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Your practice 2010: GPs' new golden age — or dark days ahead?

Where will general practice be in 2010? Here Bronagh Miskelly rounds up our debate

Throughout the summer, GP has been presenting the views of many connected to the profession on the future of general practice and the changes we could see by 2010.

We have seen a range of opinions on subjects as diverse as private providers, IT and working with secondary care — all of which our contributors believe are essential elements for the future of primary care. We have heard from those who see only problems and those who see a golden future.

So where do you stand?

Over the next four pages we gather the opinions in those articles to present the optimist’s and pessimist’s views of the future. These are extremes and you may take a mix and match view, which is why we want to hear from you. Complete the survey on page 56 of 17/11/06 issue of GP or email GPletters@haymarket.com

‘A flood of new recruits for a career that promises strength and flexibility’

2010 is the dawn of the new golden age of general practice, say the optimists. GPs’ gatekeeper role reaches its zenith as they take full control of local service commissioning and do away with ill-thought-out, and now unnecessary, referral management systems.

Despite the government’s insistence on the ‘big is beautiful’ approach, practices of all sizes have proved that the public much prefers the list-based model with local GPs to faceless corporations offering one-size-fits-all primary care.

In fact, since 2007’s ‘Keep Our GPs’ protests against PCTs putting practices out to tender over the heads of existing salaried GPs, private providers have been cutting their losses and pulling out. The difficulty in recruiting GPs to their centres was another key factor in this decision.

The resulting increase in available partnerships and the newly strengthened role of GPs has increased the numbers of new doctors choosing primary care as a career path.

This has mitigated the difficult period following the bursting of the retirement bubble in 2007/8.

Flexible career options

The opportunities to combine general practice with a specialism in chronic disease, minor surgery, dermatology and so on, have also attracted younger doctors keen to enjoy a flexible career with development options.

The reversal of DoH policy on premises funding, originally signalled by a junior health minister in late 2006, has led to the opening of GP-controlled local health units. These feature standard general practice alongside GP-owned-and-run diagnostic centres and more community-based services that have moved from hospitals. Some GPs now work in ‘chambers’ with secondary care consultants to offer a wider range of service to their patient lists.

The powers of practice-based commissioning (PBC) groups have given GPs the chance to develop these services properly and still deliver care in a traditional form. By banding together, even the smallest practices can have a say. Overall, the system is increasing the power of GPs over primary care organisations and improving the local health economy by ensuring the right treatments and secondary care services are in place.

Learning from the early hiccups with PBC and Choose and Book, the rest of the UK countries have introduced their own versions of the commissioning system and electronic referrals.

This means GPs in border areas in Wales, Scotland and England can in fact send patients to other countries where appropriate. Indeed, patients have travelled further afield in the UK to find shorter waiting lists, be near family members or access a specific technique.

Countries moving closer

Following the seeming fragmentation of the NHS away from national standards in the early years of the decade, the development of commissioning activities and the support for community focus, traditional practices in many areas across the UK have seen the four countries coming closer together.

Clinical aims and quality of outcomes are driving investment and decision-making, rather than disparate, devolved political views.

Meanwhile, the rethink over the National Programme for IT has ensured that clinicians and public alike are much more confident about the security of patients’ details with new protocols to limit access more effectively.

Paperless reality

Electronic transfer of records, handheld devices that link to patient records when on home visits and the start of remote chronic disease monitoring, mean records are more up to date and fully paperless practice is becoming a reality. This also means that whatever new twists the DoH tries to add to the quality framework, the data is at the practice man-ager’s fingertips.

Another advantage of co-operation between practices and commissioning groups has been the development of ways to outsource or share some administration functions to cut costs. Opening hours have proved one of the thornier issues to resolve. Although practices could garner public support against the ‘corporate monsters’, they needed to square this with patients’ wishes for longer opening hours. Again, GP collaboration has helped, with commissioning groups or co-operatives bidding for walk-in centre contracts.

As a result of the GPC negotiating an ‘access bonus’ for early morning and evening surgeries, practices have found ways to reorganise sessions to offer different opening times with fewer problems than expected.

The rewards of 2010 have come through hard work and innovative thinking, as well as a co-operative attitude from the profession as a whole. Yes, general practice may seem unfamiliar to GPs from a few decades ago, but it retains at its core the same ethos of list-based practice and gatekeeping with a strong patient focus.

2010 is the dawn of the new golden age of general practice, say the optimists. GPs’ gatekeeper role reaches its zenith as they take full control of local service commissioning and do away with ill-thought-out, and now unnecessary, referral management systems.

Despite the government’s insistence on the ‘big is beautiful’ approach, practices of all sizes have proved that the public much prefers the list-based model with local GPs to faceless corporations offering one-size-fits-all primary care.

In fact, since 2007’s ‘Keep Our GPs’ protests against PCTs putting practices out to tender over the heads of existing salaried GPs, private providers have been cutting their losses and pulling out. The difficulty in recruiting GPs to their centres was another key factor in this decision.

The resulting increase in available partnerships and the newly strengthened role of GPs has increased the numbers of new doctors choosing primary care as a career path.

This has mitigated the difficult period following the bursting of the retirement bubble in 2007/8.

From the optimists...

We must be prepared to extend our role to mastermind the development and provision of most, or even all, local healthcare services.

Dr Michael Dixon, NHS Alliance chairman

I do not see a future where single-handed GPs are an endangered species. They are popular with patients and services patients want and use will not only survive, they will thrive.

Dr David Colin-Thomé, DoH primary care tsar

It would be too big a step to disband the practice list but we can evolve the thinking around it.

Dr Mayur Lakhani, RCGP chairman

List-based practice is essential to the survival of the primary care system, which acts as a gatekeeper to manage demand.

Dr James Kingsland, NAPC chairman

‘The opportunity to lead has been lost’

What follows is not for the faint-hearted.

In 2010 the true fall-out of recent government policy has become apparent with the fragmentation of UK primary care.

As predicted, the push to bring private firms into under-doctored areas soon moved beyond a few PCTs. Big business, including a couple of supermarkets, now runs 30 per cent of practices. On top of this, hospitals in some areas have taken over practices and brought them into outpatient departments.

Instead of making it easier for everyone to see a GP, the result has been doctor shortages and new access problems.

The past five years have seen a massive drop in the number of GPs — young and old — working in UK practices. The government’s plans to cap dynamising factors as part of the GMS renegotiations and NHS pension reforms prompted many older GPs to enjoy the fruits of their hard work and retire.

Lack of partnerships

Meanwhile, newer medics have been put off general practice by a range of factors. The lack of partnerships has made primary care less attractive. The Modernising Medical Careers reforms resulted in fewer training places. And the rise of the private provider has produced a plethora of comparatively poorly paid salaried posts, without the compensation of the NHS pension scheme.

The result is overworked doctors in smaller traditional practices and private provider- owned large operations. The latter are, in effect, nurse-led walk-in centres without the ready access to GPs promised by the government. The few GPs in these centres are from elsewhere in the EU because UK trainees head for Wales, Scotland and Northern Ireland.

Life for GPs in these countries is slightly better than in England because they have less private sector involvement. But all three are now enduring the chaos of versions of dual registration thanks to their governments’ access policies.

Putting practices out to tender has created a two-lane — if not a two-tier — primary care service. On one side, healthier young people requiring occasional check-ups gravitate to practices with longer opening hours and attached walk-in centres run by private providers.

Older and chronically ill patients seek continuity of care from traditional GPs, who have to contend with high workloads and stretched resources.

Private providers have been able to cherry-pick the best services of those moving from secondary care because they have the resources to invest in suitable premises more quickly than GPs. These providers’ advertising budgets also mean they win patients who choose the services they have seen in the local paper.

Practice-based commissioning failed to let GPs shape the local healthcare landscape and take a lead on service provision. So commissioning groups did not take off and GPs do not have the combined financial clout to wrestle back services.

Ticking boxes

Despite difficult caseloads, GPs complain they spend ever more time as ‘glorified data entry clerks’ ticking boxes for the increasing number of quality indicators and Choose and Book. This is on top of completing commissioning forms but at least they gain fees for the directed enhanced service. In reality most of this work is pointless due to the commissioning system, and the primary care organisation’s referral management system rejects most Choose and Book requests anyway.

A lot of time is wasted chasing up records and referrals following the collapse of  Connecting for Health’s central data spine. Security fears related to the number of people able to access demographic details led to mass public withdrawal from the scheme when the government pressed ahead with plans regardless of the doubts raised by experts.

Overall, GPs have lost the opportunity to lead the NHS and primary care can be a very different experience depending on where you live.

We desperately need doctors with the ability to think strategically. Private providers are not going to be confined to the under-doctored areas.

Dr John Chisholm, former GPC chairman

The private companies will want to customise activity in the best Tesco tradition so that variation is reduced and profits maximised.

Dr Alan Maynard, professor of health economics, University of York

We face fragmentation. Responding to convenience on minor ailments will mean less resources for other services.

Professor Rebecca Rosen, part-time GP and policy adviser at the King’s Fund

GPs have always had the public on board. Unfortunately, the public has a different agenda — it wants an easily accessible nursemaid service.

Dr John Lando, GP in Lanarkshire

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