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Primary care chief wants GPs to form larger providers

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GPs should form larger provider organisations or networks as part of a rapid development of out-of-hospital services, England’s lead GP is proposing.

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NHS England deputy medical director Mike Bewick spoke to LGC’s sister title Health Service Journal as the organisation today launches a consultation on the future of primary care.

A document explaining why services need to change says there is “growing dissatisfaction with access to services” in general practice.

It also says there are “persistent inequalities in access and quality” – often there are fewer services in poorer areas – and “growing reports of workforce pressures”.

Dr Bewick, in his first interview since taking up his NHS England post in March, said: “General practice is talking about the difficulty of sustaining the current model.

“A major reason for change is that quite a lot of the public in certain areas of the country are not very satisfied with [current GP] provision.”

He said this was due to difficulty getting seen “at particular times”.

“People are bypassing primary care and going to accident and emergency or elsewhere. The scrum that occurs on Monday morning [to get appointments] is becoming increasingly difficult.”

The engagement will explore several potentially significant and controversial policy changes. They include incentivising practices to merge or form networks, and introducing “new providers to stimulate innovation and improve capacity”.

Dr Bewick told HSJ he wanted to see “a little bit of revolution and step change” in reforming services. He said: “To get this moving we are going to have to have some pace and scale.”

He said many small GP practices were rated highly by patients but, “the question is whether you can sustain the workforce in that current model”. Becoming larger did not have to mean closing practices, but grouping and sharing service across localities, he added.

Today’s publication says general practice should “[operate] at greater scale, for instance through networks, federations or practice mergers - [but] in a way that preserves the greater relationship continuity that comes from individual practice units.”

Another suggestion made by NHS England is for it to work with clinical commissioning groups and local authorities to jointly contract “primary care plus” services, which could incorporate general practice, community services, and local council responsibilities such as social care.

NHS England will publish further national plans in the autumn, and has also encouraged localities to develop their own primary care proposals. It took on responsibility for commissioning primary care in April under the Health Act reforms.

Read HSJ’s analysis of the issues being considered in the consultation:

Analysis: Pointing the way to change in primary care

Dr Bewick said practices networking with each other, and with other urgent care services, would also help provide seven day access to primary care.

He said there “must be some access to types of primary care throughout the weekend”, and called for a debate about how services and the current workforce could meet that.

Dr Bewick also predicted an imminent “sea change” in identifying and addressing poor quality general practice. This would be a result of NHS England’s new role, alongside the Care Quality Commission’s overhauled inspection regime which includes a yet to be appointed chief inspector of general practice, and revalidation of doctors.

He said when cases of poor care are found, “If you can’t improve it you must put in mechanisms [with which] we can do something about that inadequate provision. I think that would be very rare.”

NHS England’s engagement is happening at the same time as health secretary Jeremy Hunt consults on his plans to make named clinicians responsible for patients receiving community care. He has also suggested giving GPs direct contractual responsibility for providing out of hours primary care, which many had before 2004.

Dr Bewick predicted direct contractual responsibility for out of hours would not be returned to GPs in the near future, but indicated they would have greater involvement and oversight, while some CCGs may choose to overhaul their out of hours service in coming years.

Meanwhile, NHS England’s engagement document asks: “How do we ensure that people with more complex health and care needs have a named clinician with responsibility for coordinating their care”.

It is likely the GP contract for 2014-15, which is currently being negotiated, will include measures to give GPs more direct responsibility for a specific group of complex or frail patients.

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