In April 2016, the NHS in England embarked on a far-reaching overhaul of general practice in an effort to build resilience and capacity in the NHS GP network.

Rising numbers of older people requiring care for the more complex conditions usually associated with older age have cornered the NHS into a sink-or-swim situation, where survival will depend on a robust network of GPs able to reduce demand on hospitals - at the front door, by providing a less-costly alternative service, and at the back door by enabling faster supported discharge into patients’ own homes. 


What does it mean for me?


For people with arthritis and other musculoskeletal (MSK) problems, this revolution in GP care should mean a radical redesign in treatment, believes Dr Alastair Dickson, GP, Health Economist, and Communications Officer at the Primary Care Rheumatology (PCR) Society. Brokered by an NHS strategy document, the ‘GP Forward View’ (GPFV), the improvements seen by GPs will include more funding, innovation in IT and business support, which aim to usher in more cost-effective services that improve results for patients and save money for the NHS.

"Musculoskeletal problems could be taking up to as much as one in three GP consultations."

For musculoskeletal problems, which include back pain, joint and ligament problems, this is important. They currently make up a substantial component of GP workload: estimates range from one in five to one in three GP consultations – a baseline that is expected to increase as the population ages, and as new generation biological treatments open up new possibilities in care.

Changing the way that GPs do things for these patients is crucial, believes Dr Dickson: “We simply can’t afford to carry on as we are: primary, secondary and social care are ‘bust’.”


Boosting standards of care


Founded 30 years ago, the PCR Society aims to give GPs and primary care teams the professional education and support they need to operate in the changing world of MSK care. In the latest iteration proposed by the GPFV, GP practices will merge physically or virtually into operations that can exploit economies of scale to deliver services to patient populations of between 30,000-50,000.

"GPs will merge physically or virtually into operations that can exploit economies of scale to deliver improved services to huge patient populations."

Faced with the clear and present danger of the current shortfall in the GP and nursing workforces, a whole raft of non-GP healthcare professionals and support staff will be trained up – pharmacists, physiotherapists, physician associates, healthcare assistants, for example, who will work alongside GPs in their new super-size practices.

For MSK patients, this will mean a lot more diversity in the primary care team and a lot more procedures done in-house rather than in hospital. This will demand a change in some patients’ mindsets. Dr Dickson believes: “We’ll need to educate some people that GPs are not necessarily the best person to see; in a properly functioning team, they should become more like a consultant. The only way the GP plan will work is if we use the most appropriately-skilled and cost-effective people for the job.”


Trust vs. overmedicalisation


Another challenge will be to convince MSK patients to trust their healthcare professional when they say that according to the evidence they probably don’t need that MRI scan or consultant referral.

"This can result in procedures that have little or no benefit, and sometimes even do harm."

Dr Dickson explains: “For example with low back pain, most people will get better within eight weeks whatever you do – but there is still overmedicalisation of MSK and this can often result in procedures that have little or no benefit, and sometimes, even do harm. Reflective of this the PCR Society has been involved with developing the North of England Regional Low Back Pain Pathway that has designed and assessed a better way of working based on the evidence-base. It has reduced over treatment and more importantly shown improvements in patient outcomes. The pathway has now been adopted by NICE.” 

Capacity constraints and knowledge gaps among GPs mean that MSK does not always get the discussion that it needs to optimise care and build resilience in patients so that they become able, with support, to take a greater role in their own care. Dr Dickson believes: “With these larger practices we will have sufficient size to be able to use the in-house expertise in a more structured manner to develop GP-led specialist primary care teams in MSK, rheumatology and other diseases. This will improve patient outcomes, minimise the need to refer patients to hospital and speed-up time to treatment whilst also saving money on referrals.”