The current focus on financial crises in hospitals diverts attention from the crisis in general practice, argue Professor Martin Roland from the University of Cambridge and GP Sir Sam Everington in an editorial published in The BMJ today.

Hospitals’ £2bn deficit “certainly sounds dramatic”, they argue, “but hospitals don’t go bust – someone usually picks up the bill.” General practice doesn’t have that luxury, and its share of the NHS budget has fallen from 11% in 2006 to under 8.5% now.

Recent research shows that GPs are experiencing unprecedented levels of stress with increasing workload and overwhelming bureaucracy. A GP’s comment at a recent national conference encapsulates the sense of despair: “The pressure of work leaves me in constant fear of making mistakes”.

GPs are finding it harder to recruit trainees and to find partners to replace those increasingly retiring in their 50s.

Politicians and NHS leaders want more care to be moved into primary care, yet the share of funding devoted to general practice is falling as a high proportion of the NHS budget is channelled into hospitals, and in the past 10 years, the number of hospital consultants has increased at twice the rate of GPs.

GPs currently manage the great majority of patients without referral or admission to hospital but if this balance shifted only slightly, hospitals would be overwhelmed.

“It is general practice that makes the NHS one of the world’s most cost effective health services,” they say. The £136 cost per patient per year for unlimited general practice care is less than the cost of a single visit to a hospital outpatient department.

The authors, who are both internationally renowned experts in general practice, present a number of solutions. They say GPs need a “substantial injection of new funding” to provide more staff in primary care.

In addition, new roles are needed to take the “strain off” clinical staff, for example, physician associates, pharmacists, and advanced practice nurses. They also argue that reviews of practices’ contracts that threaten serious financial destabilisation should be put on hold while a fair funding formula is developed to replace the 25 year old ‘Carr-Hill’ formula.

NHS England should tackle spiralling indemnity costs by providing Crown Indemnity similar to that for hospital doctors, as GPs increasingly do work previously done by specialists.

Bureaucracy should be slashed, in part by changing the £224m Care Quality Commission inspection regime to one where only the 5-10% of practices found to be struggling are revisited within five years.

In hospitals, the ‘Choose and Book’ referral system needs radical reform – the authors estimate that communicating by phone, email, and online video link could reduce outpatient attendance by as much as 50% in some specialties. And the ‘Payment by Results’ system for funding hospitals must become a population based, capitated budget that incentivises hospitals to support patients and clinicians in the community.

The authors identify two ‘elephants in the room’ that can no longer be ignored. First, cuts to social care make it increasingly difficult for hospitals to discharge patients.

Second, the UK’s funding for healthcare has fallen well behind its European neighbours – now thirteenth out of 15 in healthcare expenditure as a percentage of gross domestic product. In 2000, Tony Blair promised to raise NHS spending to mid-European levels. Today, this would require another £22bn a year.

“Urgent action is needed to restore the NHS,” warn the authors. “But the crisis will not be averted by focusing on hospitals. If general practice fails, the whole NHS fails.”

Professor Martin Roland, Professor of Health Services Research at the University of Cambridge, adds: “GPs need to feel valued rather than continually criticised by politicians and regulators. Many other countries see primary care as the jewel in the crown of the NHS, yet many practices are at breaking point, with an increasing number simply handing in their contracts and closing.”

Sir Sam Everington, Tower Hamlets GP and chair of Tower Hamlets CCG, says: “Patients really value the support of their family doctor, particularly in crises like end of life care. Moving care into the community means supporting patients to die at home surrounded by their loved ones – this is one of many reasons why family medicine is critical to the NHS.

“Family medicine and new developments like social prescribing show the strengths of general practice in supporting vulnerable patients in all aspects of their physical and mental well-being.”

Martin Roland and Sam Everington. Tackling the crisis in general practice. The BMJ. 18 Feb 2016.

Adapted from a press release by The BMJ.

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