General practice will need to undergo many changes if it is to deliver the on challenges facing the NHS into 2020 and beyond
The NHS in England is in the process of undergoing the most fundamental change since it was established in 1948. In the last decade much has already changed. By 2020 all sectors of the NHS could look completely different to the way they do today, particularly following the full implementation of the Health and Social Care Act 2012. However, in order to ensure that the NHS remains a public service, free at the point of need and not based on any citizen’s ability to pay, the system of primary and community care must be strengthened and expanded.
International research has shown that effective primary care delivery equates with higher patient satisfaction rates, lower expenditure and lower levels of hospitalisation. With 80% of all contact in the NHS occurring in general practice, this is where more finished episodes of care need to be delivered. However, as GPs juggle an increase in demand for their services alongside the changing needs and expectations of the general population, a re-engineering of general practice is required in order to meet the challenge of improving quality, safety and outcomes for patients, while being more productive with NHS resource allocation and utlisation. It is also the key to solving the urgent care crisis and management of long-term conditions. This needs a significant rethink to both the form and function of general practice, with the estate, workforce and skill mix, new technologies and diagnostics and co-location of other primary and community services all being part of the re-work.
Some GP surgeries across the country are already providing services above and beyond their GP contract. Some are already co-located with pharmacies and dental practices. This is just the beginning of the development of a ‘primary care campus’, which in itself will have a real impact on how secondary care is delivered. A wider range of specialised community services will need to be provided within primary care with the re-establishment of community nursing, in its broadest sense, being within the ‘campus’ along with allied healthcare professionals (AHPs), appropriate social carers and the third sector.
This will require significant investment in this sector, something that previous health service reforms have often ignored.
Hospitals will be places where consultants consult, and they and their teams provide high-tech, highly complex planned and emergency care and procedures. With more day case surgery and shorter hospital stays as a result of an extended range of services in the community, the local hospital will need fewer beds, no outpatient department and a smaller estate.
As the role of the GP evolves, so must that of the local medical practice. The new legislation directs GPs to both broaden the provision and be the commissioner of NHS care, but, faced with an abundance of inadequate primary care buildings, the task could not have arrived at a more difficult time. Not only do many properties need updating or refurbishing, many need rebuilding completely, not least to accommodate new technologies to improve diagnostics, IT systems to improve patient access and telemedicine for remote consultations and monitoring of patients
Whatever the future holds for our beloved NHS over the next decade, one thing is unlikely to change – people will always want to register with their own GP surgery – contrary to some commentators’ views. Patients still want face-to-face contact in a familiar environment; it isn’t necessarily important that it is the same healthcare professional they see every time, but they need a consistent and dedicated service. However, while list-based practice should remain, patients will expect more from their registration and general practice must be more ambitious in its care delivery,
While a patient’s registration is limited by location, continuity of their medical record is provided by this process. As early as 2020, health records may be held on a device similar to a credit card, which can connect to a remote general practice or other NHS provider service, where a patient may be temporarily residing. Data protection can be provided by existing technology, but the current drive to realise patient-held, and possibly owned, records this may be how the longstanding debate about accessing care where you both live and work may be delivered. This technology must be centred in the primary care estate and lessons learned from previous failed attempts at such a national programme.
Across the wider health service, the focus will no longer be just on reactive care; rather it will focus on broader determinants of health and wellbeing and improve pre-primary preventative care. Primary care services will need to take a more strategic approach to population health further, demonstrating the benefit of list-based practice.
There will be an ever-increasing emphasis on self-care, with waiting rooms used more to improve health education and monitoring, more than just seating people who are waiting their turn to see a healthcare professional. Blood pressure and weight monitoring are already commonplace, but further fitness and diagnostics could be available. A simple example of this could be in the treatment of obesity, where some practices prescribe exercise through mapped walks around the area with information.
Externally to the surgery, devices fitted in home toilets could monitor urinary glucose, portable heart monitors can send updates on cardiac irregularity, and motion sensors will be able to confirm that elderly people have got out of bed that morning. These types of facility and more will be able to reduce the need for health centre visit and identify issues as soon as they arise.
Primary care has historically had a variable outlook about institutional remodeling and new technology, but that must change. This is possibly the last chance to rejuvenate the NHS and history will be very critical of any failure of the current reform agenda. The popular press are already reporting some of the early noise about how the funding of the NHS may be supported by co-payments or penalties for inappropriate use, none of which are getting much hearing yet. By 2020 the health service in the UK may be far removed from what we know now, but the emphasis on a service, free at the point at which a patient accesses care, must be the founding principle and this will only be maintained by an investment programme in primary care, the like of which we have not previously witnessed.
