A realistic vision for primary care?

Jeremy Hunt announced an independent Commission on the Future Primary Care Workforce at the RCGP conference last year, and – like magic – its report has now appeared. The front cover carries a quote from the report “With its highly skilled workforce, effective multi-disciplinary teams and well-developed IT systems, the NHS is in an unparalleled position to develop a modern primary care system that is truly world class”. When GPs all around us are retiring in their 50s (or even earlier), is this hopeless optimism or blind faith? How does the Commission come to this conclusion? And what else does it say?

Its first set of recommendations are for more staff: more GPs, more nurses, more pharmacists and more admin staff. Everyone agrees we need more GPs, but even if the government recruited the 5000 extra they’ve promised, we all know that that would be nowhere near enough to solve the problems of primary care. I know (as we’ve not seen Martin much recently) that the Commission has toured the country, and seen some fairly radical examples of practices using very different skill-mix to improve care for patients and (importantly) improve working conditions for staff. They even recommend more physician associates, having seen examples of them working really well as part of practice teams, despite many GPs still being sceptical. And as for pharmacists, although the report reckons they could be doing more in their own premises, the main recommendations are for more pharmacists working in GP practices and supporting GPs in care homes.

As you will no doubt be thinking by now, all this will cost money, and a lot will depend on the government committing to reverse the long term decline in investment in general practice relative to hospitals. But – yippee – apparently not all the recommendations will cost money. The report calls for support for GP federations, and sees a major role for them in future. Perhaps such federations will employ staff. They will certainly be supporting practices working with new types of staff (e.g. physician associates), and providing better integrated care by holding contracts for community nursing and out of hours care. The report also calls for different relationships with specialists, with GPs and practice nurses easily able to phone and email consultants (I know), as well as hospital specialists working more in the community to support primary care staff. The Commission also points out that there needs to be especially close relationships with and support from geriatricians, paediatricians and psychiatrists, who should have practice attachments.

The report also sees GPs and practice nurses being able to share email with patients, but (a note of caution here), it calls for research into the impact on workload, rather than making an outright recommendation. However, they point out that patients in Denmark have been able to email their GP for years. Under this system, the GP controls the length of message that the patient can leave on a web interface (typically 150 words), GPs get paid four euros for each email and apparently it seems to work well, especially as GPs usually employ medical assistants or nurses to screen emails, only passing on to the GP those that need the GP’s expertise. In fact, the report calls more generally for an expansion of administrative support for GPs. In some US practices, medical assistants deal with most of the electronic tasks and emails that drag down so many GPs here. If half of the admin tasks currently done by GPs could be delegated to someone else, that would be equivalent to 1400 extra GPs in England. Which sounds pretty good.

On access, the report says that the real problem is people’s ability to see a doctor or nurse of their choice and the increasing loss of continuity of care that’s becoming a threat to patient safety. They point to resources which will help practices improve continuity of care, making life better for patients and GPs alike.

In his foreword, Prof Roland says that he never had any doubt that he wanted to be a GP, and that general practice had always seemed to him to be the most rewarding branch of medicine. The report wants to see “primary care increasingly becoming the career of choice for young doctors, nurses and pharmacists”. Whether this comes true will depend on how everyone reacts to the report: NHS England and CCGs by supporting primary care financially and also by supporting new models of care, Health Education England by providing training and support for new roles, and GP and pharmacy practices by being willing to work in new ways. Watch this space.

A PDF of the full report can be found here.

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