The shift of activity from secondary to primary care is starting to pick up pace.  Does this represent a threat or an opportunity for general practice?

This government has been clear that it wants to see a shift of activity from hospitals to the community, listing this as one of the three big shifts it is seeking to achieve.  These are intended to form the foundation of the forthcoming 10 year plan for the NHS, but there are early indications of what is to come in the recent Reforming Elective Care for Patients document (which we discussed in a recent podcast here).

This contains the ambition for the number of advice and guidance requests to be increased from 2.4M to 4M, along with more patient initiated follow ups, greater use of the NHS App, and GPs to support patients activating choice of treatment provider.

All of these have workload implications for general practice.  Funding has only been identified for the advice and guidance requests (although even then the £20 per request feels inadequate given the amount of work each request entails), but we await details of the 25/26 GP contract.

It is not just elective care.  A similar plan for reforming urgent and emergency care is due out (a draft has already been leaked to the HSJ), and it is hard to see a scenario in which this does not have further workload implications for general practice.

More is likely to follow once the full 10 year plan is released.

Practices, however, are operating at full capacity.  There is not the workforce or space within practices to cope with the existing work, let alone take on more.  Practices are already undertaking collective action in protest at the underfunding and underinvestment in the service in recent years.  One of the things that has irked the service most has been the unfunded shift of work from hospitals to practices.

The threat that this poses to the existing model of general practice is real.  The government is not going to suddenly reverse its push to shift care from hospitals to the community, and practices cannot magic capacity out of thin air.  Something is going to have to give.

General practice could respond to this threat by scaling up collective action to attempt to make the government reverse its plans to increase the workload on general practice in this way.

But given the government has already announced its intention to invest in general practice beyond the levels it will invest into other sectors, it is hard to see a scenario where choosing to do this ends well for the service.  The government has been insistent on the need for reform to go alongside on additional investment, and clearly has question marks about the current model of general practice.

Instead, are there any opportunities that potentially lie within the shift from secondary to community care for general practice?

The most obvious opportunity lies in the funding.  Even with any uplift that is given, the core GP contract is never going to be funded sufficiently again.  All new money now comes with additional expectations, which means general practice is highly unlikely to ever be able to really thrive again if it is relying solely on this contract.

But funding for the shift of secondary care activity is new.  If general practice can find a way of both working this at a profit and of scaling it sufficiently then it does hold out the promise of a secure new future.

The question, of course, is how can it do this?

Each practice can’t do this on its own.  There is not the physical or workforce capacity.  But by working together or at scale, by accessing the resources that come via the PCN, and by developing an infrastructure beyond that which exists within practices and most PCNs, then the capacity can be put in place.

Historically federations and even PCNs have operated too independently from practices for this type of model to be effective in securing individual practice sustainability.  But if practices can develop a model whereby the at-scale work is a core component of the practice business model, and at the same time the at-scale work can develop to make the most of the coming shift of activity, then there is a scenario where general practice can once again thrive.

The shift of activity from hospitals to the community could end up being the final nail in the coffin for the existing model of general practice.  If the elective reform plan is anything to go by then this could come sooner rather than later.  This threat is real.  But it may also be an opportunity for a brighter future for an evolved model of general practice, where a proper support infrastructure enables practices to make the most of this shift in activity.