Feature

Let 1,000 pilots bloom

Looming GP shortages mean we will have to think differently about the primary care professionals we need, say Rebecca Rosen and Diane Gray

Following the Wanless report on the NHS and the Budget boost to health care funding, a string of policy statements have emerged about the future of the NHS. We are promised more doctors, more nurses, new facilities, new ways of working and more patient choice.

But what difference will all this change make for people with a dose of ‘flu? Will they still go to see their GP, or is the whole face of primary health care changing?

There are around 30,000 GPs in England. Two years ago, the NHS Plan promised 2,000 extra GPs by 2004. The Wanless report estimates that the UK may need 29,000 more GPs by 2020.

At present, nearly 3 per cent of GP posts are vacant. Of the 1,100 GPs who leave their posts each year, two-thirds leave general practice completely – often well before retirement age. Up to two-thirds of the Asian doctors recruited in the 1970s, to tackle the then shortage of GPs, will have retired by 2007. Deprived inner-city areas will be particularly affected by this trend.

The number of newly trained GPs increased by only 18 more in 2001 than in the previous year. While Europe is now viewed as a potential source of new doctors, recruitment is not guaranteed: a recent attempt by an English health region to recruit 40 GPs from Spain attracted only 22.

Targets for GP numbers ignore the fact that many work part-time. While 21 per cent of England’s 10,000 female GPs worked part-time in 1991, 43 per cent did so a decade later. Over the same period, the proportion of male GPs working full-time fell from 93 per cent to 81 per cent.

Despite its best intentions, the Department of Health will find it difficult to meet the targets for GP numbers in the NHS Plan. Rather than focusing on numbers, the greater challenge will be to develop innovative responses to the health needs of local communities.

And there are plenty of opportunities for such developments. The new GP contract proposes fundamental changes to the way money can be used: instead of being tied to recruiting GPs into an area, the local health economy (via the primary care trust) can now invest in new types of health centre facility or care in under-served areas.

The revised NHS Plan proposes new ‘one-stop centres’ staffed by primary care nurses, specialist GPs, pharmacists and therapists, and offering diagnostic services. Central to the success of these initiatives will not be the numbers involved, but the different skills that each health professional – nurse, doctor, or therapist – can offer.

Many changes in working practices have already occurred. NHS Direct and NHS walk-in centres are nurse-led services offering advice and treatment for minor ailments. Nurse practitioner clinics in GP surgeries are now commonplace. Community pharmacists are increasingly involved in repeat prescribing and are developing new roles such as issuing emergency contraception. Health care assistants are working with nursing and medical staff in some primary care centres. And as nurses take on some of GPs’ clinical work, ‘GP specialists’ are emerging, offering local and (hopefully) faster access to specialist care than hospital outpatient clinics.

Recent studies have shown that nurse-led clinics are popular with patients and have similar outcomes to GP clinics. Yet much of this research has centred on clinics for selected patients with minor illnesses and we have little evidence about nurse-led clinics for all-comers. The enthusiastic front-runners in these pilot projects have excelled, but the skills required to do this work are not yet clear. To maintain good outcomes as these clinics spread, standards for training, education, and support must be established.

The situation is similar for GP specialists. The number of specialist clinics offered by GPs is growing rapidly. While there is a national scheme to train GP specialists in ear, nose and throat care, many other clinics are emerging on an ad hoc basis. The Royal College of General Practitioners has issued guidance on accreditation and quality assurance of GP specialists, but there are no widely accepted standards, and there has been almost no research on how the quality of their care compares with hospital specialists.

It is very likely that urgent necessity, rather than evidence-based policy, will drive the growth in these new forms of primary care. Many districts will simply not be able to recruit the target numbers of GPs and nurses, and will have to think laterally about mixing skills – which in itself will be a challenge in the light of the recruitment and retention problems facing the nursing workforce.

Whatever the driving forces, it seems likely that many of us will be using a broader range of primary care services in future. Traditional GPs may continue to exist in some areas, but in others patients will pick and mix from a variety of nurse practitioners, GP specialists, pharmacists and other therapists.

It will be essential to monitor the outcomes of all these new roles and services closely. We will need to learn quickly from pilot projects, have the flexibility to modify services, and be sure to invest in the necessary training and support. And central to these developments must be a commitment to provide high-quality care, rather than blindly pursuing numerical targets.