Professor David Colin-Thome
Is List-Based General Practice Under Threat?
In this blog, I address a topic very dear to my heart. I was a GP at The Castlefields Practice, Runcorn, for 36 years- my choice to work in a socially deprived area with the added piquancy of a predominantly Scouse patient population who had moved from Liverpool for New Town opportunities. I loved it and would happily repeat the experience if I were young again.
The NHS Plan’s commitment to the individual GP practice is unclear to many readers, raising the question: is the current model worth preserving? Whenever NHS reform is proposed, such questions resurface – now with more urgency due to:
- A significant dip in public satisfaction
- Increased workload beyond pre-COVID levels
- Recruitment challenges
- Relative funding reductions within the NHS
Endorsements of Traditional General Practice
The present practice-based service has my unwavering support, matched by service and academic luminaries:
USA based academics extolling the virtues of UK general practice:
“soul of a proper, community orientated, health-preserving care system”
Donald Berwick, former Administrator of the Centers for Medicare and Medicaid Services (CMS)
“That aspect of a health service that assures person focussed care over time to a defined population……coordination of care such that all facets of care (wherever received) are integrated”
Prof Barbara Starfield (Primary care: Balancing health needs, services, and Technology, 1998)
From the UK:
“general practice is the beating heart of the NHS and when it fails the NHS fails. There is clear international and UK research showing that seeing the same GP over a long period of time leads to fewer hospital visits, lower mortality and less cost for the NHS.There can sometimes be a trade-off between access and continuity, and we believe that the balance has shifted too far towards access at the expense of continuity. Seeing your GP should not be like phoning a call centre or booking an Uber driver who you will never see again: relationship-based care is essential for patient safety and patient experience. It is also much more motivating for doctors.”
House of Commons Health and Social Care Committee (The future of general practice, 2022)
And from the public:
“A major new research project has found that the public wants the government to focus more on improving primary and community care than hospitals and is willing to pay more taxes to improve NHS services”
The Health Foundation (Public want government to prioritise primary care over hospitals, 2024)
From the Plan:
“However, truly revitalised general practice will depend on more fundamental reform. Having served us well for decades, the status quo of small, independent practices is struggling to deal with 21st century levels of population ageing and rising need. Without economies of scale, many dedicated GPs are finding it difficult to cope with rising workloads. Far too often, that means work is causing chronic stress and mental illness among hardworking professionals. Many GPs are voting with their feet: 74% of fully qualified GPs were partners in 2015, compared to just 55% today. Where the traditional GP partnership model is working well it should continue, but we will also create an alternative for GPs. We will encourage GPs to work over larger geographies by leading new neighbourhood providers.”
Department of Health and Social Care (10 Year Health Plan for England: fit for the future, 2025)
While the description of current challenges is accurate, the wording- intended or not- suggests the potential demise of individual practices, which concerns many GPs.
The Value of Independent Practices
To retain list-based general practice is fundamental to my vision. At Castlefields, we aimed to:
- Extend primary care provision
- Reshape aspects of hospital-based care
- Take population responsibility for registered patients
Only the autonomy of being an independent contractor made this possible. Despite originating the Primary Care Home concept, we received only patchy support from the local NHS.
Nationalising general practice risks damaging its heritage and key hallmarks:
- Localism: Being part of local social capital
- Anchor organisations: Especially vital in “left behind” communities
For many ‘left behind’ communities, the larger NHS organisations as with many others have become distant and unreachable. These deprived communities are at the heart of current policy, informed by the work of The Independent Commission on Neighbourhoods. It’s not GPs alone who are key to local health, but the practice as an organisation providing local access to other care professionals. A home!
“Evidence shows that primary care helps prevent illness and death.”
Prof Barbara Starfield (Milbank Q, 2005)
The distinguishing unique feature of UK general practice is its population responsibility- the only provider in the NHS with such responsibility.
“The partnership model of general practice delivers exceptional benefits for the NHS. It allows GP teams to innovate and tailor care and services to their local patient populations. It is extremely good value for money for the NHS because it relies on the goodwill of GP partners going above and beyond.”
Prof Kamila Hawthorne, Chair of the Royal College of GPs
We have to reinforce the importance of offering personal continuity of care to a local population. Not an impersonal service at a distance. If that was on offer in the past, many of us would not have become GPs.
Embracing Adaptive Leadership
To address current challenges, general practice- and the NHS- must move beyond binary thinking. Adaptive leadership is urgently and universally required. Concomitantly, for general practice, being little and local yet large and strategically influential. The local practice must be maintained with clinical and service accountable autonomy, but may be best served as part of a larger organisation as is increasingly and successfully the case. I trust this is what the Plan aspires to.
I will only briefly address future general practice contracts as there is much to unpick from the two contract models of the Plan.
- What will be the relationship with the GMS contract?
- Will innovators be rewarded through locally mediated contracts- reviving the PMS model?
- Will the proposed Integrated Health Organisation (IHO) be fully budgeted, incentivising all providers to deliver optimal quality and cost-effectiveness?
These are questions my group is currently exploring, so I may have more to share in due course.
This is the final blog in a three-part series. If you haven’t yet, read the earlier posts to follow David’s full journey.
