Rethinking Primary Care Design

For as long as I can remember general practice in the UK has been central to the success of the NHS. Policies since the 1980’s have pointed to a “primary care led” service and that meant the GP practice as the base building block of NHS infrastructure. On the face of it this makes sense as 60-70% of patient contact takes place in a primary care setting and GP’s act as the referral gateway to hospital services.

Early infrastructure plan for the NHS envisaged local authorities providing new “health centres” hosting primary and community care services. The demise of local government and separation of “health” and “social care” in England brought that to a standstill. Premises development was largely taken on by individual practices often working with specialist developers and part funded through the NHS cost guidelines. This was given strong push at the end of the 1990’s with the introduction of Local Investment Finance Trusts (LIFT), a centrally supported development finance model.

These developments were all predicated on the GP practice (or usually the jointly liable partners) signing a head lease for 20-30 years backed by their copper bottomed long term primary care business. Locally agreed rent could be reimbursed through a set of “Red Book” rules. On the face of it, an excellent system.

Unfortunately, it’s not been working for years.

The model of a GP holding the head-lease or owning premises has become increasingly uncertain. Ownership can make attracting new partners very difficult and the long-term liabilities can be prohibitive. The NHS client has been reluctant to allow general practice to operate as limited liability organisations. Not surprisingly GP’s are unenthusiastic taking on long term personal financial liability for what is their workplace. For example it can mean being unable to take on a mortgage for a house.

Added to that there is a perfect storm conspiring against the historic model. Declining GP numbers, an aging workforce and reduced opportunities for recruitment mean some pockets of the UK are short of provision. Allied to that uncertainty over GP contracts has encouraged practices to “federate” forming large commercial entities that provide care for populations of hundreds of thousands of individuals. Acute Hospital Trusts seeking stability in their pipeline of referral have started to buy out GP practices and are forming their own proprietary chains. Smartphone based services such as GP@Hand are disruptive and signal an entirely new relationship for consultation and algorithmic diagnostics.

Doctor Findlay's vision of the lifetime vocational GP based in a practice in one community is disappearing fast.

The key to rethinking the place for primary care is to look at the younger incoming generation of GP’s and to speculate on what future generations will expect. This Kings Fund post summarises the issues.

Young doctors are more likely to pursue portfolio careers, much more driven by good information technologies and working as part of an integrated health team. They certainly don't want to be bound by inflexible asset ownership. This change is long overdue but offers the appealing prospect of really effective out-of-hospital treatment and better support for home-care. How this might look was signalled a decade ago by Andy Black and Mungo Smith.

The model for new NHS Centres in England does not yet exist (although Scotland and Northern Ireland have good working examples). However there is pent-up demand for a new class of infrastructure that is run by the NHS and managed in a way that supports a much wider range of clinical services sharing space efficiently, open for longer hours. Your salaried GP may be based here along with urgent care for minor ailments and a wide range of diagnostics and treatments. Services will be focused on care for older people with complex and continuing needs. This kind of new infrastructure could serve a population of 30-50k and be 20 minutes travel time from most households.

This changes the building blocks of NHS infrastructure. One size will not fit all; meeting local needs will require a variety of scale and complexity. Above all these new places need to feel right and create an identity for health outreach teams, primary care and community care teams working together.

As well as transforming the service, this will need ambitious designers, creative developers and talented managers to make this feel like the future NHS that we all want.

#healthcare #architecture #design #nhs #gp #transformation