General Practice after the election. (First published on the LMC Newsletter)
In 2008, Professor Don Berwick wrote in the British Medical Journal,
Reinvest in general practice and primary care—These, not hospital care, are the soul of a proper, community oriented, health preserving care system. General practice is the jewel in the crown of the NHS. Save it. Build it.
His advice was ignored. The NHS has an unprecedented funding-gap of this governement’s own making and it has no credible plan to fill it. General Practice is in a parlous state: one in three GPs are planning to retire in the next five years, one in three training posts and one in six vacancies unfilled. Older GPs are retiring early and one in five younger ones are emigrating and many more are choosing to work part-time. The loss of MPIG could force dozens of practices to close. The consequence is that the remaining GPs cannot cope. Something has to give.
What GPs want, according to the recent BMA survey is more time with patients, with 80% ranking continuity of care as essential. They said they needed more core funding, longer consultation times and a reduction in bureaucracy. GPs are attempting to practice relationship-based, patient-centred care in an increasingly performance and guideline-centred NHS. This is in the interests of neither GPs nor patients.
In 1992, Julian Tudor Hart asked rhetorically, “can contexts for clinical decision-making be structured so that doctors’ interests coincide with those of patients individually and society collectively? He knew that the solution would “require revolutionary changes in the way care is conceived, organised and resourced.”
GPs are still reeling from the last revolutionary re-disorganisation that was the 2012 NHS Act and there is very little appetite for radical change. Having said that, British General Practice has been, in large part because of its independent contractor status, favoured by 82% of BMA respondents, incredibly innovative and new models of federating and networking are actively growing. The vast majority of GPs, despite their political differences, are deeply committed to their patients and still find great satisfaction in spending time with their patients. Our future resilience depends on the quality of this time.
It is very unlikely that there will be enough GPs to continue working the way we are. We could work a lot more efficiently by being better prepared for the patients we see, either by speaking to them on the phone or by employing community health workers/ health trainers/ physician assistants. Patients who need help with housing, benefits, hospital appointments, lifestyle changes, minor illnesses, a blood test, blood pressure check or other weights and measures could get help with all these things without having to make their case to a GP. There was a pilot project in Wales for community health workers, physician assistants are being trialed and Turntable health makes good use of them. But it is not yet clear how they can best work with primary care teams, whether they represent good value for money or whether sufficient numbers could be trained. Experimentation needs to be combined with evaluation.
What then do we want from the new government?
- Trust and support. As Don Berwick said in his report on Mid Staffs, “[the government] should foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work”. Money presently wasted on inspection and regulation should be spent on education, research and support.
- Outcomes that matter. In her essay, Arm in Arm with Righteousness, Iona Heath warns that “we risk destroying quality in healthcare in our attempts to measure it”. We should stop measuring things that don’t matter and start measuring those that do.
- Fair funding. For one thing, funding should reflect workload. For another, “Despite being an oft-repeated command to dying institutions, the ability to do more with less is an inherent impossibility”. The government’s pledge of 8am to 8pm seven day a week GP access is an inherent impossibility.
There is nothing the government can do to increase the numbers of GPs, but it can help to make general practice a more attractive career. Then the new GPs will come.