THE CURRENT STATE OF PLAY
With the changing economics of financing the healthcare system of the UK, the future direction of primary care remains cloudy and uncertain. GPs, as fundholders and key CCG stakeholders, will need to make decisions within an increasing resource-scare NHS. Yet the workforce demographics are shifting. The GP workforce in the UK consists of a rapidly growing proportion of salaried GPs who are not in partnership roles; this number has risen over 10-fold since 1999 to around 28%.1 Different authors have cited different reasons for this change, but common ones include feminisation of the workforce, younger professionals seeking flexibility, and wariness surrounding the future uncertainty of independent contractor status due to wider shifts in the medico-political landscape. It remains to be seen whether these changes will represent a bright new future or the gloomy demise of primary care.
Looking more closely at the issue of increasing salaried GPs from the current perspective of doctors, Dale et al conducted a rigorous mixed-methods survey and statistical analysis, which found that partners were more likely than salaried GPs to cite a heavy workload as a reason for wanting to leave the profession.2 Furthermore, ever-rising levels of administration and perceived bureaucracy were highlighted as key factors contributing to this workload. It seems that these are significant issues for GP partners and may go some way to explaining the apparent decline.
As one might expect, salaried GPs are paid less than partners, but the annual salary for both is falling;3 however, the salaried professional workforce is evolving rapidly and for different reasons. For some, the stable income provided by these salaried positions may be more attractive due to the incentive of having no administrative responsibilities within the practice. Yet if more and more GPs refuse to take up partnership roles, there will be no one to lead practices. Clear leadership with direction is essential to progress and improve standards. Moreover, Cresswell states that the roles of doctors and managers have begun to merge following reforms in the delivery of public health care.4 This apparent shift appears to align with Freidson’s prediction of intra-professional splits between those with responsibility versus a larger body of rank-and-file workers with low levels of autonomy5 [p.210].
In primary care, it has been widely noted that there is an ongoing shift towards fewer, but larger practices.6 In general practice, policymakers have anticipated that it will become normal for general practices to work together in federations or networks,7 and this commitment to joined-up care was underlined in a recent announcement from the government of an extra £2.4 billion in annual funding for general practice, part of which will go towards supporting new models of care, and a new contract for larger GP groups.8 It is unknown whether these recent developments will reassure those GPs who feel that the uncertainty of funding in general practice means that long-term strategic planning is extremely difficult and stressful. In addition, academics are predicting the impending demise of independent contractor status, and the views of the profession on such reform is largely uninvestigated.9 Such smaller practices are often preferred by patients because of the personable nature of care that they receive. Nevertheless, combining practices and streamlining backroom functions will help to make practices more efficient and able to potentially provide a greater variety of services. This is especially important within a competitive provider environment that has predominated thus far.
CHANGES AHEAD
Within general practice, significant change is anticipated in terms of how services will be delivered, and this will require GPs to possess both managerial and leadership skills. In their document The 2022 GP, the RCGP acknowledge the need to work together with the Faculty of Medical Leadership and Management (FMLM) to create a GP training scheme which focuses more on leadership skills.10 There is much to learn from dentistry in this respect, where private ownership of practices and concurrent managerial and leadership roles are not uncommon. In a time when the future of health and social care in the UK remains uncertain, GPs appear to be splitting into the groups that have been labelled as ‘incidental’ or ‘willing’ clinical hybrids.11 ‘Incidental’ hybrids are thought to protect traditional professional values while in short-term leadership roles, whereas ‘willing’ hybrids serve as a disruption to the established professional hierarchy. The qualities that these individuals possess should be transferred to others to instigate the transformational change that is sought in primary care.
With increasing managerial responsibilities and aligning leadership qualities, academics have also anticipated that there is likely to be increased collaboration between GPs and general dental practitioners (GDPs) in the near future. Addicott and Ham of the King’s Fund, propose that general practice should be at the centre of interprofessional care networks.12 In these teams, GPs would work alongside other health care professionals, including GDPs, to deliver coordinated care that is able to efficiently respond to the needs of a changing population, where patients increasingly deal with multiple inter-related conditions. These ideas tie in closely with those of Simon Stevens, the Chief Executive of NHS England, who has suggested GPs work with other professionals in multispecialty community provider groups. In line with this vision of GPs occupying a central role in the UK’s future health care system, which should hopefully signal a further shift in power from the hospital clinicians, the corporate monopolists as defined by Freidson, back to the GPs, or professional rationalisers. Perhaps the collaborative working of both professions will lead to synergies and efficiency improvements through the better provision of services. Such changes will only serve to enhance the opportunities offered by the formation of federations and hence, this provides a unique opportunity for constructive innovation, enhancing the notion of a brighter future for general practice.
It is evident from the arguments presented above, that general practice is undergoing a period of substantial change. Furthermore, it appears that these changes counteract each other, negating their potential.
It is arguable that the formation of federations and commitment to integrated care will serve to produce synergies and service improvements that will undoubtedly be beneficial for patients in terms of service provision and patient care. Yet the contrasting decline in partnerships may suggest that there may be fewer managerially-minded healthcare professionals to lead and drive these larger organisations. Moreover, the evidence gives weight towards GPs not wanting to undertake these intensive roles. There may be a bright future ahead, but perhaps the government must first consider and address the concerns of the key personnel before this can be realised.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2018