undertake the simpler bits of GPs’ jobs, and physiotherapists deal with many of the musculoskeletal conditions. Finally, patients whose health problems arise from adverse life circumstances will come under the wing of social prescribers – who, as a New Statesman reader pointed out, are the medical social workers of yesteryear.
There is quite a lot of common sense here, which explains why NHSE’s vehicles for delivering this transformation, primary care networks (PCNs), were greeted with enthusiasm when they were proposed last year. PCNs are groups of practices, covering populations of 30-50,000 patients, through which resources to support the expansion of primary care will flow. In most surgeries there would be insufficient work to justify a full-time pharmacist or physiotherapist, for example, but a PCN would be able to employ them and apportion their hours between the member practices.
I have some reservations about PCNs – they are being funded on a shoestring and, were things to go wrong, would represent a substantial financial liability to practices – but broadly speaking the profession sent up two-and-a-half-cheers and got on with the job of setting them up. Across England, dynamic GPs with leadership flair stepped into the newly inaugurated roles of PCN clinical directors. Network agreements were drafted, involving expensive legal advice, and member practices signed up. Initial recruitment of allied professionals got under way.
Then, just before Christmas, NHSE published its draft PCN contract. It is difficult to overstate the strength of the negative reaction. GPs who had hitherto been prominent cheerleaders for the project let out a collective howl of dismay. At least one director has already resigned and many others are expressing doubt about continuing in their fledgling roles. The BMA and the Royal College of GPs have both issued strong condemnation. Emergency meetings of local medical committees have been called, with many advising practices to withdraw from the PCN contract altogether. Grass-roots GPs have taken to social media to air their disbelief and sense of betrayal.
This vehement reaction is partly because the draft contract is impossibly ambitious. Originally PCNs were supposed to develop over a five-year timescale. Having seemingly forgotten this, NHSE is demanding in 12 months achievements that simply cannot be realised.
The other problem is NHSE’s nanomanagerial culture. PCNs were supposed to be locally controlled; able to shape new services and staff roles to their particular circumstances. The draft contract specifies in inordinate detail the processes networks are to follow in every area of activity, together with the onerous bureaucracy they will have to engage in to prove they’re doing what they’re told.
NHSE held a short period of consultation on the draft terms; the profession has made its rejection unambiguous. NHSE must now decide what to do; if it merely tinkers with the details, the PCN initiative is going to be stillborn. GPs have been developing and adapting primary care for decades, and given freedom, support and sensible timescales, we will do the same with these new services and roles. But if NHSE insists on trying to impose its one-size-fits-all prescriptive vision, then my suspicion is that many in the profession will simply walk away.
This article appears in the 29 Jan 2020 issue of the New Statesman, Over and out