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General practice key to survival of NHS, say experts

If it fails, so will the entire health service; urgent action needed to fund it properly

Caroline White

Thursday, 18 February 2016

General practice is key to the survival of the NHS. If it fails, so will the whole health service, argue Professor Martin Roland and Sir Sam Everington in an editorial* published in The BMJ today.

But focusing on hospital financial deficits is diverting attention away from the crisis in general practice, they insist.

Hospitals’ £2bn deficit “certainly sounds dramatic”, they argue, “but hospitals don’t go bust – someone usually picks up the bill.” General practice doesn’t have that luxury, and its share of the NHS budget has fallen from 11% in 2006 to under 8.5% now.

Recent research shows that GPs are experiencing unprecedented levels of stress amid a steadily increasing workload. GPs are finding it harder to recruit trainees and to find partners to replace those increasingly taking early retirement.

Politicians and NHS leaders want more care to be moved into primary care, yet the share of funding devoted to general practice is falling, as hospitals eat up a large chunk of the NHS budget.

In the past 10 years, the number of hospital consultants has increased at twice the rate of GPs. Yet GPs currently manage most patients without referral or admission to hospital. If this balance shifted only slightly, hospitals would be overwhelmed, insist the authors.

“It is general practice that makes the NHS one of the world’s most cost effective health services,” they say, pointing out that the £136 cost per patient per year for unlimited general practice care is less than the cost of a single visit to a hospital outpatient department.

The authors, both of whom are internationally renowned experts in general practice, put forward several solutions. First and foremost, GPs need a “substantial injection of new funding” to provide more staff in primary care, they say.

But new roles, such as physician associates, pharmacists, and advanced practice nurses, are needed to take the strain off clinical staff.

Reviews of practice contracts that threaten serious financial destabilisation should be put on hold until a fair funding formula is developed to replace the 25-year-old ‘Carr-Hill’ formula, they suggest.

Furthermore, NHS England should tackle spiralling indemnity costs by providing Crown Indemnity similar to that for hospital doctors, as GPs increasingly do work previously done by specialists.

Red tape should be slashed, in part by changing the £224m Care Quality Commission inspection regime to one where only the 5-10% of practices found to be struggling are revisited within five years.

In hospitals, the ‘Choose and Book’ referral system needs a radical overhaul: the authors estimate that communicating by phone, email, and video link could potentially halve outpatient attendance in some specialties.

And the ‘Payment by Results’ system for funding hospitals must become a population based, capitated budget that incentivises trusts to support patients and clinicians in the community.

The authors identify two “elephants in the room” that can no longer be ignored. First, cuts to social care are making it increasingly difficult for hospitals to discharge patients.

Second, the UK’s spend on healthcare has fallen well behind that of its European neighbours. It now ranks thirteen out of 15 in healthcare expenditure as a percentage of gross domestic product. In 2000, the then prime minister Tony Blair promised to raise NHS funding to mid-European levels. Today, this would require another £22bn a year.

“Urgent action is needed to restore the NHS,” emphasise the authors. “But the crisis will not be averted by focusing on hospitals. If general practice fails, the whole NHS fails,” they warn.

* Roland M, Everington S. Tackling the crisis in general practice. BMJ 2016;352:i942. DOI: 10.1136/bmj.i942

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