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The core delivery model for general practice has remained largely unchanged since the creation of the National Health Service (NHS) in 1948. General practices are independent businesses, contracted by the state to provide defined health services to a registered list of patients. Practices are owned and run by one or more ‘partners’ – general practitioners (GPs) who hold contracts and share the profits their practice delivers. In theory, this incentivises the most effective care for all patients – from a young, healthy person requiring one-off treatment to an elderly patient with a variety of long-term conditions.
Today’s consumers of care are very different to those for whom the 1948 model was built. People expect to interact with services through technology, outside of core operating hours. People’s needs have also changed – increasingly requiring care for long-term conditions. These patients account for 50 per cent of GP appointments. Across the system, care for people with long-term conditions is thought to consume 70 per cent of health and social care spending. This is set to continue. By 2018, the number of people with multiple long-term health conditions will rise to 2.9 million – an increase of one million since 2008. Today’s elderly and chronically ill patients need integrated, accessible and extended care in the community. Instead, general practice providers remain small, care is episodic rather than coordinated and technology is not exploited. For taxpayers, this creates huge financial inefficiencies, as GPs handle appointments regardless of need, care is not delivered in the most cost-efficient place and economies of scale are not leveraged.
Recent moves to change this approach offer an alternative future. In England, the Coalition Government backed a range of new models of care, offering a variety of extended services and increased opening hours, underpinned by a workforce designed to meet the needs of patients effectively. These ‘vanguard’ providers can offer such services by operating at significant scale. International providers offer further evidence of tomorrow’s healthcare model. Many providers go beyond focusing on reactive care, by proactively monitoring and tending to the needs of all people under their care. Such a ‘population-health’ approach goes beyond traditional health and care services, to focus on wider determinants of people’s wellbeing. It therefore emphasises prevention for the healthy majority of patients, and joined-up care for those who need it.
With its registered list of patients, and position as the defined first point of call for any patient entering the healthcare system, general practice is perfectly placed to lead a population-health approach. An increased focus on prevention for healthy patients, and self-management of long-term conditions, could save up to £1.9 billion by 2020-21. In addition, large providers can offer a range of extended services – including diagnostics, minor surgery and urgent care centres. Lakeside Healthcare in Northamptonshire offers an urgent care model to approximately 200,000 people at one third the price of an equivalent A&E visit. Applied across England, this could deliver savings in the region of £1.1 billion a year.
To deliver these services most effectively, providers will need to operate at much larger scale. Providers offering best practice in England and elsewhere hold patient lists at least ten times larger than today’s average list size of 7,400 patients; many aspire to operate at multiples of that. This affords providers the size to invest in front-end change and exploit back-end efficiencies, including making the most of technology. Online triaging, for example, has the potential to direct patients to self-care, rather than booking appointments. If the proportion of people using such triaging services matched the number of people who use the internet each day, savings could be in the region of £274 million a year. Underpinning this with a multidisciplinary workforce also offers the potential for more efficient care. A number of experts interviewed for this paper explained that GPs could pass 50 per cent of appointments they currently conduct to other professionals. A more diverse workforce could, for instance, see pharmacists or nurses administering the estimated 57 million appointments (15 per cent of the total number of appointments) consumed by common conditions and medicines-related problems each year. This alone could deliver up to £727 million of savings per year.
This new approach to care from population-health providers can only materialise within a healthcare system that acts as one. Today’s fragmented approach to care is driven by a funding stream that fails to incentivise integration. The commissioning of services is split between NHS England, clinical commissioning groups, and local authorities, which fund services such as public health, social care and primary care separately. Contracts also undermine incentives to provide more prevention, self-management and care in general practice. GPs receive set funds per registered patient, but secondary care is funded based on activity. This misaligns incentives for primary-care providers: with a fixed income regardless of activity, GPs are motivated to reduce care and secondary providers are incentivised to increase it.
Instead, contracts should cover the whole care needs of defined populations. Integrated commissioning bodies should replace today’s fragmented commissioners. Whole-population-care contracts should be capitated, with commissioners able to attach bonus payments to incentivise improved care in specific areas. Contracts must also be time-limited and the appropriate size to incentivise competition between providers. Patient choice of provider must be upheld.
Ultimately, general practice is one part of a patient’s journey and cannot be viewed in isolation from the rest of the system. General practice should, however, play a much expanded role in a new healthcare model. This report presents a radical blueprint for change. Designing a system that acts as one, with an increased amount of care delivered within general practice, will improve outcomes for patients at a lower cost to the taxpayer.
Interview with Alexander Hitchcock, Researcher, Reform