Remodelling primary care: an uphill struggle

Photo by Ivan2010, Wikimedia Commons

In the bleak landscape of today’s NHS, a ground-breaking service in a Somerset GP practice is seeing patient and staff satisfaction running at unprecedented highs while reducing pressure on local hospitals. Why, then, is it closing at the end of May, after only four months, and what does the future hold?

The GP Urgent Assessment Service (GPUAS) at Martock Surgery offers same-day care from a multidisciplinary team, led by GPs, for 38,000 patients registered at six surgeries in the South Somerset (West) Primary Care Network.

Patients are assessed for urgency by phone or online at their own surgery (‘triage’), and those who might have gone to A&E can be offered an appointment with GPUAS. Once here, three ‘point of care’ testing kits, rarely used in primary care, can rapidly diagnose, for example, the causes of throat infections, as well as investigate potentially life-threatening risks such as blood clotting or bleed, sepsis, and blood gases in those with lung disease. Patients can also be referred for X-rays at South Petherton Community Hospital, but if sent off-site they always come back to the GPUAS for results and any treatment plan.

Incubated over three years, GPUAS is the brainchild of GP Tim Quinlan who brought it to life with senior nurse Sue Fearn, and a £400k cash injection from NHS Somerset. This was in the wake of the 2022 ‘Fuller Stocktake Report’, addressing its requirement for “streamlined and flexible access for people who require same-day urgent access.”

When I visit the service, the buzz of enthusiasm among staff is palpable, and rare. As GP Dr Maddie Smith says

“Staff morale is through the roof; I’ve never felt as happy about coming to work” and she describes the service as “Combining really modern technology with the very best of old-fashioned medicine, having more time to be with patients and really understand what they need.”

So why, after investment and apparent success, is the service closing? Kerry White, Managing Director of Symphony Healthcare Services, which provides NHS primary care at 22 locations in Somerset and Devon, says GPUAS was always a ‘test and learn pilot’ and that while patients may like it, it has not proved cost-effective: half hour appointments are unnecessarily long, not enough patients are seen each day and the care is “too GP-heavy.”

While White concedes the need to wait for full independent assessment of the pilot, due by June, she also says “There is no new money to keep GPUAS running, so version 2, which we are committed to and plan to open by the end of the year, will need to be staffed from our existing capacity.”

A glance at the NHS jobs website shows Symphony advertising numerous GP posts, suggesting “existing capacity” may not be enough. Dr Smith is mindful that ‘version 2’ will need to attract and retain staff, but can be made more efficient:

“About 70 per cent of patients who come to GPUAS don’t need 30 minutes with a GP, they need, for example, a consultation with a nurse practitioner and, possibly, a quick test to see if antibiotics are needed. We can help GPs get better at triage, and then those that work within GPUAS can provide clinical oversight and do more by phone.”

While Symphony mulls over how best to resurrect GPUAS, another technological advance, Anima, using artificial intelligence to triage, its decisions, ‘finessed’ by clinicians, has just been introduced into surgeries. As Dr Smith explains

“GPUAS tended to be sent patients who were too well, who probably could have waited to see their own GP, but it’s very challenging to make these decisions. Anima may help ensure we are sent patients who really need our help who would otherwise go to hospital.”

Dr Quinlan, who joined Symphony as Clinical Transformation Director but, clearly frustrated by GPUAS’ imminent demise, leaves when it closes, is passionate about remodelling primary care:

“Are we really meeting the values of the NHS? Do we just want more of the same, which isn’t working, or can we find people with the strength and conviction to back change?”

And his words echo many themes in a recent King’s Fund report, Making care closer to home a reality, which states:

“The failure to grow and invest in primary and community health and care services ranks as one of the most significant and long-running failures of policy and implementation in the NHS and social care for more than 30 years. If this shift in focus does not happen, more expensive hospitals will need to be built to manage people with acute needs that could have been prevented or better managed.”

Dr Quinlan says relying solely on the economic case for GPUAS is misguided, citing other key gains as:

  • care closer to home;
  •  reduced funneling of patients to hospital:
  •  enabling more appropriate resource utilisation;
  •  improved responsiveness to patients who are becoming more unwell; and
  • – vital to tackle recruitment and retention challenges – enhanced training, skills and resources to upskill staff to work to the top of their professional licence, with better job satisfaction.

 He adds

“If you were going to pursue an economic argument, you would need to consider a shift of activity away from hospitals into the community and consequently resource this both financially and with clinical and managerial support. Some feel this work should be undertaken within the current primary care financial envelope, but under-resourcing and failure to keep up with inflation has resulted in significant financial pressures to deliver traditional GP services, never mind support for innovative and transformative practice. And the creep of traditionally hospital-based work into general practice has stretched things further still.”

There are no easy fixes for the NHS’ woes, but if GPUAS can be re-modelled in a way that makes it sustainable while still injecting humanity into primary care (98 per cent of patient feedback rated it outstanding) while reducing hospital admissions and attracting and retaining staff, one can only hope it rises from the ashes.