The Nature of Primary Care

Strong and effective primary care is typically considered to be critical to a high-performing health care system because of its role in improving outcomes and containing costs. Recent research has concluded that strong primary care is associated with lower rates of avoidable admissions to hospital and fewer potential years of life lost for most of the conditions that were studied; yet Primary Care requires higher levels of health spending to achieve such benefits, with likely savings accruing in the longer term. Primary care comprises of those services that lie between self-care and hospital/specialist care and fulfil a range of functions including:

• Prevention and screening

• Assessment of undifferentiated symptoms

• Diagnosis

• Triage and onward referral

• Care coordination for people with complex problems

• Treatment of episodic illness

• Provision of palliative care
  

This intermediate territory between self-care and specialist/hospital care is changing, with primary care playing an increasing part in coordination of care provided by different services including community care. Furthermore, developments in technology have created opportunities for changes to the location and mode of care. Electronic prescribing and dispensing are set to change the way in which pharmacists work with patients and general practice. Expanding the functions of existing Patient Administration Systems (PASs) eg EMIS Web and the intranet are leading to a significant reappraisal of where a person’s first contact with health advice and support takes place.


Drivers of Change

Primary care in England is under pressure as a result of multiple drivers of demand. There is evidence that demand for Primary Care has been rising significantly over time, with the number of general practice consultations having risen by 75% between 1995 and 2009, resulting in an increased clinical workload of over 40% when compared to 1998. 
A substantial proportion of this additional workload is the result of an ageing population and a significant rise in the number of consultations for patients over 60 years old. 


Disease Trends

The prevalence of long-term conditions continues to rise due to an ageing population and better diagnosis and case finding.  Thus the need for better coordinated care for people living with complex co-morbidities becomes more pressing. People with at least one long-term condition account for 50% of all general practice appointments and by 2025 the number of these patients is due to rise from 15 million to 18 million. The number of patients with multi-morbidity (having more than one long-term condition) is also increasing.


The Desire for Integrated Care

Research suggests that poor communication between primary care, hospitals and medical specialists can result in fragmentation of care, low-quality patient experience and sub-optimal clinical outcomes. 

The role of primary care in providing improved coordination of care is a subject of significant debate in the UK and elsewhere, for primary care often struggles to influence care beyond its own immediate remit. The Francis Inquiry into events in Mid Staffordshire NHS Foundation Trust vividly demonstrated the need for better coordinated and joined-up care.


The Primary Care Workforce

Against the increasing complexity of patients presenting to general practice care, is the additional problem of an overstretched workforce.

A combination of falling numbers of new GP entrants and returnees, a rise in the number of leavers and the projected retirement bulge in the next few years and a higher proportion of the workforce working part-time means that general practice is facing a workforce crisis.

In response to this compendium of evidence the Government recently announced a £10m new package - the ‘Golden Hello’ designed to: 1) boost the number of GPs joining the profession, 2) deter early retirement and 3) encourage those who have taken a career break, to re-join the workforce. 


Funding

The increasing complexity of health care and growing fiscal constraints are placing new demands on GPs.  Expenditure on primary care has lagged behind that for secondary care. Although the amount spent on primary care increased in the period 2003/2004 to 2011/2012, expenditure on primary care as a proportion of overall NHS spending reduced from 26% to 24% and spending on GP services has been static since 2005. While 24% of NHS spending went on primary care, secondary care received 53%.

As part of the 2013-14 contract imposition, the Government in England planned far-reaching changes to practice funding. From 1st April 2014, the wide variation in core funding per patient between practices will begin to reduce. This undoubtedly will have a profound effect on individual practice income.

Practices with above average levels of funding generally receive either large correction factor payments (as a result of the Minimum Practice Income Guarantee (MPIG) negotiated at the time of the new general medical services (GMS) contract) or above average personal medical services (PMS) funding.  A breakdown of how this is affecting South Worcestershire practices is shown in Appendix 1.

From 1st April 2014, practices in receipt of correction factor payments will lose one seventh of their 2014 correction factor funding each year for 7 years. The aim is for all GMS practices to receive the same weighted price per patient by 2020-2021. The correction factor funding will be recycled into global sum payments.

PMS practices locally were invited to revert to a GMS contract providing a 5 year period in which the PMS premium would be phased out. The new GMS contract will take effect from 1 April 2015.
Strategic and Contractual Context

In late October 2014, the national leadership of the NHS published a Five Year Forward View. This document makes clear that a new deal must be created for primary care to secure a sustainable future for the NHS and that co-commissioning of primary care should be established in one form or another across England. National policy appears to have shifted from a position of possibility to a place of certainty.

Changes to the GMS Contract

As well as major changes to practice funding in April 2014, important changes were made to the GMS Contract. GP practices are now contractually required to:

• Provide more proactive care for people with complex health needs, empower patients and the public, give parity of esteem to physical and mental health

• Named, accountable GP for people aged 75 and over who will have overall responsibility for their care

• Promote more consistency high standards of quality and reduce inequalities

• More personal care for older people and those with complex health needs

• Out of hours services becomes a contractual duty for GPs to monitor and report on the quality of out of hours services and support more integrated care, eg through record sharing whilst aiming to reduce unplanned admissions through unplanned admissions through and enhanced service scheme