General practice must change to deliver higher-quality care at a lower cost to taxpayers. This is central conclusion of Reform's latest research paper, Who cares? The future of general practice.
Today’s small, isolated practices, should be replaced by a new model: large-scale primary-care centres offering a wider range of services, seven days a week.
What are the issues?
Small-scale practices
Little use of technology
Inconvenient opening hours
Today's model of general practice was designed for 1948. It is small scale and offers limited services to an average list of 7,461 patients. There are 7,875 separate surgeries across England. Sixty-one per cent of practices have fewer than four GP partners and only 6 per cent have 10 or more.
Small size is a problem for patients. The Care Quality Commission highlights a clear correlation between size and quality of care. Smaller practices struggle to offer extended services, such as diagnostics, and multi-professional teams, which drives patients into secondary care and undermines the quality of the services on offer.
Today's practices fail to incentivise patients to use technology. GPs are yet to be won over by the benefits of access to electronic health records and many are worried about the value for money of online services. The result is that, in 2016, eight in 10 people report not using any online services.
At the same time, opening hours are inconvenient. Since 2004, GPs have been able to opt out of providing longer opening hours - resulting in 90 per cent doing so. Typical opening times are 8am to 6.30pm, five days a week, with which many, particularly full-time workers, are becoming increasingly dissatisfied.
Poor access is costly for the NHS. Six million people attend A&E each year as a result of failing to get a GP appointment. A further six million attend out-of-hours GP surgeries. These consultations are much more expensive than a GP appointment, which wastes £869 million each year.
As a result, 70 per cent of GPs believe that the current system requires fundamental change.
What should the future look like?
Population-health providers
Large scale
A different workforce
Seven-day services
Primary-care providers should operate at scale to deliver a 'population-health' approach to care. This goes beyond providing limited, reactive care to offer a wider range of services and focus on prevention for healthy people and self-management of people with long-term conditions, who currently consume 50 per cent of GP appointments. Delivering this would align providers with best practice across the globe.
This approach would benefit patients and the taxpayer. Previous Reform research has outlined that prevention and self-management could save £1.9 billion by 2020-21.
To most efficiently deliver care, tomorrow's providers should embrace technology. Using online services to triage demand could save the NHS £274 million a year if the number of people who used such services matched the number of people who use the internet each day. Video appointments are also 40 per cent quicker than face-to-face consultations.
More flexible consultations would allow clinicians to address the complex needs of people suffering from long-term conditions. Twenty-minute appointments could become the norm for these patients - with shorter appointments for those with less complex needs.
The workforce must also radically change. As much as 50 per cent of the 372 million appointments currently administered by GPs could be better delivered by another professional. As GPs currently handle two-thirds of appointments, this would entail only one in three people visiting their GP seeing a doctor.
The NHS could save over £700 million each year if nurses or pharmacists administered the 57 million appointments dealing with minor ailments. The Government must therefore scrap its commitment to employ 5,000 more GPs by 2020-21.
Primary-care providers should offer a greater variety of services to improve care for patients and ease the pressure on the rest of the NHS. Lakeside Healthcare, a super-practice in Northamptonshire, has introduced an urgent care centre which delivers appointments to 200,000 people at less than a third of the price of an A&E visit. Applied across the country this could save the NHS £1.1 billion per year.
Primary-care providers should also offer seven-day services. Contrary to recent criticisms, demand for these appointments rises following implementation - as shown by Taurus Healthcare, which covers 185,000 patients in Herefordshire. Seven-day services have also been shown to reduce
A&E demand.
What can policymakers do?
Fewer commissioning bodies
New, time-limited contracts
Policymakers must act to incentivise change. The current commissioning framework delivers a fragmented approach to care - with primary, secondary, social-care and public-health services currently designed separately. The 209 clinical commissioning groups - created in 2012 to commission secondary care - are taking more responsibility for primary care. But they are too small to hold larger providers to account. The Government should investigate a reduction of the number of commissioners for larger homogenous health economies.
Competition must be unleashed to deliver improvements. Since 1948 GPs have been contracted by the state to provide services - but a vast majority of contracts are open-ended. Time-limited contracts should be held to stoke competition between providers. New contracts should also cover the whole care needs of patients to incentivise a population-health approach to care.
