The dystopian future of general practice – the hubs won’t work

Dr Katie Musgrave provides a dystopian take on the future of ‘health hubs’ and general practice

The year is 2030 and Wes Streeting is Prime Minister. Naturally, Wes got the leadership ticket after his successful ‘reform’ of the NHS.

GP practices no longer exist, as we’d have known them in years gone by. ‘Health hubs’ (as they are affectionately termed) took over when the GPs left – after they were driven to the brink of bankruptcy. The hubs serve anywhere from 50,000 to 150,000 patients. There can be a bit of travel needed to access them, but the buildings are impressively modern and well-designed. Many even have their own onsite X-Ray machine! Patients are encouraged to interact with their health hub via the NHS app, and the NHS also offers discounts on smartwatches and other health wearables.

The original principle behind the hubs was this: if you had a medical concern, you’d complete an online form, and a patient navigator would respond within half an hour. You’d either be provided with self-help advice, signposted to a pharmacy, booked in for a same day clinician call back, or booked directly into a clinical hub appointment within the following two weeks.

Initially, the hub system seemed effective, with appointments readily available. Streeting was heralded as the saviour of the NHS, and tech companies lined up to invest – attracted by access to large scale patient data and other opportunities for medical innovation.

But as patients learned how to navigate the system, and demand increased (there was subsequently an exponential increase in medical enquiries), the hubs began to flounder. The target for a call back within 30 minutes had to be relaxed to four hours. Patient navigators now struggle to meet even these targets. Face-to-face clinical appointments routinely have a waiting time of four to five weeks, far longer in some places.

The total number of contacts required to manage simple complaints, such as a self-limiting rash or throat infection has significantly increased, and the number of appointments per head of the population has doubled. More complex patients with significant comorbidities are generally seen by a hub doctor but as these doctors cover huge numbers of patients, they rarely know the individual, and patients complain of having to repeat their history over and over.

The loss of continuity across the hubs has also led to increased secondary care referrals, as well as acute admissions. Reduced continuity has been correlated with increased prescribing of medication and increased rates of investigation – without evidence of clinical benefit. This has led to a vast increase in health spending across the board. The hospitals have never managed to get on top of waiting times for surgery or outpatient appointments. The private sector is thriving, as patients increasingly face the choice of four years on a waiting list, or using their life savings to pay for basic outpatient medical care.

The age of patients consulting the hubs has shifted away from the over-75s, towards younger adults and the more digitally enabled. There has also been a shift away from patients in the lowest socio-economic groups and ethnic minority groups. This has led to increased health inequalities, but satisfaction ratings amongst the voting age population and the middle classes (including most of the media), have improved.

The new primary care model has received billions in investment. Thousands more nurses, paramedics, physician’s associates, pharmacists and social prescribers have joined the hubs.

But like GP practices before them, they are overwhelmed, and cannot keep up with demand. The redesign of primary care has proven a costly and complicated business, with questionable benefit. Another NHS reform which has papered over the cracks, but not provided a sustainable long term solution. Commentators argue that some of the magic of a smaller local GP surgery has been lost. One wonders whether bigger really was better; or whether perhaps we threw the baby out with the bathwater?

Dr Katie Musgrave is a GP in Devon