Rebuilding the NHS 'front door': Changing primary care to meet future healthcare needs

The closures of 138 general practice (GP) surgeries across the UK hit the headlines in May 2019. According to the medical website Pulse, these closures from 2018 are the most recorded for a given year, compared to just 18 in 2013. Some arise from practice mergers designed to benefit patients, but others reflect recruitment and retention problems. Although surgeries are banding together to gain greater efficiencies and improve business operations, the smaller practices often merge with another simply to survive.

Of the practices forced to close in 2018, 86% were smaller surgeries. This worrying situation suggests that there has never been a better time for the NHS to usher in the wide range of service enhancements at the core of the NHS long-term plan. There’s real scope for positive change within the area of primary care, especially with the sustained support of the wider NHS across each geographical area.

The case for rebuilding the NHS ‘front door’

Primary care is often referred to as the ‘front door’ of the NHS as it is the first point of contact in the NHS healthcare system. It includes general practice surgeries, community pharmacies, dental, and optometry services.

One of the aims of the NHS long-term plan is to bring primary and community care closer together so there’s more opportunity to offer diagnosis and treatments to patients and thereby reduce hospital admissions. Not only does this doorway act as the first point of contact, but it is also often the means to continuing care for patients—as the GP, dentist, or optometrist is likely to be the key person to decide any specialist care and arrange it. About 90% of all health interventions are made through primary care (despite only receiving approximately 10% of the NHS budget), so it should be the focus for reviewing how the system is working presently and addressing key bottlenecks and issues.

The changes cannot come soon enough. The NHS does not have the resources—both money and trained professionals—to continue to carry out the range of services that it currently provides over the long term. It’s well known that patients are finding it difficult to book appointments at GP practices with some entailing waiting times of up to a month. In many cases, this is because practices are overstretched with too few GPs covering increasing demands for patient care. This is particularly apparent where recruitment and retention are difficult, such as in rural, coastal, and inner-city practices.

According to a 2019 Medscape survey looking into the pay and satisfaction of UK doctors, about 50% of GPs state that they would not follow a career in medicine now if they had the opportunity again. The main reasons were cited as staffing problems, workload pressures, and inadequate pay. The findings indicate serious issues for GPs and the whole NHS.

The long-term plan also calls out the need to provide better and fairer access to health. As stated within, it isn’t possible to ‘treat our way out of health inequalities’ and the comprehensive vision for clinical and service improvements presents some disturbing data.

Finally, there’s the strain of meeting future demands, as the nation’s needs have altered due to evolving technology, advancing medicines, and changing lifestyles.

An increasing number of people are ill, coping with chronic problems, have mental health issues, or the challenges of being elderly and infirm. In addition, in recent years, there are growing numbers of patients with ‘diseases of affluence’ or ‘Western disease’ which are usually chronic, non-communicable, and often caused by issues like our increasingly sedentary lifestyles.

"Reviewing care and making improvements outside a hospital setting is, encouragingly, a headline commitment in the NHS long-term plan."

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It’s a consistent approach that builds on progress made as a result of the preceding General Practice Forward View. To support this commitment, the NHS released five-years of funding beginning in 2018 that will ultimately provide a 3.4% average increase to the budget between 2019 and 2024. That roughly £20 billion boost will make proposed changes possible.

Some proposed changes show early promise

While much work is left to be done, many concepts from the long-term plan are already in practice across the country and showing real improvements for patient accessibility and care and clinic business stability. Others are in the planning stages and soon to launch.

Primary care networks

Primary care networks are, rightly, the essential cornerstone to how GP practices will operate in the future under the long-term plan. GPs have already been finding new ways of working together to improve how they operate in networks of partnerships, federations, and clusters.

However, in April 2019, a more formal framework was introduced which supports practices coming together to form primary care networks. The idea is that neighboring practices will join up to cover 30,000 to 50,000 patients. Along with existing contracts, GPs in these expanded networks will be expected to enter new network agreements—which will include a single fund from which the network will share its resources.

One of the new responsibilities from 2020 and 2021 is to actively manage population health within their locality and assess who would benefit from targeted proactive support. This should not constitute a tall order, particularly now that increasingly sophisticated population heath techniques can pinpoint priority patients. At-risk patients and patient groups should prove much easier to identify and target for care at home or within the community.

A shared savings scheme has been proposed, which will reward networks for finding creative and appropriate ways to treat patients without using accident and emergency departments or hospital admissions. Similarly, the NHS will reward GPs under a new scheme for finding more personalized forms of care.

Fully integrated community-based healthcare

On a par with the establishment of primary care networks, the plan outlines a commitment to developing fully integrated community-based healthcare. The idea is to establish teamwork and avoid the different disciplines operating solely in distinct silos, where best practice and joined-up care is not easily shared.

GPs, pharmacists, district nurses, physiotherapists, and allied health professionals will actively develop multidisciplinary teams to work collaboratively across primary care and hospitals. These teams will be tasked with increasing capacity to enable crisis response services to meet response times, and other requirements, stipulated by the National Institute for Health and Care Excellence guidelines.

Vanguard organizations pilot new care models

For primary and community care, one of the routes to improvement is via tried and tested piloting of new care models. The use of vanguards recognizes the experience and value that existing NHS staff can bring to try out new approaches to solve familiar problems that they will have encountered. By focusing initial efforts on integrated primary and acute care systems, enhanced home health care, and community providers, new methods are already helping produce better outcomes for patients and better business stability.

Early wins must be coupled with continued support

When the vanguard phase of the new care models ended in March 2018, NHS England expected individual vanguards to sustain themselves without further national funding or transformation. It isn’t yet clear whether they will be successful in taking the next step of scaling up. So, it is very much a case of ‘watch this space’ to see what happens next.

The long-term plan’s focus on primary and community services is well placed but still presents a challenge, particularly as staff vacancies are an issue. The King’s Fund points out that so much is to be carried forward by primary care networks, but they are still in their infancy.

On the positive side, the long-term plan is still being actioned and rolled out so there is scope for checks to ensure that quality is enhanced—not reduced. Allowing necessary adjustments during adoption is vital to embed appropriate changes over the next five to ten years. This period must also allow for time to focus on good, evidence-based best practices to govern the direction of future transformation.