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 training posts and one in six vacancies unfilled while older GPs are
retiring early and younger ones are emigrating or 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 assistantsare
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?
1. 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.
2. 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.
3. 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.
This piece was first posted in the LMC newsletter.
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