Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan
“If you want to shake things up, you start with something small. You break a norm or an idea or a convention, some little business model, but you go with things that people are kind of tired of anyway. Everybody gets excited because you’re busting up something that everyone wanted broken in the first place. That’s the infraction point. That’s the place where you have to look within yourself, and ask: Am I the kind of person who will keep going? Will you break more things? Break bigger things? Be willing to break the thing that nobody wants you to break? Because at that point, people are not going to be on your side. They’re going to call you crazy. They’re gonna say you’re a bully. They’re gonna tell you to stop…Because as it turns out, nobody wants you to break the system itself. But that is what true disruption is.”
Miles Bron in ‘Knives Out: Glass Onion’
I was thinking about distruptors after watching the Netflix ‘Glass Onion’ movie. Disruptors are people who shake up systems, pioneer new ideas and challenge the status quo, sometimes for good, sometimes dangerously. Labour seems to have its own version of a disruptor in Wes Streeting, the shadow health secretary. In a recent interview with the Times, Mr Streeting declared that he wants to phase out the system of GP partners, scrap the gatekeeping model of primary care, and challenges how practice finances are led.1 His comments have put Labour and the BMA on a collision course over GP funding, but how many of this comments are based on what we know about partnership and the gatekeeping model?
Labour seems to have its own version of a disruptor in Wes Streeting, the shadow health secretary.
Though the Labour party has scaled back on Mr Streeting’s comments about ‘tearing up the GP contract’, Labour is consulting on the possibility of making all new GPs directly salaried with the existing partnership model being phased out over the course of a generation of reforms. Critics of this kind of reform highlight that the partnership model has several strengths including the freedom to innovate, autonomy to respond to local patient population needs and provides good value for money. Clinical microsystems thrive with good leadership, and strong leadership at the level of GP practices, along with innovation, creativity and high motivation, are cited as reasons why high-performing practices succeed.2 The independent GP Partnership Review, published in 2019, highlights the strengths of the partnership model above an alternative salaried model, but accepts that without the input of new partners, the model could be lost. Most GP trainees are choosing to work in a salaried position, with only 35% of trainees intend to work as a GP partner 10 years after qualification compared to 45% of trainees intending to work as a partner when surveyed in 2016.3 As fewer GPs go into partnership roles, ‘sustainable alternative models’ might need to be considered where it’s not possible to recruit or retain GP partners, but the GP Partnership Review firmly focuses on sustaining the current model and reducing personal risk and workload associated with partnership.4
But is Mr Streeting’s main gripe with the current model the clinical outcomes or the money? He challenges the finances of the partnership model, stating that ‘the truth is that the way GP practices operate financially is a murky, opaque business’. GP funding and contracts are complex, but this kind of statement unhelpfully constructs GPs as shady and disreputable business owners, rather than small business owners with strong incentives to run a clinically effective and efficient service. While there are pros and cons to the capitation model for core funding in general practice, higher capitation funding is consistently associated with higher ratings under the care quality commission (CQC), implying that better quality and safety of patient care can be achieved through more, not less investment in primary care.5
But is Mr Streeting’s main gripe with the current model the clinical outcomes or the money?
Mr Streeting challenges the role of general practice as the front door of the NHS, stating that GPs shouldn’t be the sole gatekeeper to the NHS, and that ‘sometimes it’s pretty obvious that you don’t need to see the [family] doctor’ before self-referring for care. How efficient is the gatekeeping model? A systematic review published here in the BJGP looked at the impact of GP gatekeeping on quality of care, spending and health outcomes. The review found that gatekeeping was associated with better quality of care in terms of preventative care and appropriate referrals for specialty care, fewer hospitalisations and lower specialist use, though the findings for cancer were mixed with potential associations between gatekeeping and delays in cancer diagnosis. Although gatekeeping models resulted in lower healthcare use and expenditure and helped control the costs of unnecessary specialist care, studies showed that in general, patients prefer direct access to specialists.6 Sometimes it is ‘pretty obvious’ that a patient can self-refer themselves, and flexible gate-keeping models for services such as mental health or physiotherapy allow patient self-referral. But not all patients will know when it’s ‘pretty obvious’ to access direct care, and some population groups, such as those with lower socio-economic status, low levels of education and elderly populations, prefer the gatekeeper model.7 If gatekeeping is associated with lower specialist use and appropriate referrals, the converse suggests that an open-access model would result in higher specialist use and potentially inappropriate and undifferentiated referrals. Given that the NHS is dealing with increasing waiting times for secondary care, and GPs themselves are finding it more difficult to make referrals to consultant-led care with an 87% increase in referral rejections (partially due to pressures and lower capacity in secondary care), it seems unlikely that the workforce and systems capacity is in place to facilitate an open-access system.8
In order to ‘tear up’ the general practice contract, Labour needs to be clear on the goals and benefits of disrupting the current model. I want to see how moving to a salaried only funding model or allowing an open access referral system would improve outcomes, save money, or be sustainable in today’s NHS. It’s one thing being a disruptor, but breaking the system without a proven, cohesive and viable alternative that works for our communities is a dangerous misstep for the future of general practice.
1. Sylvester R. Wes Streeting: We must think radically – I want to phase out the existing GP system. The Times. 2023 6 January 2023.
2. Dunham AH, Dunbar JA, Johnson JK, Fuller J, Morgan M, Ford D. What attributions do Australian high-performing general practices make for their success? Applying the clinical microsystems framework: a qualitative study. BMJ Open. 2018;8(4):e020552.
3. Bergman K. Workload issues affecting GP trainees’ plans for their future careers: The King’s Fund; 2022 [Available from: https://www.kingsfund.org.uk/blog/2022/09/workload-issues-affecting-gp-trainees-plans-their-future-careers.
4. GP Partnership Review Department of Health and Social Care; 2019.
5. L’Esperance V, Gravelle H, Schofield P, Santos R, Ashworth M. Relationship between general practice capitation funding and the quality of primary care in England: a cross-sectional, 3-year study. BMJ Open. 2019;9(11):e030624.
6. Sripa P, Hayhoe B, Garg P, Majeed A, Greenfield G. Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review. Br J Gen Pract. 2019;69(682):e294-e303.
7. Gross R, Tabenkin H, Brammli-Greenberg S. Who needs a gatekeeper? Patients’ views of the role of the primary care physician. Fam Pract. 2000;17(3):222-9.
8. NHS backlog data analysis: British Medical Association; 2022 [Available from: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis.