Last reviewed 15 October 2018

In this feature Thoreya Swage, healthcare consultant, highlights the interim findings of the GP Partnership Review, published on 2 October 2018.

Background

In May 2018, the then Secretary of State for Health and Social Care, Jeremy Hunt, announced a review of GP Partnership working and how it needs to develop in the context of a modern NHS.

GP practices are the first port of call for patients who make up the million appointments that occur every day in primary care.

As the NHS achieves its 70th year, primary care needs to evolve and shape new ways of working for the family doctors of the future. While retaining best practice, consideration should be given towards different options around the partnership, clinical, business and career models moving forward.

This article describes the initial findings of the interim report which was published on 2 October.

Setting up the review

The review is chaired by Dr Nigel Watson, a GP with over 30 years’ experience and managing partner at the Arnewood Practice in the New Forest in Hampshire. He was a former chair of a multi-specialty community provider and now represents GPs on the Hampshire and Isle of Wight Sustainability and Transformation Partnership.

Dr Watson is being supported in this review by the General Practitioners Committee of the British Medical Association, the Royal College of General Practitioners, NHS England and the Department of Health and Social Care.

The terms of reference

The Terms of Reference for this review were clarified in July 2018 and include the following.

  • Understanding the demands on partnerships in primary care and the wider NHS and how effective the current models of service delivery are and areas where this is less effective.

  • Examining the advantages and disadvantages of the partnership model for different stakeholders — ie patients, partners, all types of GPs (eg salaried, locums, etc), practice staff and the wider NHS.

  • Seeking how to enhance the partnership model such that it supports the transformation of general practice to the benefit of primary care staff and patients.

The final report is to be preceded by an interim report, the function of which is to highlight areas for discussion with key stakeholders in general practice, and identify any quick wins that could enhance general practice together with defined timescales. The interim report was published on 2 October 2018.

The final report, due at the end of 2018, will identify the findings and recommendations which should be focused, practical and affordable.

Key lines of enquiry

At the same time as the publication of the Terms of Reference in July, a call was made for evidence into four identified key lines of enquiry requesting responses from GPs and others interested in primary care. These included workload and workforce issues, the role of general practice within the local healthcare community and the business model of general practice. These were accompanied by a set of questions to stimulate discussion around each theme.

Following engagement and discussion the emerging issues were refined and placed in the interim report.

It was also acknowledged that the GP Partnership Review was taking place at the same time as other independent pieces of work such as the GMS contract negotiations, state-backed indemnity, the continuing implementation of the General Practice Forward View, the Next Steps on the NHS Five Year Forward View and the 10-year Plan for the NHS.

The process of engagement

A series of (over 20) visits to general practices across the country located in rural and urban settings and list sizes ranging from 7000 to over 360,000 were undertaken, as well as round table discussions facilitated by local medical committees (LMCs). In addition, written evidence was considered in response to the call for evidence for the key lines of enquiry.

A stakeholder reference group was established to provide support to the development of recommendations.

Findings

Although the timescale for obtaining views was tight, 300 responses were received to the key lines of enquiry, the sources of which are shown in the table below:

Source

Percentage of the responses

GP partners

37%

GPs (not partners)

25%

Practice managers

10%

Trainees

3%

Other

19%

Unknown

6%

Although most of the responses were from individuals, other replies came from LMCs, practices, Clinical Commissioning Groups and the National Social Prescribing Student Champion Scheme. The responses were broadly divided into concerns and solutions.

During the visits and gathering of the information, consistent themes came through including the following.

  • Problems with recruitment and retention with workforce being a major factor as well as uncertainty about the future of general practice.

  • The workforce not equipped to deliver the required care, for example, there is a shortage of community nursing services and mental health services supporting primary care. This then has a knock-on effect on workload.

  • The wider community services, eg community and mental health services are less integrated with primary care compared to a generation ago leading to fragmented care.

  • The benefits of being a partner being far outweighed by the risks; these included responsibilities with respect to premises, medical indemnity costs and the unlimited liability held by partners.

  • Resources identified for investment in general practice are difficult to bid for and are far too small in quantum to support primary care services. The process of bidding is also seen as too burdensome and the monitoring of the delivery so bureaucratic that many practices do not engage with this.

The report then goes on to propose possible solutions to the current partnership model in the following areas.

Workload — it is essential that the workforce issues are addressed as this would clearly impact on workload. The focus should shift to disease prevention; a greater emphasis on preventing the long-term complications of chronic disease such as cardiovascular conditions and diabetes and more self-care and self-management by patients supported by the use of technology.

Workforce — doctor numbers could be increased by making partnership more attractive compared to working as a locum, enhance general practice by expanding the multi-professional team which supports GPs — this could also include the embedding of other community services within the primary healthcare team.

Improve support to practices through the creation of primary care networks which can enhance the use of resources to frontline care through rationalisation of common services.

Risk — the issues of unlimited liability and the risks of lease holding and property ownership need to be addressed as well as the introduction of a comprehensive indemnity scheme.

Status of general practitioners — doctors in primary care need to feel valued by not just their patients but also politicians and the wider NHS. General practice should be recognised by the General Medical Council as a specialty — a change in the law is needed to achieve this.

There needs to be more time for training for medical students and GP trainees in primary care supported by greater funding of placements such that they are the same rate as for hospital placements. In addition, hospital trainees, including foundation trainees, should have greater exposure to general practice

Leadership of the local health and social care system — general practice needs to be more integrated at the system leadership level with a greater role to enable smoother working across patient pathways and facilitate the breaking down of institutional barriers

Emerging issues

In addition to the key lines of enquiry highlighted above, further issues have emerged which require in-depth discussion including digital technology and the status and morale of general practitioners.

Digital technology

It has not only been recognised nationally but also among frontline staff that digital technology is a key enabler to support the workload in primary care. However, much more needs to be done in order to fully take advantage of what digital technology can offer and what support GPs and practice staff require to utilise the data to best effect. The review has identified three main user groups that could make better use of digital technology: patients, practices and the wider health and care system.

User groups

Opportunities for better use of digital technology

Patients

  • Engagement with practices using online methods such as booking appointments, requesting prescriptions and obtaining results

  • Patients owning and managing their own health and care records

  • Encouraging patients to use self-care and self-management apps to enhance their health and wellbeing

  • Different consultation methods, eg by telephone or video

General practice

  • Use of video consulting and video-conferencing to facilitate multi-disciplinary team working and care planning as well as facilitating remote and homeworking

  • Sharing information between GPs and the primary healthcare team through the use of a single technological solution. A key mechanism would be a common health record that can be accessed by relevant health and social care professionals across institutional boundaries

  • Opportunities to automate standard measurements, eg blood pressure, height and weight, etc and merge these with clinical records

Health and care system

  • Common health records that are easily accessed by relevant health and social care professionals to aid the smoother working across different services

  • Streamlining the management of long-term conditions across primary, secondary and social care through the use of digital technology and a common record would make the delivery of care more efficient across the whole system

  • Common datasets to enable better patient ownership and access their own data

  • Better digital technology needs to be supported by faster internet connections, greater spread of universal WiFi within buildings and adequate scanning and printing facilities

It is necessary to be mindful that there is a risk that increasing accessibility to care for patients may increase demand which must be avoided.

Status and morale of general practitioners

The review comments that negative messages about general practice that medical students receive throughout their training and the status of general practice in relation to other specialisms is affecting recruitment and retention of primary care doctors. Evidence from the visits includes low morale of current partners and a perception that general practice may not be as rewarding career-wise as other specialties. By permitting the continued negative comments about general practice to students, the profession should not be surprised that this will not lead to them to want to take on partnerships.

A more positive vision of general practice needs to be formulated and supported by the NHS 10-year plan, the Government and NHS England.

General practice as a career

In order to enhance the profile of general practice, two suggestions were made: to recognise general practice as a specialty and to have consultants in general practice.

General practice as a specialty

There are two lists held by the doctors’ regulatory body, the General Medical Council: one for specialists (hospital doctors) and the other for generalists (general practitioners). This means that general practice is not formally recognised as a specialty in the UK (unlike most of Europe). The change of status requires a change in the law which is a campaign that has been spearheaded by the General Practitioners’ Committee of the British Medical Association and the Royal College of General Practitioners.

Equality of value and treatment with hospital consultants

General practitioners are skilled in their area of work as are hospital consultants; the former are specialist generalists while the latter are specialists in a narrower specific area of medicine. The general public regard general practitioners in the highest esteem and the title “general practitioner” is a strong brand. However, general practitioners do not feel as valued and treated as consultants and this could be achieved by a name change. This is an area of continuing debate.

Next steps

The review into GP Partnerships continues throughout the autumn. During this time contributions are encouraged either through email at GPPartnershipReview@dh.gsi.gov.uk or through engagement events, the details of which are publicised through Local Medical Committees, the Royal College of General Practitioners, Department of Health and Social Care and NHS England.

In addition, updates will be posted on the chairman’s blog.

There is also a Twitter feed @gppartnershipr1.

The final report will be published at the end of the year.

References

GP Partnership Review, Interim Report, chaired by Dr Nigel Watson, October 2018.