The focus of government reforms to the NHS in England must focus on how primary care services provision should be developed, rather than putting so much emphasis on its new role in commissioning, experts say.
Too little attention has been paid to how primary care will be provided in future, despite a significant problem brewing with the old "corner shop" model of general practice, according to a new report from health policy think-tank the Nuffield Trust. Its report goes on to say that this model no longer works economically for many GPs, who are struggling to meet demand and often lack the resources and organisational capacity to take on work shifted out of hospitals.
It adds, however, there is much for the new clinical commissioning groups (CCGs) and primary care providers to learn from the 20 years' experience in New Zealand, where GPs have joined forces to form strong provider organisations that are now well-placed to deliver more integrated care.
These independent practitioner organisations (IPAs) have been formed to counter-balance the government and other funders during contract negotiations, and to take collective action to improve specific areas of local healthcare, such as out-of-hours cover, prescribing, professional development for general practice and the management of chronic disease.
Their experience shows there is much value to be gained from enabling strong provider organisations rooted in general practice, says the report. For example: the IPAs have been successful in scrutinising collectively the quality of care provision, developing a wider range of practice and community services, providing infrastructure support for general practice and wider integrated care development, and encouraging peer review, it says, and identifies several lessons from the New Zealand experience that can help inform the next steps for primary care development in England.
Learning from New Zealand
First, it says, new provider networks or federations across general practice may be necessary to secure the enthusiastic engagement of a majority of GPs, which is crucial to the development of new community-based services.
Networks of GPs could choose to take the form of autonomous or private organisations which resemble more closely personal medical services (PMS), provider organisations or New Zealand-style IPAs. Such groups would literally be owned by local GPs and, not being statutory NHS bodies, they could not be swept away in any potential future NHS reorganisations. General practice networks could take informal service delivery contracts led by CCGs or the NHS Commissioning Board, within a robust framework of public commissioning and accountability, the report suggests.
Second, autonomy and independence is critical for GPs. NHS policymakers need to take account not only of the requirement for strong public accountability for devolving budgets and decisions to clinicians, but also of the importance to grassroots GPs of feeling that they can 'own' influence and benefit from any organisation to which they belong.
A possible way of enabling CCGs to co-exist with local GP provider organisations may lie in the community ownership idea that has been adopted by some New Zealand primary health organisations and IPAs - private (in the sense of non-state-owned) not-for-profit bodies, with a high degree of community and professional involvement at the governance level.
Third, the study points out, the need for strong GP engagement can initially be an obstacle to a more inclusive population health approach. The New Zealand experience suggests that, on their own, GP-led groups will struggle to bridge the divide between general practice and public health, and they will require significant time, management support and organisational development as they move through general practice priorities to focus on broader concerns such as illness prevention, proactive management of chronic disease and attention to the wider determinants of health, it says.