David Oliver rightly notes there is no clear direction for change in general practice.
The small practice model is being made redundant, possibly for largely politically motivated reasons. However much this model gives good value (in terms of doctor effort), responsiveness and continuity (for patient care), it also may no longer fit modern health technology. Just as everyone wants their local district general hospital and A&E at the end of their garden, sub specialisms, expertise and availability of expensive equipment mean bigger, centralised hospitals are necessary for care. Maybe now we need to relinquish the idea that one GP can offer care for 2000 patients from cradle to grave. Actually, a specialist nurse can look after your chronic disease much better. A specialist team would keep you well and in the community once if you are older, frail and approaching the end of your life.
Out of hours needs to be linked to patient records and to surgeries. Referrals and investigations can usefully be taken forward during 8-8, 7 day appointments. Bigger practices or groups are needed to achieve this. This is the model we are being asked to, or told to, embrace as part of our democratic, political process.
Holding on to small practices and small hospitals maybe keeping our health care in the 20th century, with, for example, high infant mortality rates and low cancer detection rates when compared to our European compatriots.
New models of care combining primary with community or secondary care seem to be thought of as fringe ideas. However, this is not only where we are headed, with new Trusts to be negotiated and in place by 2020 but also key to abandoning the internal market. The purchaser-provider split is under exposed, neither discussed within our journals, among ourselves or as part of an electoral or political debate. It is very expensive, in terms of management and information costs and destructive, for instance to specialists or hospitals taking an overview of the population's health.
The reason there is no consensus among my primary care colleagues is clear to me. Most GPs earn around the rates of pay of a train driver; £60,000 for a 4 day week (driver) or a 32 hour, 2 day in surgery week (partner) or a 3-3.5 day, salaried GP, 35-hour week These GPs would happily hand in undated resignations, for instance. However, CCGs provide many GPs and practices with an inordinate additional income. My pension suggests I brought £200,000 extra into my practice for a 2 session a month post lasting two and a half years. These CCG post GPs would neither want to give up the internal market, combine primary and community care or have any reason to want to give up their job-for-life as a small/medium sized practice partner. The conservative coalition in the government before last have pulled a very clever divide-and-rule move, which only our LMCs seem to have acknowledged.
Clearly primary care is failing, both our patients and us, the staff working within it.Vested interest is holding us back. A clear direction, or a generalised and helpful acceptance of the direction being offered, would be one big step forward for us as well as our patients. It might also bring us more respect for doing a better job among our acute sector colleagues, such as David Oliver..
Salaried GP, Bedfordshire
(previously a partner in Hertfordshire)
Competing interests: No competing interests