Andy Burnham’s ambitious and timely speech at the King’s Fund, which introduced the idea of whole person care, focused on the vital issue of integration around the patient – bringing health and social care more aligned around the needs of the patient. This approach should be welcomed and I hope other political parties follow suit in identifying and acting on this important issue.
Integration is vital as we move forward to address the problems caused by poor continuity of care and fragmentation. Patients have multiple needs that require more than ‘health’ and are not best served by competition but instead collaboration between health (physical and mental) services, local government, housing, education and others.
General practice has always been a cornerstone of the NHS and will continue to be essential in the NHS of tomorrow; whatever system emerges there will always be a need for a generalist practitioner, able to deal with undifferentiated symptoms and act as a bridge to the rest of the health and social care system.
Even today, but more so in the future, the GP keeps the NHS safe, fair and offering value for money. Data shows that already over 1 million people are seen each day in general practice, who carry out 90 per cent of all activity for as little as 9 per cent of the NHS budget. General practitioners refer around one in 20 patients to a specialist, meaning that the vast majority of a patient’s care is carried out by the GP and GP nurses.
GPs have always adapted to change and are skilled at creating solutions to problems that arise and will continue to deliver high quality but low-cost primary care; making the best use of the time and resources available to them to reduce health inequality throughout the UK; use IT effectively in delivering care; and become leaders in research and development.
There are problems, however, with the current system of general practice which will have to be addressed if GPs, in the future, are to be able to deliver the care that is required for their patients. The patients of tomorrow will be increasingly complex, and have many more ‘comorbidities’ (for example, a single patient may have diabetes, hypertension, heart disease, depression, osteoporosis and many more long-term problems). Many of our patients will have dementia and many will lead isolated lives. The problems that therefore need to be addressed, which are not unique to the UK (and paradoxically which, because of our GP system of care, we are best able to deal with), are the twin scourges of poor continuity of care and increasing fragmentation of care. Both of these increase costs, as patients are passed from one specialist to another, or from health to social care providers and in doing so, risk duplication of effort and poor patient outcomes. GPs are ideally placed to deal with patients with complex problems. But given the paucity of investment in the profession and the increased move of care outside hospitals, GPs are heaving under the workload, coupled with the decreased number of doctors entering the profession. Real investment – through redistribution of current resources (moving monies and people from hospitals to the community) – is required to create the capacity for GPs to undertake the work necessary to deliver a sustainable health service.
Together with investment, GPs will need to change the ways they work. To start, the concept of a fixed 10-minute GP-patient consultation is outdated and does not allow us to focus on the complex needs of our patients or to deliver the care we need to keep them safe in the community for as long as possible.
Consultations in the future will need to be flexible in duration depending on individual patient needs. They must offer flexibility in the location of consultations to incorporate home visits and there will be fewer each day, in order to offer longer consultations.
As set out in the the Royal College of General Practitioners’ (RCGP) future vision for general practice, The 2022 GP, general practice will also move beyond face-to-face appointments. Patients will be encouraged to remotely ‘visit’ their GP by telephone, email, text message and through social media. This has the potential to extend to virtual examinations by doctors and practice nurses in settings outside the confines of the surgery and at more flexible times.
GPs in 2022 will promote self-care by referring patients to e-health information systems. Shared decision-making between GPs, patients and carers will also become the norm.
In addition, patients will have remote interaction with their GP, with the ability to move directly from registration to treatment, as well as online access to their medical records, an innovation that is already in motion.
Given more GPs, we will be able to deliver better integrated care – joined-up care where different professionals come together around the needs of the patient, rather than expecting the patient to travel across multiple providers. Integrated care in this context is GP led multi-professional teams, working together with communication that goes beyond the simple exchange of letters, with the different professionals working across their professional boundaries (so in and out of hospital, in and out of ‘core’ hours), ideally with pooled budgets and ideally with shared GP electronic records. Patients identified as high risk of hospital admission (for example, the frail elderly) or those at the end of their lives are best suited to an integrated approach, which should include better-personalised care during the 24-hour period. This does not mean the GP returning to 24-hour responsibility for all patients, but sharing the care of patients to help improve their lives and reduce unnecessary hospital admission.
General practitioners in the UK do more for more patients, and to a greater level of complexity, than many GPs across the world. Yet we have one the shortest training programmes. Three year compulsory vocational training was introduced in the UK 30 years ago, yet a UK GP now delivers care that would have been the territory of a consultant physician, or psychiatrist or public health doctor. In 2012 the RCGP obtained educational approval for enhanced GP training – meaning that, once ministerial go ahead for implementation is given, the GP of the future will have enhanced and extended training, with all new trainees completing a four-year training programme.
GPs will continue to be experts in generalism but enhanced training will equip them with the skills to: co-ordinate cost-effective care for patients with multiplemorbidities and individual conditions; effectively manage complex and chronic medical conditions as well as endof- life care; deal with polypharmacy (use of multiple medicines); understand the health needs of the community; and lead care in nursing homes and take care of the homeless and those with mental illness.
Extended training will include specific clinical training, focussing on paediatrics, care of the elderly, mental health and alcohol and substance misuse. GPs in 2022 will also acquire leadership skills to become leaders in education, training and research and in planning services and public health.
To meet the challenges facing general practice, there needs to be adaptation of the practice and the teams in which GPs work. Increasing numbers of the future work force are women working part time. However, far from being a disadvantage, given the complexity of our clinical work, part-time working is perhaps the best way of ensuring that patients continue to receive care from an empathetic and alert GP. However, we will have to learn to deliver continuity of care while adapting the ways we work to accommodate the changing demographics of our workforce, for example through job sharing, buddying systems or other organisational changes.
The 2022 GP sees practice nurses and staff completing vocational training in primary care in order to help patients understand their illnesses. Practice teams will also include practitioners with specialist knowledge, skills and experience in order to effectively integrate care.
Communities will contain GP practice federations, working together to provide extended primary care services, including nursing and other community care programmes, such as dietary workshops.
The role of GP as gatekeeper will diminish as more services are provided directly and with self-referral possibilities for patients. However, the GP will continue to work towards less fragmented care, working with specialists and private, NHS and third sector healthcare providers. The GP’s role will increasingly become one of the patient advocate and navigator – helping to coordinate their patient’s care across an increasingly complicated provider network.
What must not change is the relationship between the GP and their community, and through this the registered list. Removing GP boundaries by allowing patients to register with any GP, anywhere, will destroy this relationship and will widen health inequalities risking the creation of ‘sink practices’. GPs must care for patients within the context of their families and communities – and a geographical boundary and registered population is the way of doing this.
The future is bright for general practice but in order for The 2022 GP to become a reality we need to attract more graduates to enter general practice and retain the existing workforce, offering all GPs opportunities for high quality training and employment. Despite the pressures that the NHS is under today – and will no doubt be in the future – only by investing in primary, community and social care can we hope to deliver a health care system fit for the future.