The Primary Care Workforce Commission was created as part of Health Education England at the end of 2014. This six person commission had a specific remit: to conduct a relative rapid reporting exercise on the state of primary care in the UK and what would need to be done in order to move from the current picture to some unclearly defined preferred state. Whilst there is consistent reference to the Ten Point Plan for GPs and to a number of recommendation documents, there is no one stated vision of the desired end point or any sense of the commission giving their perspectives on the validity of the government-level recommendations.
A literature and site review was conducted between January and May 2015, resulting in the production of the Future of Primary Care report. Although a likely outcome of the speed at which this commission had to work, there is an apparent lack of strategy about the literature reviewing process or the selection of sites visited. Whilst what is included seems logical and relevant, we cannot know what has not been included in drawing up this report, and thus what influence other sources of information might have had on the recommendations made.
Bearing this in mind, this appears to be a sound document in the context of being a rapid appraisal and a summary of some common sense thinking about the limitations of primary care as things stand and what most people with a sensible head on would recommend doing about these limitations. There’s nothing wrong with that.
Or is there?
If six academic and clinical experts are brought together to really focus on, “making careers in primary and community care more attractive,” and to think about the development of staffing to support a primary care service that improves population health, patient experiences and professionals’ working lives, as well as containing costs, is making recommendations enough?
Perhaps it is. There is a lot in this report that is positive, logical and evidently grounded in how things actually look ‘on the ground’ in terms of staffing in primary care. What isn’t here, alongside the ‘what things are like now and what we would like them to be’ is the HOW. And that is a far more difficult, but far more useful question.
Let me bring in the movie review analogy. When was the last time you felt really fired up to see a three star movie, going over familiar ground in an entirely sound and satisfactory way, but doing no more and no less than that? Do you get more from films that push the boundaries, try to extend beyond the usual limits, and sometimes hit the five stars, and sometimes end in dramatic failure but hey, at least they gave you something different to think about? For me, I want to see the brilliant minds push themselves and try to build something new, and that applies to academia and clinical research too. If I can already find out about the ‘what’ from a number of different places, I don’t need it summed up again, even if the new summary is more succinct and well presented than the existing summaries – I want to know how to get from A to B, or at least be given some helpful ideas.
I want to present my stance on this clearly, because I do not wish to demean the work that has been done here. This is an impressive summary given its scope and the time constraints for the work, and it will be helpful for commissioners in terms of relating local problems to the national picture, and in thinking about staffing issues and solutions in a constructive way. However I suspect that for many commissioners it will simply feel reassuringly familiar rather than particularly inspiring.
It is not possible in a review of this length to cover the report completely, and for those daunted by the size of the report but interested in an overview, there is a video with Sir Martin Rowland outlining the report available online. The organisation of primary care is also something of a moving target, and much may change between the time I write this and its posting, with the recent debates about junior doctor contracts, the British Medical Association publishing ‘Responsive, safe and sustainable: Towards a new future for general practice’ and political conference season getting into full swing.
The HEE Commission report focuses on roughly twelve aspects of human resource recruitment, training, planning and development, and it does not shrink from the very real problems in recruitment and retention of GPs and community nurses, or the realities of budgetary limitations.
Where GPs are concerned, recommendations about recruitment, retention and training are all logical and address the widely recognised accelerating shortfall in GP numbers. The reality at the moment is some distance from these recommendations and the direction of strategies at a government level to raise GP numbers seems to be at least partly based on restricting other options. It is ironic that the promotional recruitment video made by Health Education England has met such stony criticism from current GPs, given the evident will to support GPs showcased in this report. However there is a distinct lack of practical ‘how to’ advice to accompany the nods made to the Ten Point Plan.
In terms of skill mixing, there are more ‘how’ suggestions, such as employing more medical assistants to complete administrative work, thereby freeing GPs to do more clinical work. Attention is paid to the broad professional palate available to primary care managers. By employing a wider mix of professionals, the hope is that the work required can be done at a lower cost. And it needs to be, because the report recommends that primary care practices need to offer more services whilst staying close to their communities, need to make sure their GPs are federated, need to establish better IT systems, need to provide end of life care and just to add to the bargain, need to make sure their premises are “high quality.”
This is just at the practice level. There are bigger systemic and behavioural changes which seem to lack suggestions about ‘how’ to carry them out. The commission suggest that GP care, “…needs to be less episodic and reactive” (p.29) but this is the way that it GP services are set up operationally, and it is not entirely clear how these kinds of ground-level systems will be altered in order to change the way patients interface with the primary care system.
Subsections on training, sustainability and research are treated very briefly in comparison with the other areas considered, and given the scale of the task it is unsurprising; one wonders what has been lost in trying to cover everything, and although I suspect that pulling the whole picture together makes this more accessible for commissioners, I am unclear as to why it is these particular topics that have become the runts of the litter. In terms of training, there are some innovative ideas to shake up leadership training for primary care staff and support is given for the work of Community Education Provider Networks. As far as research goes, the recommendations here seem tired and unnecessarily so; there is plenty going on in the world of implementation science to help practitioners put research and interventions in place in practice settings, and there are rapidly advancing networks of research teams linking NHS services to university input in many CCGs.
It is heartening to see that inequalities in service provision are discussed and the helpful example of GPs At The Deep End is provided. However, inequities and inequalities in healthcare are massive topics in their own right and their presence here does feel more like an acknowledgement than a deep consideration.
Overall, my thoughts about the report can be best illustrated by another use of the word count function. In the 38 conclusions, the word ‘should’ appears 48 times and the word ‘need’ or ‘needs’ 35. The word how? Once.
Primary Care Workforce Commission. (2015) The future of primary care: Creating teams for tomorrow. Leeds: Health Education England