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Editorials

General practice and the Sustainability and Transformation imperatives

Ben Jackson, Helene Irvine and Elizabeth Walton
British Journal of General Practice 2017; 67 (658): 196-197. DOI: https://doi.org/10.3399/bjgp17X690569
Ben Jackson
Academic Unit of Primary Medical Care, University of Sheffield, Sheffield.
Roles: Senior Clinical Teacher
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Helene Irvine
NHS Glasgow and the Clyde, Glasgow.
Roles: Consultant in Public Health
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Elizabeth Walton
Academic Unit of Primary Medical Care, University of Sheffield, Sheffield.
Roles: NIHR Clinical Fellow
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Sustainability and Transformation Plans (STPs) have now been submitted for all 44 areas across England, swiftly followed by corresponding plans from clinical commissioning groups (CCGs) for how they intend to strengthen and transform health services across their communities. CCGs were required to outline how the investment described in the General Practice Forward View (GPFV) will be utilised to support general practice, to reverse some of the damage done by years of underinvestment, and create a position from which primary care can begin to strengthen.1 Stronger general practice is an imperative for the sustainability of STPs if the NHS is to function in a form recognisable from its founding principles.

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.

Notes

Provenance

Freely submitted; externally peer reviewed.

  • © British Journal of General Practice 2017

REFERENCES

  1. 1.↵
    1. NHS England
    (2016) General practice forward view, https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf (accessed 5 Apr 2017).
  2. 2.↵
    1. Payne RA,
    2. Abel GA,
    3. Guthrie B,
    4. Mercer SW
    (2013) The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. Can Med Assoc J 185(5):E221–E228.
    OpenUrlAbstract/FREE Full Text
  3. 3.
    1. Busby J,
    2. Purdy S,
    3. Hollingworth W
    (2017) Br J Gen Pract, Opportunities for primary care to reduce hospital admissions: a cross-sectional study of geographical variation. https://doi.org/10.3399/bjgp16X687949.
  4. 4.↵
    1. Barker I,
    2. Barker I,
    3. Steventon A,
    4. Deeny SR
    (2017) Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ 356:j84.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Department of Health
    NHS hospital stay. https://data.gov.uk/data-request/nhs-hospital-stay (accessed 5 Apr 2017). p 2015.
  6. 6.↵
    1. Health & Social Care Information Centre
    NHS Payments to General Practice, England 2014/2015, http://content.digital.nhs.uk/catalogue/PUB18468/nhspaymentsgp-14-15-rep.pdf (accessed 10 Apr 2017).
  7. 7.↵
    1. Mercer SW,
    2. Watt GCM
    (2007) The inverse care law: Clinical primary care encounters in deprived and affluent areas of Scotland. Ann Fam Med 5(6):503–510.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Barnett K,
    2. Mercer SW,
    3. Norbury M,
    4. et al.
    (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380:37–43.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Levene LS,
    2. Baker R,
    3. Wilson A,
    4. et al.
    (2016) Population health needs as predictors of variations in NHS practice payments: a cross-sectional study of English general practices in 2013–2014 and 2014–2015. Br J Gen Pract, https://doi.org/10.3399/bjgp16X688345.
  10. 10.↵
    1. IIrvine H,
    2. Gomez J
    (2015) Using routinely collected data to figure out where the NHS is going wrong, http://www.gla.ac.uk/media/media_443697_en.pdf (accessed 10 Apr 2017).
  11. 11.↵
    1. Royal College of General Practitioners
    (2017) GP Forward View interim assessment, http://www.rcgp.org.uk/-/media/Files/Policy/2017/RCGP-GP-Forward-View-Interim-Assessment-2017.ashx?la=en. (accessed 5 Apr 2017).
  12. 12.↵
    1. Marshall M,
    2. Gray DP
    (2016) General practice is making a leap in the dark. BMJ 355:i5698.
    OpenUrlFREE Full Text
  13. 13.↵
    1. Health Education England
    (2016) South Yorkshire & Bassetlaw Primary Care Workforce group Proposal to STP executive and LWAB for investment to build a multi-professional primary care workforce across South Yorkshire and Bassetlaw, https://sybwg.files.wordpress.com/2016/11/proposal-for-investment-in-pc-workforce-transformation-syb-final.pdf (accessed 5 Apr 2017).
  14. 14.↵
    1. Walton E,
    2. Markus K,
    3. Torkington M,
    4. et al.
    Re: General practice is making a leap in the dark [letter]. http://www.bmj.com/content/355/bmj.i5698/rr-2 (accessed 5 Apr 2017).
  15. 15.↵
    1. Ham C,
    2. Alderwick H,
    3. Dunn P,
    4. Mckenna H
    (2017) Delivering sustainability and transformation plans From ambitious proposals to credible plans, https://www.kingsfund.org.uk/publications/delivering-sustainability-and-transformation-plans (accessed 5 Apr 2017).
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British Journal of General Practice: 67 (658)
British Journal of General Practice
Vol. 67, Issue 658
May 2017
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General practice and the Sustainability and Transformation imperatives
Ben Jackson, Helene Irvine, Elizabeth Walton
British Journal of General Practice 2017; 67 (658): 196-197. DOI: 10.3399/bjgp17X690569

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General practice and the Sustainability and Transformation imperatives
Ben Jackson, Helene Irvine, Elizabeth Walton
British Journal of General Practice 2017; 67 (658): 196-197. DOI: 10.3399/bjgp17X690569
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