General Practice is under severe and mounting pressure. There is a rising demand for appointments, with a 15% increase in the number of consultations evident from 2010 – 2015, coupled with a growing dissatisfaction from the public over the difficulty in accessing GP appointments. There is an ageing and increasingly diverse population, with more complex (and often multiple) conditions. There have been significant cuts to social care budgets, which has increased GP case loads. And there is an ongoing workforce recruitment and retention problem, with vacancies having risen by 10.5% in the last year.
Against this backdrop, there is an ever increasing expectation from the public around the care they receive, including a desire for personalised care which is increasingly tailored for their needs. For example:
- Healthy adults (often referred to as the ‘working well’) may want quick and convenient access to a GP at a time that fits around their working day, and may also be happier to access services online;
- Patients with long term conditions, disabilities or complex health needs often need more specialist care and frequent appointments. They may be willing to wait longer to see their GP and often require a multi-disciplinary team approach to care;
- The elderly may want to see the same Primary Care clinician each time and be most concerned with continuity of care. They are more likely to have multiple health conditions;
- Parents of young children are often more frequent users and likely to end up using A&E due to the perceived urgency of their needs, which are not always met in a timely fashion by Primary Care providers.
The challenge of not servicing these patients in a tailored way can create several issues. Decreased patient satisfaction may result from patients having to navigate their own way across multiple providers and care settings. This can also lead to care and advice being provided in an unsuitable and less cost effective setting.
One of the reasons for this is that the current systems and structures make it difficult to meet patient expectations, with care often designed around supply and not around patient need. Segmenting patients by their different needs, and designing services that are tailored to those needs could be a way to better meet expectations. This is likely to allow GPs to be more flexible with their time to allow them to focus on those patients that most need their support. This is not easy in the current framework, which applies a one size fits all model in General Practice :
- The standard ten minute slot for GP appointments and associated funding mechanisms and incentive structures, leads to practices having to balance more time consuming patients with those that are more routine. This prevents GPs from being able to specialise or develop tailored models for any one group.
- The funding allocation (on average c.£100 to £150 per head) with registration at one practice requiring a deregistration at another, discourages patient choice by ‘punishing’ patients for moving to try tailored, more focused service models.
- Data is not joined-up across practices, making it harder to bring together information about patients that enables a fuller understanding of their needs.
All of this contributes to a model in which different patient needs are treated in the same way – irrespective of need – until they reach specialist or secondary care.
What could the future hold?
A new mindset is needed that identifies these different needs earlier and builds the insight and understanding to serve them. Many of the solutions being developed in General Practice are starting to encourage this mindset, however it cannot be done in isolation. To achieve a truly needs-based segmentation in the NHS, national and local solutions need to work together to drive a consistent move away from supply-led care, towards needs-led care.
This would include:
- A new local model of practices working together to serve their populations through:
- Working at scale, to:
- Build financial resilience to navigate funding disincentives;
- Have a large enough patient pool to manage the ten minute appointment average;
- Build deeper local patient knowledge and insight to enable local segmentation.
- Using their wider workforce to support segmentation of the population, including using multi-disciplinary teams (nurses, physician associates, clinical pharmacists etc) to direct patients to the most appropriate professional.
- Managing care across practice boundaries and work with neighbouring practices or federations to manage care. For example, access hubs could see the more ‘straightforward’ patients, whilst the local practice sees the more complex. Or practices in a group could specialise in particular areas of care such as mental health or diabetes.
- Harnessing the potential of digital technologies as both a source of data and as a tool for managing and servicing patients:
- For example, Skype consultations with your GP or booking repeat prescriptions online;
- As a tool for self-care / prevention, such as NHS Choices.
- A new national commissioning and regulatory framework that acknowledges and removes the constraints of the current funding model and appointment slots. This will give CCGs the flexibility to develop appropriate solutions for the needs of their populations.
In short, patients’ needs are not all the same, and could be better treated if they were segmented with different service models for each segment. This could lead to:
- Reduced unnecessary A&E attendances – by accepting that there could be a different way to treat the ‘working well’ to the ‘frail elderly’;
- Improved patient experience, by providing a more tailored service;
- Reduced readmissions and cost of care for the most complex patients, by freeing up GP time to focus on them;
The move to an ACS (Accountable Care System) model within STPs is a positive step in this path, seeking to align funding to pathways rather than individual elements of service. For this to truly work, it needs to be genuinely supported by capable at-scale GP practices with the freedom and resilience to serve their patients in targeted and tailored ways. If this is achieved, then it will go some way to fixing the fragmented and strained General Practice landscape, in which patients fail to receive the value of care they want and need.
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