06 Jan What will 2018 bring for general practice?
It is customary at this time of year to speculate about what the coming 12 months may bring, so how might key issues and developments impact on general practice?
The here and now is, of course, very challenging indeed. GP surgeries are full and everyone works long hours, as the pressure bears down on general practice and other parts of the health and care system. The additional government funding was announced too late to have much impact, and the pre-emptive cessation of hospital elective work is unlikely to help much, and may in fact create more work for surgeries – as cancelled patients seek advice and support
Stepping back a little, the current pressures are a seasonal exacerbation of an already challenging working environment. Recruitment difficulties and workforce shortages remain dire, with no evidence yet that the (commendable) initiatives such as Career Plus are moving the needle, and the (real or not) additional 5000 doctors are some way away. Earnings for partners are falling, practices are closing, and many feel the era of independent contractors in general practice might be coming to an end as GPs opt for locum work, portfolio careers, or early retirement.
There is no shortage of national initiatives, although it is not always clear whether they are aimed at supporting general practice in its current form, or transforming the system and general practice along with it? Those emanating from the GP Forward View, such as the 10 High Impact Actions, are sensible but hardly transformative. Those aimed at implementing the Five Year Forward View (FYFV) are aimed at whole system transformation, without spelling out in detail what role the local GP surgery will play in the new system.
The STP (Strategic Transformation Partnership) process, and the ACOs (Accountable Care Organisations) that are developing from it, offer a future that many in healthcare accept as the best way forward – population-based healthcare, focussed on wellbeing and health maintenance, with a single budget and blurred organisational boundaries that aim to align the many elements of service delivery around patient need. The local GP and their team must be an integral part of this approach, but there is still much to be debated and agreed on how this should be brought about.
This may be because the whole process is occurring ‘under the radar’, without legislative reform and parliamentary and public debate that should run alongside it, and consequent lack of accountability. The confusion and apprehension around the change is increased further by the obvious discrepancy between the level of activity the NHS is required to provide, the degree of transformation planned to happen, and the funding being made available.
As Richard Vize of the Guardian cogently observes, this is leading to misunderstanding and mistrust, which is unfortunate when most informed commentators feel the direction of travel is the right one. Indeed, the current lawsuit against ACO development is based largely on the view that it may lead to a privatised service, which is a separate issue and not exclusively linked to ACO creation.
Perhaps then, the greatest challenge of all is the lack of a coherent vision of the future? If NHS staff and the public are experiencing a combination of a struggling service today and uncertainty about tomorrow, it is not surprising that morale and confidence is so low?
What is the outlook for general practice in this scenario? I see some positives, which should not be overlooked in the general pessimism of the moment. Firstly, patients still trust their GP above all else, and GPs and their teams still handle the vast majority of patient consultations with the NHS. The per capita cost of this care is remarkably low, so it is hard to imagine how the service would cope if general practice were not functioning. Secondly, there is abundant evidence that GPs themselves are mobilising, planning and implementing new ways of practicing, which preserve what is special for both doctors and patients. Ben Gowland summarises reasons to be optimistic in his recent blog and we have published many positive pieces on this website.
The lack of detailed plans for the service as a whole could be seen as an opportunity for general practice? GPs are naturally innovative and quick to adapt, and well suited to filling the vacuum that currently exists. Most innovation is local, and not nationally directed, so the time is right for GPs to demonstrate their ability to create solutions. Here is some original thinking, with a festive flavour, by Gavin Ralston, a GP in Birmingham.
Finally, it is evident from articles we have published here that GPs of all ages retain the strong commitment and sense of vocation that drew them into general practice in the first place. If this is combined with a willingness to come together in groups to solve problems and work in new ways, as many are demonstrating, then they will gain long overdue influence over how the NHS transforms, and how general practice develops, in the coming years.
Please share your predictions and wishes for General Practice in 2018, in comments below and on Twitter with a hashtag #GPin2018.
Happy New Year!