What are the challenges for GPs across England and London?
General practice in England is under significant strain. Many GPs and their teams struggling to meet the increasing pressures of decreasing resources and an increased burden of long-term lifestyle conditions.
They also lack time to reflect on how to provide and organise care for the future.
There are many factors that are contributing to the increased pressures on primary care provision. The combination of the global recession squeezing money from strained health systems and the explosion in prevalence of long-term conditions is a major factor. The exhibits overleaf illustrates some of the pressures currently affecting primary care.
The development of primary care networks in North West London is part of a wider adaptation taking place across England in primary care to meet the challenges illustrated above. For more information about the wider context for this shift, refer to the document published by the Nuffield Trust and the King’s Fund, Securing the future of general practice, which is included in Supporting Material J: Useful Articles
"If practices come together to share knowledge and resource, patients will benefit and it should help my GP with the huge number of demands on their time. It’s important that GP practices work together to ensure that services in my area are consistent, both in terms of the quality of care I receive and the range of services that I can access. "
Lay partner in North West London
What are the challenges in North West London?
The context of health- and social-care in North West London is to the rest of the UK. We have significant financial, system transformation and workforce challenges that require fundamental change across the entire system. The response to these challenges has involved a strong focus on integrated care. There has been recent success as North West London became one of the 14 National Pioneer pilots selected by the Department for Health to develop more integrated ways of working to share across England.
The list below enumerates the specific challenges that face primary care in North West London that the module working group were most pressing:
- Quality of care was lagging behind national indicators in some areas, with clinicians describing care as ‘reactive and uncoordinated’.
- Service user satisfaction was variable.
- Commissioners in North West London are facing a combined £1bn funding gap in 2014/15, at the same time as healthcare demand is increasing by 4% a year.
- A siloed approach to the provision of complex services and the differential entitlement to receiving them – free at the point of delivery for health and means tested social-care – had created perverse and costly incentives for providers, increasing the need for an integrated approach.
- Siloed working also meant that there was limited awareness of all services that were provided, and poor professional working relationships across sectors, organisations and professions. The ICP model should serve as a platform for bringing all these professionals together to achieve a shared outcome.
- North West London had poorly aligned organisational boundaries preventing coordinated decisionmaking, and creating slow and incomplete information exchange between providers
- Projected workforce capacity problems e.g., some 50% of GP’s in North West London are in their 50’s and will retire in the next ten years
The future of primary care
This analysis suggests that GPs and their teams are caught on a treadmill of trying to meet presenting demand whilst lacking time to reflect on how they provide and organise care. In addition workforce trends suggest that the gap between supply and demand is likely to worsen. Working in new ways such as in larger primary care Networks which are better integrated with other parts of health- and social-care provision and with a different use of professional skill sets is likely to be the way forward. Considering the compelling case for change presented above, the future of primary care in North West London will need to look very different from the landscape that exists today. The list below shows the fundamental changes that will need to happen for primary care to meet the challenges that it currently faces.
- Changes in skill-mix- The growing range and complexity of health needs that are seen and can be managed in the community means that GPs must be supported by a wider range of health (and social) care professionals.
- Partnership with people who use services- Evidence suggests that more time is required for professionals to work with people who use services, especially in multi-ethnic settings, to develop trust and to build in shared decision making that supports people to self-care. Indeed, improving continuity of care within general practice has been argued to be more important in determining outcomes than establishing more intricate systems of integrated care delivery
- Sharing care with hospital and community services- For people with multi-morbidity, frail older people and those at the end-of-life, general practice has a pivotal role to play in co-ordinating care across care providers and settings, and helping patients, users and their carers to navigate the health- and social-care system
- Meeting the health needs of the wider population- The development of health and well-being boards provides an opportunity for GPs and their CCGs in London, jointly with local authorities, to engage more proactively in this agenda and seek new and innovative ways to prevent ill-health and tackle long-term and persistent inequalities. This is likely to require the development of new integrated care partnerships that seek to make specific joint commitments to improving the health of local communities
‘We all have different reasons for choosing a career in General Practice but for most of us, one of the attractions was the variety of opportunities working in primary care provides.Networks of primary care build on these opportunities, helping practices to expand the range of services they offer their population and the options they can provide for their staff in skills development and escalation.”
GP in North West London
The foundations of general practice in the future will be very different. The list below lays out the four major tenets that will need to underpin a future system of primary care in North West London.
- Effective networks of practices- the principle of shared accountability for patient care rooted in and around primary care practices that act as the hub around which the wider system operates will deliver better outcomes for people in need of care co-ordination
- Remodelling the primary care estate- Given the future demands that will be placed on primary, care, it is becoming harder for general practices to deliver high-quality care from premises that are not fit for purpose and from small buildings
- Better and smarter use of information and IT - Exploiting the potential of IT to support care – e.g., through linkage of care records across providers, identifying high-risk people with complex conditions to manage more actively and allowing individual access to records so that they can better self manage their health
- Training and development of the workforce- to ensure that GPs, nurses and other community based staff gain the experience necessary to deal with greater complexity confidently, and to work together effectively in teams. New and extended roles will need to be created for clinicians, practice managers and other support staff. Clinical leadership will be vital in making the case for change and actively modelling the values and behaviours to deliver it.