What future for general practice?
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1) General practice is under pressure due to increasing patient populations, consultations, complexity of cases, and costs while receiving decreasing relative funding and workforce. 2) The needs of patients are changing as more have multiple long-term conditions requiring holistic and ongoing care rather than occasional acute issues. 3) To meet changing patient needs, general practice will need to move away from the traditional model of GPs as gatekeepers and work more collaboratively within integrated systems using a broader workforce.
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What future for general practice?
- 1. @robertvarnam What future for general practice? @robertvarnam Dr Robert Varnam Head of General Practice Development robert.varnam@nhs.net bit.ly/160920rcgp
- 2. @robertvarnam One of the things motivating me as I first looked outside the walls of our practice, to lead some local service redesign for diabetes, was fear. A fear that general practice, despite being a service depended on by the country, had a very uncertain future. In fact, I was afraid that general practice was being run into the ground. Although NHS spending was rising, with growing amounts of staff and money, the majority was going elsewhere in the system. Even though we were talking increasingly about the importance of providing more care outside hospital, the investment was going inside hospital. Does general practice have a future?
- 3. So why are people talking about change? It’s partly about the pressure we’re under right now, and partly about the huge opportunity to do something better. And, for once, the same changes that would help with one are also necessary for the other. Pressure Opportunity
- 4. www.england.nhs.uk @robertvarnam Pressures on general practice ↑ population ↑ consultations ↑ complexity ↑ costs ↓ relative funding ↓ relative workforce
- 5. www.england.nhs.uk @robertvarnam At the heart of the case for change is not the workload of practices – important though that is – it is the needs of patients, and they way they are changing. When the NHS was founded, its purpose was fairly simple. Every now and then, people got ill. When they did, they consulted their doctor. If it was a straightforward problem, they would give a prescription, the person would get better, return to work and, in a year or two, they might need the doctor again. If it was less straightforward, they would be referred to a clever doctor – who would give a prescription or cut out the offending part. The patient would then get better, return to work, and, in a year or two, they might become ill again. That accounted for the majority of the anticipated work of the NHS. And, for some patients, that’s still the kind of care that’s needed. However, a growing proportion of our work is fundamentally different. This now seminal chart illustrates the central fact underlying the quantitative and qualitative change in the work of primary care. It illustrates the rise in multimorbidity with age. As people get older, they have more simultaneous longterm conditions. So that, by the age of 75, for example, at least a third of people are living with four or more LTCs. And, as our demography changes, the proportion of older people increases. Dealing with longterm conditions already accounts for over half of work in primary care. It is set to increase. And, crucially, this represents a qualitative change in the nature of work. These are not people who visit the GP every year or two to get cured of their problem. These are people with problems that we cannot cure – they are living with multiple issues which will not go away, and they visit the GP six, seven, eight or more times a year. At least. Furthermore, the more simultaneous problems someone has, or the greater their frailty, the less helpful it is to pass their care to a doctor specialising in one part of the body. These people need treating as people, not diseases. So the population of people who need what only primary care can offer has grown, the amount of time they need has grown – and both are set to continue growing. This is the chief case for change in primary care, the pressure of patients’ needs. This is not a blip requiring a short-term correction to the priorities of the NHS. It is a fundamental shift which requires every developed nation on earth to turn away from what Muir Gray has termed the ‘century of the hospital’, and place the emphasis where the population’s need is. Based on: The Lancet doi: 10.1016/S0140-6736(12)60240-2
- 6. @robertvarnam@robertvarnam Perspective: Holistic Care: Personal, comprehensive, preventive Organisation: Close to a community, accountable Primary care principles to be proud of…
- 7. @robertvarnam@robertvarnam More reactive / rescue than proactive / preventive Holistic perspective but medical care Disconnected Disempowered Primary care daily realities…
- 8. @robertvarnam@robertvarnam What does good access look like?
- 14. @robertvarnam Deliberately designed … around patients’ needs not GP’s skills Whole system approach Collaborative working @robertvarnam Self-care Broader workforce Tech
- 15. @robertvarnam GP Gatekeeper Non-specialist Lone ranger Investigations Specialist opinion / care Community services In the early days of general practice every patient needing help was dealt with by the GP, who largely worked alone. If specialist care, investigations or treatment were needed, the patient was referred out to another service. The GP was often described as a gatekeeper to other services, a non-specialist who was there for straightforward problems. It was sometimes said that they chief skill was in knowing the best specialist to refer to.
- 16. @robertvarnam GP Activesignposting Pharmacist Clerical Nurse Therapist MH practitioner Patient Self management Care & support Paramedic Welfare adviser Care coordinator Conductor Expert generalist Investigations Specialist opinion / care Community services
- 17. @robertvarnam@robertvarnam o Personal expert generalist o Diagnostician o Complex care planner o Expert coach of expert patients o Consultant, coordinator & connector o Improvement leader o Population manager o Leader in the local system o Social shaper The future GP Realising more of the promise that attracted me in the first place Not requiring everything to reside in one person
- 18. @robertvarnam@robertvarnam Clarity about what must not change Honesty about releasing more of the promise Courage & skills to lead How will we get there? england.nhs.uk/gpfv bit.ly/160920rcgp
Editor's Notes
- One of the things motivating me as I first looked outside the walls of our practice, to lead some local service redesign for diabetes, was fear. A fear that general practice, despite being a service depended on by the country, had a very uncertain future. In fact, I was afraid that general practice was being run into the ground. Although NHS spending was rising, with growing amounts of staff and money, the majority was going elsewhere in the system. Even though we were talking increasingly about the importance of providing more care outside hospital, the investment was going inside hospital.
- So why are people talking about change? It’s partly about the pressure we’re under right now, and partly about the huge opportunity to do something better. And, for once, the same changes that would help with one are also necessary for the other.
- 2% population growth /yr 2.5% inc in consultations every year since 2007 GP numbers grown by 5,000 FTEs in past 10y - but hospital consultant numbers have roughly tripled
- At the heart of the case for change is not the workload of practices – important though that is – it is the needs of patients, and they way they are changing. When the NHS was founded, its purpose was fairly simple. Every now and then, people got ill. When they did, they consulted their doctor. If it was a straightforward problem, they would give a prescription, the person would get better, return to work and, in a year or two, they might need the doctor again. If it was less straightforward, they would be referred to a clever doctor – who would give a prescription or cut out the offending part. The patient would then get better, return to work, and, in a year or two, they might become ill again. That accounted for the majority of the anticipated work of the NHS. And, for some patients, that’s still the kind of care that’s needed. However, a growing proportion of our work is fundamentally different. This now seminal chart illustrates the central fact underlying the quantitative and qualitative change in the work of primary care. It illustrates the rise in multimorbidity with age. As people get older, they have more simultaneous longterm conditions. So that, by the age of 75, for example, at least a third of people are living with four or more LTCs. And, as our demography changes, the proportion of older people increases. Dealing with longterm conditions already accounts for over half of work in primary care. It is set to increase. And, crucially, this represents a qualitative change in the nature of work. These are not people who visit the GP every year or two to get cured of their problem. These are people with problems that we cannot cure – they are living with multiple issues which will not go away, and they visit the GP six, seven, eight or more times a year. At least. Furthermore, the more simultaneous problems someone has, or the greater their frailty, the less helpful it is to pass their care to a doctor specialising in one part of the body. These people need treating as people, not diseases. So the population of people who need what only primary care can offer has grown, the amount of time they need has grown – and both are set to continue growing. This is the chief case for change in primary care, the pressure of patients’ needs. This is not a blip requiring a short-term correction to the priorities of the NHS. It is a fundamental shift which requires every developed nation on earth to turn away from what Muir Gray has termed the ‘century of the hospital’, and place the emphasis where the population’s need is.
- Not JUST more of the same… Starting point: general practice is already very good (high pt satisfaction, quality & safety; cost effective internationally … one of the best implementations of the principles of primary care) BUT not currently delivering enough of its potential (constraints, changing demography, new opportunities) Vision of future strongly influenced by GPs’ feedback: current dissatisfaction relates to volume and APPROPRIATENESS of work
- Through the General Practice Access Fund we’ve seen examples of stimulated transformational and sustainable change with practices joining together to deliver broader range of at scale services an increase in the choice and range of contact modes a wider range of practitioners introduced the success of integration of other practitioners into primary care provision. Joint working with ANPs, pharmacists, the voluntary sector, care homes, physiotherapists and paramedics has released local GP capacity and more appropriately matched the needs of patients with practitioners. a reduction in demand elsewhere - 14% reduction in A&E attendances (minors)
- Through the General Practice Access Fund we’ve seen examples of stimulated transformational and sustainable change with practices joining together to deliver broader range of at scale services an increase in the choice and range of contact modes a wider range of practitioners introduced the success of integration of other practitioners into primary care provision. Joint working with ANPs, pharmacists, the voluntary sector, care homes, physiotherapists and paramedics has released local GP capacity and more appropriately matched the needs of patients with practitioners. a reduction in demand elsewhere - 14% reduction in A&E attendances (minors)
- Through the General Practice Access Fund we’ve seen examples of stimulated transformational and sustainable change with practices joining together to deliver broader range of at scale services an increase in the choice and range of contact modes a wider range of practitioners introduced the success of integration of other practitioners into primary care provision. Joint working with ANPs, pharmacists, the voluntary sector, care homes, physiotherapists and paramedics has released local GP capacity and more appropriately matched the needs of patients with practitioners. a reduction in demand elsewhere - 14% reduction in A&E attendances (minors)
- Through the General Practice Access Fund we’ve seen examples of stimulated transformational and sustainable change with practices joining together to deliver broader range of at scale services an increase in the choice and range of contact modes a wider range of practitioners introduced the success of integration of other practitioners into primary care provision. Joint working with ANPs, pharmacists, the voluntary sector, care homes, physiotherapists and paramedics has released local GP capacity and more appropriately matched the needs of patients with practitioners. a reduction in demand elsewhere - 14% reduction in A&E attendances (minors)
- Through the General Practice Access Fund we’ve seen examples of stimulated transformational and sustainable change with practices joining together to deliver broader range of at scale services an increase in the choice and range of contact modes a wider range of practitioners introduced the success of integration of other practitioners into primary care provision. Joint working with ANPs, pharmacists, the voluntary sector, care homes, physiotherapists and paramedics has released local GP capacity and more appropriately matched the needs of patients with practitioners. a reduction in demand elsewhere - 14% reduction in A&E attendances (minors)
- Through the General Practice Access Fund we’ve seen examples of stimulated transformational and sustainable change with practices joining together to deliver broader range of at scale services an increase in the choice and range of contact modes a wider range of practitioners introduced the success of integration of other practitioners into primary care provision. Joint working with ANPs, pharmacists, the voluntary sector, care homes, physiotherapists and paramedics has released local GP capacity and more appropriately matched the needs of patients with practitioners. a reduction in demand elsewhere - 14% reduction in A&E attendances (minors)
- In the early days of general practice every patient needing help was dealt with by the GP, who largely worked alone. If specialist care, investigations or treatment were needed, the patient was referred out to another service. The GP was often described as a gatekeeper to other services, a non-specialist who was there for straightforward problems. It was sometimes said that they chief skill was in knowing the best specialist to refer to.
- The work of GPs has already changed a great deal, but there is more to do to ensure that their unique skills are used to best effect. We already see GPs dealing with considerably more complex medical problems and treatments in the community. However, they also report being overloaded with work which other people could do, as well as finding it too difficult to ensure care is properly wrapped around their patients. NHS England is supporting the development of new models of care and innovations in productivity which will improve care for patients and enhance working life for GPs. To release GPs to spend more time doing what only they can do, practices are developing their skill mix and changing workflows. Some issues are best dealt with by a member of the clerical team, another clinician or someone trained to address social needs. GPs themselves are increasingly seeking to collaborate more closely with specialists and community teams, pulling in advice and providing more care without having to refer the patient away from their primary team. Patients themselves are playing a greater role in their own care, and GPs are increasingly helping to wrap other services around them, including non-medical care and support. They are also wanting to develop their knowledge, skills and confidence to manage their own conditions. This makes better use of GPs’ unique skills and strengthens their role in coordinating input from other professionals. These trends combine to confirm a new identity and status for GPs. While they are giving away some tasks to other members of the team, they are also gaining renewed status at the heart of enhanced systems of care in their community. GPs have moved from being non-specialist gatekeepers to expert generalists providing complex care and coordinating services around their patients. This has been compared to the role of the conductor of an orchestra.