Who Cares? The Future of General practice
Reform claims to be an apolitical think tank but some commentators have pointed out its funding by big pharmaceutical companies and private health providers. One of the authors works for MacKinsey's. It is the result of in depth interviews with 22 contributors none of whom were jobbing GPs. Indeed all of the job titles listed were NHS managers, academics or representatives of super practices and other providers barring one former health minister and a "senior official, BMA." There is much here that is reasonable and true but unfortunately the points are often couched in terms of gratuitous insult. We read that primary care is "fit for the past...fragmented...out of date...[and] unsuitable." I think it is true that "...as GPs handle appointments regardless of need...economies of scale are not leveraged (sic - this probably means "used" or "exploited")" but really whether £1.1 billion could be saved if most urgent care was delivered as it is to 200,000 people in Northamptonshire via a super practice is doubtful: one would have to close or downsize every emergency department to achieve real savings. But mere details like this are of no interest to these zealots for change. Addressing the "inefficiencies" of primary care could "go some way to helping NHS England find the £22 billion it has targeted...by 2020." Really? From a sector that accounts for much less than 10% of NHS spending? "The paradigm shift" required to revolutionise care so that it is provided "by larger providers, capable of offering a range of extended services, such as diagnostics, urgent care or minor surgery, seven days a week" by integrating primary, community and secondary care will provide "better, more accessible care at a lower cost to tax payers." But the authors cannot resist adding to this panacea that we need a system "based around the needs of the patient, rather than the GP." This is, then, a confused paper. It trots out the tired old one-trick pony of primary care being the "jewel in the crown" and pointing out that properly funded primary care systems work best around the world in preventative care and saving costs. It shows how dissatisfied GPs are with the present system but then accuses them of having vested interests in maintaining the status quo. It demonstrates to its own satisfaction, if no one else's, that "small practices are a problem for patients" because the CQC is more likely to designate a large partnership to be outstanding and a smaller one inadequate. No mention is made of the bias the CQC inherently has for larger, more bureaucratic organisations. We get the Vitality line that, for example, knee replacements are handed out at the "whim" of practitioners rather than on the basis of good cost-benefit analysis data. Patients with painful knees of course speak of nothing else. Indeed there is a, to my mind, false and rather offensive presentation of a duality where patients in small practices are the passive recipients of paternalistic care whereas those seeing other healthcare professionals in super practices are equal partners in exciting, new and generally cheaper, models of care. The frankly outrageous statement is made that "the traditional attitude of "doctor knows best" prevails: GPs fail to see patient preference as an important aspect of their work." Professor "Steve" Field himself has quoted "the link between scale, the ability to offer multi-professional teams and quality." It must be satisfactory to be able to define quality along the lines of one's own practice. There is confusion too about how other parts of the health care system impact on primary care such as the wasted time chasing up hospital referrals and navigating patients through the complexities of the NHS. This must be true of all practices, not just small ones? On the other hand, one can well sympathise with the view that federations "tinker round the edges" being defensive. Half of all federations share no single function across all their practices and Mike Bewick is quoted as saying this shows "lack of ambition and clear priorities." Current contracts do not incentivise change either and this is true. Extended hours enhanced services which state that most appointments must be face-to-face with a GP for example. The focus on process in QOF as opposed to outcomes is justifiably criticised. GPs are given credit for being dissatisfied with 10 minute appointment times. Core contract opening times are too restrictive with "only 60%" of working age people happy with them. These "inconvenient" hours put unnecessary pressure on out of hours services which are, of course, more expensive. How traditional general practice can be so inefficient and yet so cost effective is, of course, outside the scope of this paper which has made its mind about the future. We are told that in 2012-13 5.8 million A&E visits were made at a cost of £124 each. So much cheaper to go to your general practice, no matter how questionable the data. Then again, the authors go on to make an irrefutable point about the woeful lack of the use of IT in healthcare when compared with so many other aspects of modern life. One official, interviewed for this paper, put this down to GPs being reluctant to "relinquish control over patients' care." Nothing much is said about the poor record of NHS IT programmes. Demand for primary care is unprecedented with 372 million consultations in 2014-15 but general practice is castigated for increasing GP numbers by 15% between 2004-14 at the same time as employing only 11% more practice nurses. The fact that practice nurses do not grow on trees and that, allowing for population increases, that 15% rise in GPs means a 1.5% reduction per head of population is not mentioned. All that is said is to criticise the sector for being too GP-centric. This may well be true. One of the recommendations of the report is for the DH to abandon Mr Hunt's pledge (or aspiration) to recruit 5000 "more" GPs by 2020. Circumstances will surely render that redundant in any event?
All the traditional methods of improvement are recounted. Better triaging, more use of telephone and other web-based methods of communication with naturally no mention of the legal standard of care being that achieved by actually seeing and examining a patient.
So much that is common sense or devoutly to be wished for, such as longer consultations, is argued for in this paper. It is heavily flawed by its manifest bias to the status quo and use of doubtful or even outdated arguments. We may not be able to order complex imaging as GPs in Somerset but I do not think we learn much from being about doctors in 78 practices in the Netherlands being able to ask for a chest X Ray reducing the number of referrals to secondary care. But this is, nevertheless an important paper, not least as it is designed to resonate with government thinking. It settles down towards the end, curbing its animus towards these turbulent, stuck in the mud and in their silos GPs. It suggests that practices can work together in groups, serving populations and supported by integrated care teams. As usual there is an assumption that all patients come along with a neat single problem but we are, by now, well used to that lack of insight. We can only hope that "jaw, jaw" will be better than "war, war" and that traditional general practice will really be seen as part of the solution rather than the cause of the problem.