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The seismic upheaval in health care in England following the Lansley reforms has put the focus firmly on delivery of health care in General Practice – from commissioning to provision – to the alarm of many and the satisfaction of a few.
The underlying principle was that GPs are capable of understanding and managing risk in a way in which an administratively led health system was not and that these risk management skills could be applied to system design as well as to patient care.
There is a mantra developing that much work traditionally done in hospitals could and should be done in a primary care setting as being cheaper for the system and more convenient for the patient. However, no-one seems to have cracked the 4 hard facts: -
- Hospitals have high fixed costs and high profile community support
- It is political suicide for a local MP to advocate hospital closure in their patch.
- Getting the cash out of the secondary care sector to invest in primary care is becoming a real stumbling block.
- Decommissioning services is hard.
General practice in its present form is at breaking point. There is just no slack in the system for GPs to take on more work. The funding of general practice is falling as a percentage of the overall health spend – 90% of health care is provided in General Practice and attracts a derisory 7.5% of the health budget (8.47% if you include prescribing costs).
The perfect storm of diminishing incomes, increasing pension costs and decreasing lifetime caps leading to earlier retirement and a poor career structure with increasing emigration of GPs threatens the whole future of general practice. General practice has ceased to be a great career choice for the new medical graduate – and we need the cream of the crop in GP-land. Not just those who can know everything there is to know about the left shoulder or the functioning of a nephron but those who can know pretty much everything about pretty much anything, can deal with unsorted illness presenting in its earliest guises and deal with the burden of chronic disease management as well as running their businesses in general practice.
So, how do we move from a system at breaking point to the “crown jewel” of the NHS that general practice could and should be?
Let’s start with the most important person in any general practice.
Nope, not the doctor but the patient. What does the patient look for in a modern general practice? I think there are two groupings of people here and they are not discrete groups as people move from one to the other freely.
The first group is those who have a simple self-limiting illness. On the whole, they are not too bothered about which doctor they see as long as they are affable, available and able.
The second group is those who think that there is something mortal wrong with them. As one of my patients recently said “I know I can go to the Walk-in Centre, out of hours, the Darzi Clinic or A&E to see someone but, when the chips are down I want to see you – my doctor, whom I have known for years. I know you will give me a straight answer and make sure I am looked after”.
This Continuity of Care is an idea whose time has come. Goodness Gracious, even La-lite is using the phrase as part of his “wishlist” – although I did ask him to put it at the top rather than the bottom. Continuity of relationship medicine is proven to reduce health costs and increase patient satisfaction. The doctor-patient mutual investment company is still one of the best underpinnings of cost-effective and patient-sensitive health care.
So – how do we deliver this in the 21st century’s 24 hour society?
First, let’s get rid of the silly notion that General Practice is a commodity like a trip to Tesco. Just because I can buy baked beans on a Sunday does not mean I need to have my GP at my beck and call and open all hours. The Darzi experiment has shown that this is a dreadfully expensive way of dealing with perceived wants, not needs and the NHS cannot be funded from general taxation to deal with this. It may be helpful to revise the regulations which prohibit willing doctors from seeing their patients out of their contracted hours and charging a fee – but that is an argument for another time.
What we must do is not to provide 7-day access but really good access for 5-6 days a week. There are various models of how to do this (again for discussion on another blog) but patient safety and satisfaction is best served by quick access to a GP. Yes a real GP, not a yanban (yet another nurse by another name) or other healthcare person but a GP. It is cheaper to employ a GP at the front end as they can make quick and safe decisions, more satisfying for the patient and more efficient for the system. Consultation rates which have risen from 3.1/patient per year in 1995 to 5.8 in 2008-9 (last official government figures) to about 9 now mean we have to work smarter. There are only so many hours in the day and the average GP principal works an 11-12 hour day already.
The corner shop model of general practice has served well for 60 years. Now we need to build on its strengths and deal with its weaknesses. I believe it is vital to retain health care local to patients, within a pram-push from their homes, especially in deprived communities who not only lack social mobility but mobility of any sort. However, lots of the backroom functions of practices can usefully be shared – payroll, HR, protocol development, cleaning contracts – the list is endless. We need a super-manager to cope with a group of practices and an administrator on site to deal with day-to-day things, leaving the GPs and clinical teams to do what they do best – the medicine.
Whether you call it federation or something else, closer co-operation is key. In many areas there is bad blood between practices for reasons almost lost to human memory. We must grow up and work in teams. We managed it in out-of-hours co-operatives, we need to use the same esprit-de-corps in-hours. Different models will work in different areas – from loose federations through partnerships to mergers and to super-practices with a few partners employing a lot of salaried GPs or even practices owned by commercial firms or Foundation Trusts – there is room for all. The workforce is also changing and no longer do most new graduates expect to work full time in the same practice for 30+ years – there is an increase in part time working and career mobility.
But let’s remember who we are working for. Not a faceless foundation trust, not a PCT, a LAT or a CCG.
We are working for our patients as their doctor, their mentor, their friend, their advocate and their navigator through the health system. Keep our eye on this and General Practice will flourish.
Dr Peter Swinyard is National Chairman of the Family Doctor Association