The primary care sector is set for a major upheaval under new plans to improve patient access, according to ministerial briefing to the Times.
Details of funding and a timetable for the move are hazy, but it appears to revolve around a ‘vertical integration’ model which would see GPs widely employed directly by the NHS via hospital trusts – an idea already piloted in Birmingham, Cheshire and Wolverhampton – and effectively abandon the independent contractor model that has been in place since 1948.
A second element of the restructure – the establishment of a ‘national vaccination service’ to take over the administration of health campaigns such as the annual flu inoculation drive which GP practices are currently paid to manage, could further undermine the role (and finances) of existing local surgeries.
This new initiative from health secretary Sajid Javid follows on from his comments last autumn blaming overloaded and under-resourced A&Es on a perceived lack of GP appointments, which was embraced by various right-leaning media outlets and saw doctors being subjected to physical and verbal abuse from patients.
But despite the Times’ attempt to brand Javid’s plan as a form of nationalisation that will complement the government’s much-hyped ‘levelling up’ agenda, the report offered no evidence that the restructure will address the main issues facing the sector: declining GP numbers and the poor provision of general practice in deprived areas.
In terms of numbers, the government has a lamentable record of delivery on its pledges relating to general practice. The health secretary admitted in November that it would not be able to boost GP numbers by the promised figure of 6,000 by 2025, and only last month research by the Royal College of GPs showed that less than 10,000 of the 26,000 extra health professionals pledged three years ago by the government had actually been hired by surgeries.
And if Javid is at all serious about integrating primary care staff into the fabric of the NHS the government’s broader workforce planning record will provide scant comfort for those worried about the long-term impact of his plan, concerns that were amplified after recent parliamentary debates on the Health and Care Bill.
Ministers rejected an amendment to the Bill in November that would have required independent, and more regular, assessments of workforce requirements, while last month former NHS ceo Lord Stevens accused the government of “wilful blindness” on the matter during a debate in the House of Lords, adding, “It is a statement of the blindingly obvious, particularly coming out of the pandemic, to say that we need better workforce planning.”
However, the statistics also illustrate the pressures on the existing practice model that Javid is seeking to ease. Increasing numbers of newly trained doctors are happier to become salaried GPs working for others, instead of running what is in effect a small business – a situation which has in many cases led to the closure of practices when partners retire.
The past decade has seen the number of salaried GPs in England rise by 65 per cent, while the figures for independent GP contractors fell almost 30 per cent – and around 800 practices pulled down the shutters, with rural areas particularly badly affected.
More worryingly, the overall size of the GP workforce has fallen more than 5 per cent since 2015, but patient numbers have risen. As a result, the number of patients per GP has increased by more than 10 per cent in the past half-decade, a particular problem in more deprived areas that are underserved by primary care.
Less care in poorer areas
Last month also saw the publication of a Health Foundation analysis of government policies designed to improve general practice in deprived areas over the past 30 years. The thinktank took as its starting point the ‘inverse care law’, first defined by GP Julian Tudor Hart 50 years ago.
This law describes how people who most need healthcare are the least likely to receive it, and the Health Foundation concluded that the law persists in the NHS today, as GP practices in more deprived areas of England remain relatively underfunded, under-doctored, and perform less well on a range of quality indicators compared with practices in wealthier areas.
The Health Foundation’s analysis notes how tackling the inverse care law should align well with the current government’s ‘levelling up’ agenda, but highlights how efforts to tackle it under the Tories since 2010 have been more limited than the efforts of the previous Labour administration.
Similarly, its research on GP numbers from 2015 to 2020 suggests that inequities in their distribution have grown while the Tories have remained in power.
Tellingly, among the lessons drawn from its analysis, the Health Foundation makes no mention of vertical integration, or of GPs being directly employed by hospital trusts to help ‘level up’, but chooses instead to lead on the core issue of inadequate funding – an issue that isn’t mentioned in the Times report.
But if the vertical integration overhaul ever gets off the ground, will GPs actually welcome the opportunity to become NHS employees? The question certainly isn’t a new one – the online publication BMJ ran a ‘head to head’ debate on the subject six years ago, and the growing number of salaried GPs suggests the idea of being ‘independent’ isn’t that important to many medics. The BMA has, nevertheless, labelled Javid’s proposals “a kick in the teeth”.
And would the health secretary’s restructure actually work? The past five years has seen several hospitals – including the Royal Wolverhampton NHS Trust and Sandwell and West Birmingham Hospitals NHS Trust – taking over and apparently successfully running GP practices, and a study by the National Institute for Health Research in December 2020 found that these takeovers enabled practices at risk of closure to stay open, and that unplanned hospital admissions were sometimes reduced.
However, the study went on to advise that vertical integration was possibly only “a valuable option to consider when GP practices look likely to fail”, and should not therefore be imposed more widely in the primary care sector.
That qualified assessment may not be the best endorsement of vertical integration of primary and secondary care, but there may be other factors at play influencing the health secretary.
In 2020 the Royal Wolverhampton NHS Trust linked up with Babylon Health – famously popular with Javid’s predecessor Matt Hancock – to use the telehealth provider’s covid app and AI digital care assistant to help patients consult their GP. And then last August it followed that up with a five-year deal to make the Babylon 360 “digital-first healthcare experience” available to 55,000 patients across its nine GP practices operating in the city.
Scaling up the vertical integration already present in Wolverhampton across the rest of England – as Javid seems to be suggesting – may or may not benefit patients in the more deprived areas of the country. But such a move undoubtedly risks scaling up the role of commercial operators like Babylon in our public health service.
There is also the concern – as noted by one GP – that once practices are under the control of hospital trusts, private health providers offering both hospital and community care would eventually step in. The activities of US giant Centene, whose recent purchase of GP surgeries owned by AT Medics is currently the subject of a judicial review in the High Court, hints at how this might play out in the UK.
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