As Martin Roland explained in an editorial in The BMJ a few months ago, general practice is facing substantial challenges. Contributing factors include problems recruiting, rising workload, increasing stress, and doctors retiring early. Recent proposals put forward by NHS England on primary care as part of its General Practice Forward View have been positively received, with a series of funding commitments and reforms geared toward galvanising primary care.
This includes a commitment to increase general practice funding to over 10% of the NHS budget by 2020 (an extra £2.4 billion a year) and provide an additional 5000 GPs by 2020. However, the NHS Five Year Forward View envisages significant amounts of care traditionally provided in hospital settings moving into the community.
In light of this, a review by RAND Europe and the University of Cambridge, as part of its Cambridge Centre for Health Services Research collaboration, is particularly relevant. The review explored how and where hospital services can be moved into primary care settings, such as GP practices or other community settings.
The study considered five key areas:
• Transfer: The substitution of services delivered by specialists for services delivered by primary care clinicians.
• Relocation: Shifting the venue of specialist care from hospitals to primary care settings.
• Liaison: Joint working between specialists and primary care clinicians to provide care to individual patients.
• Professional behaviour change: Changing the way GPs refer patients to specialists.
• Patient behaviour change: Helping patients make informed decisions about their care.
From these five areas, a range of new approaches were identified that could make better use of conventional outpatient clinics and have the potential to provide high quality care in primary care settings. Some of the most effective approaches were strategies supporting improved communication between GPs and specialists—for example, by facilitating requests for specialist advice by phone or email, or through the use of “store and forward” telemedicine.
Other approaches, which could reduce patients’ use of hospital services, include: carrying out minor surgery in primary care, having GPs with a specialist interest provide additional services to patients, and allowing GPs to have direct access to a wider range of diagnostic tests and investigations.
With these new approaches there is a risk of increasing GP workload and potentially also increasing the demand for specialist care; however, the report cites examples of improvements to patient satisfaction following moves to deliver more services in primary care. For patients, the increased flexibility of being able to visit their local practice rather than their hospital may improve their experience of care. There is also the potential of shorter waiting times resulting from additional services being delivered in community settings.
The one consistent problem highlighted in the study is the cost-effectiveness of moving care into the community, which remains unclear in many cases. Many of the services described provide benefits, but the key question remains, are these benefits enough to justify additional costs?
Ultimately, paying consultants to visit primary care community settings and training GPs to provide additional services costs money, and this may only be justified if it improves care or results in cost savings elsewhere, such as through reducing the need for hospital outpatient services. As the new models of care described in the NHS Five Year Forward View are rolled out, it will be important to look at the costs, as well as the benefits, of changes in the delivery of care.
Despite the need for further economic considerations, the study did show that high quality care in the community can be provided and is popular with patients. Ultimately, shifting healthcare from hospitals to the community will only be justified if patient satisfaction and convenience is valued above costs to the NHS, or if this shift reduces healthcare costs in the long term.
Céline Miani is a senior analyst at RAND Europe. Eleanor Winpenny is a career development fellow at MRC Epidemiology Unit & Centre for Diet and Activity Research (CEDAR) at the University of Cambridge. Both were involved in the “Outpatient services and primary care: scoping review, sub-studies, and international comparisons” study from the Cambridge Centre for Health Services Research.
Funding acknowledgement: This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number 12/135/02).
Department of Health disclaimer: The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR HS & DR, NIHR, NHS, or the Department of Health.