A brief case to nationalise General Practice

General Practice is in crisis.

With approximately 8% of the NHS budget and 90% of the daily patient contacts, General Practice is one of the most cost effective specialities in the NHS and acts as a gateway to more expensive and scarce resources.  However, the model of GP delivered care from cradle to grave is itself gravely ill.

In part, the NHS has become a victim of its own success.  Patients are living longer and as a natural consequence to this are suffering from multiple chronic illnesses associated with age as well as those associated with 21^st century first world living.  Science has played a major part in this success allowing us to understand conditions better, monitor them more closely and treat them more effectively.  However, all of these successes have contributed to a resource and workforce burden within the NHS.  As such, we can no longer afford to carry on with an attitude of “business as usual” and it is widely accepted that we either need to consider new funding streams for the NHS or re-consider how we deliver care.

We know that by 2020, the NHS will have a funding deficit of £22 billion and so there is an urgency to find a way to deliver cost effective high quality healthcare within a tight financial envelope.  There is an understandable reluctance to ask the taxpayer to contribute more money to the NHS and so the impetus appears to be around delivering smarter and more efficient health and social care using technology and staff in ways previously never considered.  A number of pilot sites across the UK termed Vanguards have been tasked with finding solutions to the crisis in the NHS with the expectation that some will fail and some may deliver results through new models of care.  We await solutions from these Vanguards and hope to implement their learning across the UK.

We have not arrived at where we are now in the NHS overnight and General Practice has been struggling to deliver high quality services for a number of years.  Recruitment to General Practice training places is at an all-time low and on the back of an ageing workforce where 30% of our most senior General Practitioners are expected to retire in the next five years the sustainability of the General Practitioner led model of General Practice has been brought into question.  Unfortunately, new doctors are not choosing General Practice as their speciality of choice.  As General Practice suffers and recruitment worsens, newly qualified GPs are increasingly reluctant to take on partnerships in practices as this means financial investment and risk in an uncertain future.

Consequently, many practices are looking to other members of the primary healthcare team to provide front line patient assessment and management, especially if this care can be provided in a cost effective manner.  An example of this is where Advanced Nurse Practitioners perform minor functions of a General Practitioner.  Other more recent examples include; Practice Pharmacists who manage routine chronic disease, Receptionists trained as Healthcare Navigators to signpost patients to the right service within the NHS, Counsellors who manage low level mental health problems, Physiotherapists who manage musculoskeletal problems, and Physician Associates who assist in similar ways to ANPs.  Whilst there are now a number of examples of where extended healthcare teams are working successfully, it is not the current predominant model of General Practice, which remains mostly GP dependent. 

However, this reliance on a GP owned and delivered model of service is now starting to cause problems with succession planning.  The inability to replace our aging workforce is forcing a number of GPs to work in the NHS longer than they had intended and is causing some to hand their contracts back to NHS England as they have been unable to find successors to their businesses.  In turn, there are consequences to patients, on neighbouring practices who feel the “domino effect” of sudden fluctuations in workload and on commissioners who often have to procure a new provider at short notice.

Unfortunately, solutions that were available to us in the past are no longer an option.  The predecessors to Clinical Commissioning Groups (CCGs) had the flexibility to provide patient care where they felt that this was necessary.  This was important to help with the handover of care from one provider to another.  Examples of this might include where a single handed practitioner left clinical practice at short notice due to illness or performance concerns a PCT would appoint and employ caretaker clinicians to continue to deliver patient care until a longer term solution was found.  Since the inception of the Health and Social Care Act of 2012, this is no longer possible as PCO’s are now ineligible to act as provider organisations.  Procurement law has added to this burden as it takes time to find a suitable alternative provider when a contract is put out to tender and also creates further financial burden to the CCG.  Currently, when a provider finds itself unable to service its contract, it can provide the commissioner with the requisite notice and the commissioner then begins the procurement process.  As the procurement process continues and until such time that a new provider is found, the struggling provider is forced to try to deliver care that it has already declared itself unfit to do.  In current primary care contracts, this can be for up to 6 months.  This has led to nervousness amongst partners and directors of being the “last man standing” where the personal mental and financial cost of winding up a business is not the only risk.  Multiple jeopardy exists for clinicians as directors or partners when a they cease to operate as a provider and wind up their business in a hurry due to circumstances such as bankruptcy, illness or unsafe staffing.  When a safe handover of care has not been possible due to the rapidity of cessation of a service, referral to the General Medical Council can be the consequence for failing to ensure a safe and timely hand-over of care of a patient.

Currently, General Practice is a nationwide network of independent contractors to the NHS operating through General Medical Services, Personal Medical Services or Alternate Provider of Medical Services Contracts.  These independent businesses carry risks and opportunities to their owners.  It is important to recognise that General Practitioners are not business people but are expert generalists who are finding it increasingly difficult to manage their businesses at the same time as managing complex illnesses.   In years gone by, General Practitioners were heavily supported by Commissioning Primary Care Organisations.  Over the years, this support has diminished and contractors are expected to operate independently within the NHS befitting of their independent contractor status.  The Department of Health by removing some elements of NHS support and increasing competition within primary care appears to have encouraged this.

This is cited as one reason why doctors are not choosing General Practice and are turning away from the partnership model.  The employed and locum models of General Practice are becoming increasingly favoured not only by new doctors entering the speciality but also by senior doctors who are retiring from partnerships to return to work as locum doctors.

Each of the aforementioned difficulties described have added to destroy the reputation of General Practice as a stable career option and has contributed to the current workforce recruitment and retention crisis.  In its current guise then, General Practice is unsustainable and General Practitioners are asking for solutions.  At the same time, NHS England agrees that the NHS is unsustainable and is in need of a radical redesign if it to have an affordable future.  Thus, the conditions are right to consider ideas that might  once have been unthinkable.  One possible solution would be to embrace the employed option that doctors currently favour and nationalise General Practices, bringing them under the umbrella of a state owned provider with their associated staff as state employees.  Of course, the alternative is to encourage increased privatisation of General Practice with the hope that  General Practitioners embrace the change and allow themselves become employees of businesses other than their own.

The conceptual model of a state owned umbrella provider ensures that NHS assets are not stripped for the purpose of profit but are invested in patient care.  Conversely, the privatisation model assures the opposite.  This argument of privatisation versus nationalisation is not further discussed here and this document makes the assumption that privatisation of the NHS is not the favoured option.

Nationalising General Practice into a state owned primary care provider under the care of NHS England or Clinical Commissioning Groups would not currently be possible without legislative change.  One possible immediately available solution, which would not require a change in legislation, would be to encourage Local Authorities to take on this role.  This would also encourage the further advantage of integration of health and social care.

There is currently an opportunity to capitalise of the dire state of the NHS to redesign the service into a model fit for the future and free of profiteering and wastage.  As General Practices fail and look for solutions, a state owned Primary Care could take on the role of last man standing to inherit primary care contracts, its staff and premises infrastructure, reinvesting any “profit” made back into the delivery of services rather than being lost from the NHS as currently happens.  This would provide an immediate solution to an aging workforce with no succession plans who simply want to hand their contracts back and work as doctors to help patients.