Laura Heath is a GP in Oxford and a Wellcome Doctoral Fellow at Oxford University. She is on Twitter: @laurahheath
Richard Armitage’s article, ‘Is the shift to urgent appointments in general practice what patients really want?’ describes the trade-off between acute, reactive, often remote care and long-term relational and preventative care.1 The article described how the availability of same-day appointment is one metric by which to measure quality of general practice and we have a responsibility to articulate the opportunity cost that providing this service may have on other aspects of care.
Are we clinical providers or clinical supervisors? Data sharers or data stewards? Secondary care helpers, or expert generalists?
Similarly, there are other ‘trade-offs’ that we should reflect on in modern primary care. Are we clinical providers or clinical supervisors? Data sharers or data stewards? Secondary care helpers, or expert generalists? Here too, if our voice is not heard the ‘trade off’ will be externally decided and unlikely to benefit patient care.
Clinical provider or clinical supervisor?
The Additional Roles Reimbursement Scheme (ARRS) was introduced in England in 2019 to support the recruitment of 26,000 additional staff into general practice.2 With these new roles come new challenges. What are the boundaries of clinical responsibility? Where is the capacity for supervision, education and training of these new healthcare professionals coming from? And importantly, do patients’ want this? Evidence is limited, but recent research suggested that having additional GPs was associated with greater levels of patient satisfaction, whereas the opposite was true for the addition of other healthcare professionals.3 Without more GPs or funding, GPs will have to reduce clinical time to offset the time required for supervision and debriefing of these new roles.
Data sharers or data stewards?
Primary care teams in the UK curate some of the worlds most detailed and information rich medical records going back decades. During the pandemic, information was accessed more quickly, with less confidentiality safeguards, under the Control of Patient Information Regulations 2002 to control the spread of disease.4 As we are co-creating these datasets with our patients, we have a role to inform our patients about what happens to their data. There is a trade-off between greater data for medical research and population health planning, and patient trust. A complicated legal framework exists, but as co-creators of these datasets, we must reflect on how increased access to the medical record may impact patient disclosure.
Hospital helpers or expert generalists?
With a finite amount of time and resource, any additional activity will result in a reduction elsewhere in the system.
To manage the increasing waiting lists, some trusts have expanded the use of Advice and Guidance services for primary care, with the aim to reduce ‘unnecessary’ referrals.5 Taking on work traditionally located in secondary care may help our hospital colleagues, but will reduce the time available for our core primary care work. Again, without more GPs or more funding, this is likely to shift patient wait times to primary care.
It is time to realistically reflect on the ‘trade-offs’ of the changes coming to primary care. Supervision of additional healthcare professionals comes with reduced GP clinical time. Greater access to primary care datasets may affect patient trust, and increased delegation of work from secondary care reduces our time as expert generalists. We need to articulate these trade-offs to policy makers. With a finite amount of time and resource, any additional activity will result in a reduction elsewhere in the system. Despite our best efforts, General Practice cannot do it all.
- Armitage R. Is the shift to urgent appointments in general practice what patients really want? The British journal of general practice : the journal of the Royal College of General Practitioners. 2022;72(716):122.
- NHS England. Network Contract Directed Enhanced Service: Additional Roles Reimbursement Scheme Guidance. https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-additional-roles-reimbursement-scheme-guidance/; 2019.
- Gibson J, Francetic I, Spooner S, Checkland K, Sutton M. Primary care workforce composition and population, professional, and system outcomes: a retrospective cross-sectional analysis. The British journal of general practice : the journal of the Royal College of General Practitioners. 2022;72(718):e307-e15.
- NHS Digital. Control of patient information (COPI) notice https://digital.nhs.uk/coronavirus/coronavirus-covid-19-response-information-governance-hub/control-of-patient-information-copi-notice#:~:text=the%20COPI%20notice-,The%20Secretary%20of%20State%20for%20Health%20and%20Social%20Care%20has,under%20COPI%20for%20COVID%2D192020[
- NHS England. Advice and Guidance https://www.england.nhs.uk/elective-care-transformation/best-practice-solutions/advice-and-guidance/