House of Commons Health Select Committee 21 April 2016
- This report analyses the challenges facing primary care and examines the long-term solutions which can improve access to services and patient care.
- Conclusions and recommendations
- Utilising information technology
- Variable quality
- Improving the patient experience
- Multi-disciplinary teams
- The role of federations
- Guarding against conflicts of interest
- Workforce planning
- Selection of undergraduates
- Tackling local shortages
- Nursing
- Training and education
- Workforce and federations
- Regulation
- GP leadership
- Changing incentives in the system
- Investing in primary care
- Future funding
- Interaction with out-of-hours care
- We recommend that clinical commissioning groups, federations and networks be given the flexibility to develop local solutions for weekend access to meet the needs of those who cannot attend routine services between Monday and Friday.
- The role of federations
- Federations and networks should be formed with the primary purpose of improving care for patients. NHS England Local Area Teams, in conjunction with clinical commissioning groups, should directly support the development of new models of care envisioned by the Primary Care Workforce Commission.
- We recommend that clinical commissioning groups, federations and networks also involve patient-facing charities and community organisations to help them maintain a focus on quality and local priorities for improving care.
- Guarding against conflicts of interest
- We believe that continued vigilance is required at national and local level to guard against conflicts of interest influencing decisions taken by clinical commissioning groups in relation to general practice.
- Workforce and federations
- Allied with NHS England local area teams, Clinical Commissioning Groups should use their co-commissioning powers to oversee and guide the development of federations so that patient care is central to their ambitions.
- Changing incentives in the system
- As the vanguard projects begin to mature we expect NHS England to identify good practice and provide clinical commissioning groups with clear guidance on redesigning financial incentives to move care out of hospital, better coordinate care and, ultimately, reduce hospital admissions
Summary
Primary care is the bedrock of the National Health Service and the setting for ninety percent of all NHS patient contacts. It is highly valued by the public but is under unprecedented strain and struggling to keep pace with relentlessly rising demand. The traditional model of ten minute appointments with general practitioners no longer allows them to provide the best possible care for patients living with increasingly complex long term conditions.
The difficulty in accessing primary care is a serious concern for many patients, especially for those who work during the week. We believe that it is vital that patients have timely access to primary care services. This includes both access to urgent appointments and the ability to book routine appointments in advance.
During the course of this inquiry we heard many examples of innovative practice which give cause for optimism that patients’ access to and experience of primary care can be improved. The priority for government should be to train, develop and retain not only more GPs but wider multi-disciplinary teams working within a more integrated system of care. Patients would also benefit from the better use of technology to assist communication with and between their clinicians. There is a pressing need to improve continuity and safety through the use of electronic patient records which can be shared, with their consent, wherever people access their care.
In line with the recommendations of the Primary Care Workforce Commission, multidisciplinary teams can harness the skills not only of GPs but physiotherapists, practice nurses, pharmacists, mental health workers and physician associates. We support the Commission’s vision of teams of professionals using their skills to meet the needs of patients much earlier in their journey through the NHS. This would allow GPs to concentrate on those aspects of care that only they can provide. We expect GP leaders to be at the forefront of the development of multi-disciplinary teams.
Patients need more health professionals from a range of disciplines to choose careers in primary care. Existing medical education does not encourage graduates to do so and greater attention must be paid to the needs of patients in designing training pathways and incentives across the entire NHS workforce. It is far from certain that sufficient numbers of GPs and nurses will be available to build new teams and improve patient access. Much greater efforts to recruit, train and retain the primary care workforce will be necessary if the vision of the Primary Care Workforce Commission is to be achieved.
The government made a manifesto commitment to seven day access to services but further clarification is needed about how this commitment is to be implemented and resourced, especially in light of the workforce shortfall.
Improving access to primary care is a welcome goal, but practical application of the seven day policy should be locally designed, led by the evidence and take account of local recruitment challenges. The policy must also focus on the continuity of patient care and avoid reducing the capacity of weekday services as well as urgent out of hours primary care cover.
Although difficulty in accessing general practice continues to frustrate patients, GPs consistently receive highly positive patient satisfaction ratings. Healthwatch England pointed out that service users are reluctant to criticise their doctors and caution that the figures may mask deep-seated concerns about quality and standards.
We heard worrying evidence about the longstanding variation in quality across primary care. The Care Quality Commission has highlighted very poor standards of care among a small proportion of practices and has developed a mechanism to close those which put their patients at risk and follow up necessary improvements in others.
We welcome the benefits which CQC inspection has brought for patients and we urge the Royal College of General Practitioners and the British Medical Association to work constructively with the CQC to protect the public from failing practices and to help to turn around underperforming practices. At the same time, NHS England, the CQC, the General Medical Council and Local Education and Training Boards must work together to reduce bureaucracy and unnecessary duplication, so that time which should be devoted to patient care is not eroded by an excessive bureaucratic burden.
Despite the rising demand for services and a consensus on the value of primary care, its funding has fallen behind as a share of the overall NHS budget. The five year funding settlement provides only a very limited uplift in expenditure on primary care. We believe that it should receive a larger proportion of overall NHS spending in order to improve access and services for patients.
