General practice and the Sustainability and Transformation imperatives

GENERAL PRACTICE HAS THE EXPERTISE

When people feel unwell, they look to the trusted places within their NHS. It is GP surgeries that have the expertise to provide comprehensive, generalist first-contact care, but when they are unable to meet demand people predictably seek help in accident and emergency (A&E); a place ill designed for their problems. On presenting to A&E, the likelihood of someone having a preventable admission is directly related to the number of chronic health conditions they suffer with and effective primary care has been shown to reduce such admissions,^2–4 with continuity of care being one important associated factor. With the average cost of 1 night’s stay in hospital being estimated in 2015 to be three times the average annual cost of GP care for a whole year (£400 versus £136) this clearly needs addressing.^5,6

IMPROVE SERVICES TO DEPRIVED AREAS

The problem is particularly acute in our most deprived areas. It is in these ‘deep end’ practices where significantly more people present with multiple health conditions, and where multimorbidity develops at a much younger age.^7,8 Decisions about funding and investment should address the fact that current funding formulae inadequately recognise this greater need, but addressing this inequity to provide greater access is only part of the story.⁹

MANAGE EXPECTATIONS

Across the board, the gatekeeping role of general practice is critical. To illustrate this, recent work carried out by a public health doctor in NHS Greater Glasgow and Clyde to understand why the Health Board was in persistent financial over-spend (and how its high activity levels might squeeze into a smaller bed complement) also revealed rising use of A&E, relative overuse of elective care by the affluent, and steep rises in emergency admissions as key problems. When health economies characterised by large areas of social deprivation under-provide to the poor and over-provide to the affluent, the funding formula responds by penalising funding for the socially deprived still further.¹⁰

We therefore propose that a ‘sustainability imperative’ is that appropriate transformation funds are channelled into addressing inequities in provision of general practice and ensuring that a coordinated, fully-functioning general practice service is available to all. Unfortunately the Royal College of General Practitioners’ interim review of STPs shows most fail to recognise this, with great variability in GP involvement and some even advocating a reduction in GP workforce.¹¹

EFFECTIVE CLINICAL SUPPORT

Even with such investment, managing significantly more care in the community will be a huge challenge. The extra GPs described in the GPFV will help if they can be found, but the shift of care will not be achieved safely without an even greater number of additional clinical support roles, led by GPs, providing high quality generalist care. General practice will continue to increasingly depend on these support roles to be effective. Yet this is where the evidence becomes thinner. Each month new (and old) roles are proposed as part of the solution: pharmacists, care navigators, physician associates, paramedics, with little evidence to show how they might successfully strengthen teams without losing the core features of general practice that help sustain the NHS.¹²

INVEST EARLY IN THE TRANSFORMATION CYCLE

For general practice to embark on this transformation it needs confidence that these support roles will emerge in sufficient numbers with the right competencies. Modelling such a transformation in one STP footprint suggests a greater increase in numbers that those described in the GPFV is required.¹³ Although some of the necessary training is already present in some areas, the numbers are not currently sufficient and the more novel roles are still in their infancy in terms of integrating into primary care.

The ‘transformation imperative’ is therefore that sufficient STP funds are invested to pump-prime the structures to rapidly train the clinical support required. Further research is also urgently required in how general practice can best transform without losing its core essence.¹²

The GPFV provides an important statement to GPs of their value, and describes how the previous damaging underinvestment in general practice can be corrected, but urgently needs to become a reality at the front line, where general practice is stretched to its limit.¹⁴ The STPs take the NHS into unknown territory, and with significant risk. As described in the recent Kings Fund report, without a strong, resilient, and highly functioning primary care service, the credibility, and indeed safety, of the STP programme is questionable.¹⁵ Early investment to strengthen primary care for our most deprived populations and develop the necessary clinical support roles for primary care, along with better evidence on how new teams will emerge are imperatives for the success of the whole venture.