by Brenda Allan & Alan Morton
Primary care is under severe pressure and described by some to be at breaking point. For most people Primary Care is their first point of contact with the NHS via their GP’s surgery (though community pharmacy, dental, and optometry services all fall under this substantial wing of the NHS).
Patient satisfaction with Primary Care has plummeted as a result of difficulties patients face contacting GP practices, getting appointments, long waits, telephone triage, and delayed referrals to secondary care.
Funding and workforce
Primary Care provides 90 per cent of patient contacts but receives only 10 per cent of NHS funding. There was a 10 per cent vacancy rate in the NHS before Covid which is now much worse. For many years there have been insufficient GP training places to cope with replacement needs and increased demand.
If general practice fails, so will the NHS, with patients diverting to emergency departments and other unscheduled care provision. It is worth noting that a year’s worth of GP care per patient costs less than two trips to emergency departments.
A range of pressures have resulted in GPs retiring early including heavy workloads, demoralisation, difficulties for partners to buy in, and lack of career structure for salaried GPs. Because of these issues many GPs give up practices which may well have continued had they received greater support perhaps to merge or partner or to gain economies of scale by sharing back office specialists like HR, IT, complaints, compliance and so on.
There is a significant disconnect between primary and secondary care. Valuable links are essential for timely advice on referrals and patient management within primary care but those that do exist need to be developed further, (Consultant Connect, the GP/Consultant calls, the Two Week Wait and Ambulatory care clinics). The two sectors focus on symptoms and pathways, rather than the whole patient. As a result, patients are too frequently referred from primary to secondary care where negative results mean they simply return with the same problems or a host of new tasks which primary care is not resourced to fully deliver.
NHS England made it clear that by 2014, all new GP practices should be on Alternative Provider Medical Services contracts (APMS). Unlike the existing General Medical Services (GMS) contracts and the less common Personal Medical Services (PMS) contracts, APMS contracts are short term and offered out to tender, generally meaning that the bidder with the lowest funding request will be most likely to win the contract. They are held by private companies or third sector organisations other than GP partnerships and have opened the door to Centene type takeovers.
One of the difficulties for GP partnerships or even GP Federations when bidding for contracts is that large multinationals have teams for contracting and can present glossy, deceptively polished tender documents. They also threaten to, or actually sue if they fail to win contracts, facing NHS commissioners with the prospect of hefty legal bills. Thus tendering is not a level playing field between the NHS and private operators.
There is Judicial Review pending on the Centene takeover, and in Haringey, Keep Our NHS Public have submitted a Freedom of Information Request requesting dates of forthcoming contracts due for renewal.
The Way Forward:
- The standard GMS and PMS contracts should be supported. APMS contracts should not be used for primary care.
- Options for increasing support to GP practices, beyond that currently available from the Federations and Primary Care Networks, should be encouraged and funded.
- Primary Care contracts should remain within the NHS, perhaps with GP Federations, Primary Care Networks or local Trusts. There should be salaried GP practice options rather than private APMS ones.
- Primary Care urgently needs to receive a larger percentage of NHS expenditure but not at the expense of secondary care which is also struggling.
- Primary care should be reviewed and resourced to give it a more central and expanded role. The aim would be for primary care to carry out some of the work now unnecessarily and less efficiently referred to outpatients and to A&E alternatives and to provide the range of consultations, diagnostics and interventions associated with the better holistic, polyclinic models. This could be a game changer, popular with both patients and primary care staff and freeing secondary care for more complex cases. The move would offer joined up, local, timely healthcare; be a better use of resources; and for primary care staff, would produce greater job satisfaction and opportunities to specialise and collaborate.
- Every patient should have a named doctor in their practice.