The Royal College of General Practitioners (RCGP) has called for an urgent rescue package and radical government action to increase the numbers of GPs and their staff, so that GPs can continue providing the care that their patients need.
RCGP is a professional network of more than 52,000 family doctors (GPs) which works to help GPs maintain high standards of general medical practice. RCGP’s statement calling for the government to deliver on its promises was issued in response to a report recently published by UK think tank, Policy Exchange. The report, At Your Service: A proposal to reform general practice and enable digital healthcare at scale, proposes sweeping reforms to NHS primary care services and how patients will access their GP.
Do GP services need reform?
For most people, getting advice or treatment for a health condition starts with making an appointment to see their local general practitioner (family doctor or GP). After considering their history to find out more about the patient’s general health and the symptoms and signs of their condition, the GP may diagnose the condition, advise and prescribe treatment, or refer the patient for tests and scans or specialist hospital care. GPs also provide regular check-ups and ongoing management of patients who have chronic health conditions which need careful monitoring, such as diabetes. Where the patient has had surgery or other hospital treatment, the GP may then provide follow up care. Where a patient presents with a life-threatening or emergency condition, the GP is responsible for referring them urgently to hospital and ensuring that they are seen immediately and receive emergency care.
GPs provide what is known as primary care. As the first place that people turn to for medical advice, they have an important role in helping people find help for minor or sudden (acute) illness and in managing ongoing health conditions. However, even before the pandemic, GP practices were understaffed and struggling to cope with their workload of care for patients with increasingly complex needs. The additional pressure from Covid-19 has only made these problems worse.
The strain on primary services has also affected patients. At its worst, delays and mistakes can cause severe injury to patients. For others needing medical help, it has led to confusion, frustration and dissatisfaction. As Health Secretary, Sajid Javid, accepts in his foreword to the At Your Service report, “A consistent message from the public was the frustration they experience when accessing their GP. Patients spoke to me about feeling bounced around between primary, community and secondary care.”
Reforms are currently being considered across the entire health service. The At Your Service report emphasises that GP reform must reflect what matters most to patients and GPs: quality, convenience, choice, and continuity. They say GPs most value their autonomy, ability to innovate and to build relationships with their patients, and that this should be maintained. They say changes to the primary care model must allow them to recruit more family doctors into the profession and warn against trying to design a ‘one size fits all’ approach to primary care.
What does the At Your Service report say?
The report’s specific recommendations include moving away from the model of small partnerships which own or lease their premises and manage their own workforces. Instead, the report recommends that GPs should be offered salaried employment by the NHS in line with hospital consultants. They should be contracted by larger NHS organisations, such as NHS trusts or larger primary care organisations, and their premises bought out by the NHS. The report says that continuity of care and their trusted relationships with their patients and local community should be safeguarded but accepts the challenge of doing this whilst scaling up general care to larger organisations.
The report recommends much more reliance on technology. Proposed measures include:
- The NHS app offering a broader and more coherent range of first-contact services for patients.
- Introduction of a ‘smart’ first-contact primary care navigation programme, called NHS Gateway, to direct patients to the services they need, and help with triage (prioritising a patient’s care needs).
- Increasing the use of video consultations between patients and GPs.
- Using technology to provide long distance remote consultations with GPs, to tackle GP shortages, particularly in deprived areas. Despite concerns about maintaining continuity of care, the report suggests GP consultations between a patient in one area of the country and a GP from a city elsewhere could become commonplace. Somewhat surprisingly, the report says provision could be made for patients to consult remotely with NHS-trained GPs who have now left the UK, or with doctors from ‘select’ countries, such as Canada, Australia, New Zealand or South Africa.
- Community hubs would be available to help patients struggling to use the technology, and provide facilities for patients and GPs to attend remote consultations.
Suggested workforce solutions include the government announcement of a package to support and retain current GP partners, and working with the RCGP, British Medical Association and medical schools to make careers in general practice attractive to new and junior doctors.
The report also recommends measures to define, monitor and assess demand on GP services and reduce unnecessary ‘failure demand’ created by inefficient processes. An example of failure demand would be when a patient decides to go to A&E for treatment of a minor complaint because they could not get through to their GP surgery’s reception by telephone. The recommended reforms also suggested gathering feedback from ‘Trip-Advisor’ style reviews of patients’ experiences.
At Your Service acknowledged that some of the suggested measures might require new legislation, and suggested that the government should introduce a Digital Health and Care bill for consideration by Parliament.
Responding to the At Your Service report
RCGP’s chair, Professor Martin Marshall, issued a statement responding to the ‘At Your Service’ report agreeing that a comprehensive rescue package is urgently needed for general practice. Reiterating the pressures facing GPs, and their willingness to explore new ways of working, he urged caution in making sweeping changes to the way GP care is delivered, without a very good reason, and without properly piloting and evaluating the effect of such change on efficiency, the trusted relationships between family doctors and patients, and patient safety.
He said, “The elephant in the room is staffing – more funding, better technology and better premises will only be impactful with sufficient numbers of GPs and other members of the team to deliver the care our patients need. The Government needs to take radical action to expand the workforce and to deliver its 2019 manifesto pledge of an additional 6,000 GPs and 26,000 additional practice staff by 2024 – and this needs to include plans to keep existing, experienced GPs in the profession longer - so that GPs and our teams can continue to deliver the care our patients need and deserve, now and in the future.”
Boyes Turner’s medical negligence team share the RCGP’s concerns about making sweeping changes to patients’ access to GP care, particularly whilst existing and basic problems, such as adequate funding and staffing shortages, have not yet been addressed. Whilst technology, such as video consultation, has undoubted benefits in appropriate circumstances, pushing patients’ first contact further away from local GP surgeries puts further distance between patients and the doctors on whom they rely for timely and correct medical treatment. It risks diminishing the doctor-patient relationship which is at the heart of general practice.
Most importantly, it will also affect patient safety as patients are less likely to be examined (in person) and treated by a doctor who knows them and understands their health condition, and who is able to provide them with timely, informed and personalised care.
Technology is a valuable tool to assist informed decision making by trained medical clinicians. It should not be relied upon to replace local family doctors or bypass them. Their broad general medical expertise and accessibility to their local community is essential to provide all patients, however technologically adept or vulnerable, with quick access to safe primary care.
The risks of harm associated with triage decisions made by technology without trained doctor input were recently highlighted by HSIB in relation to 999 call handling in maternity care.
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