Primary care: opportunities and threats Broader teamwork in primary careBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7081.672 (Published 01 March 1997) Cite this as: BMJ 1997;314:672
- aDivision of General Practice and Primary Care, St George's Hospital Medical School, London SW17 0RE
The new white papers on primary care present opportunities for general practices to extend and develop their services to patients. These could enhance professional roles within practices and lead to new partnerships with secondary care, community health services, and social services. Two examples of new services are outlined: a practice led proposal to develop an integrated service for people with learning disability across a whole district, and a community health trust's contribution to extended primary care in an inner city area. For patients, the potential advantages of the reforms include more comprehensive and more integrated care in the community. The possible pitfalls of changing contractual arrangements include threats to the gatekeeping function of the referral system and, more fundamentally, to the central role general practice currently has in primary care in the United Kingdom.
Potential for joint working
The proposals outlined in the white papers on primary care present many opportunities for general practices wishing to develop or extend services for patients (box).1 2 3 The reforms could enhance professional responsibilities and promote greater teamwork within practices. Practices will be able to try developing new partnerships with secondary care services and social services, helped by health authorities taking a facilitating and coordinating role. General practitioners and other members of the primary care team could be encouraged to develop and retain special skills and so increase their job satisfaction.
Box 1–Proposed changes that present increased opportunities for joint working
Practice based contracts for extended primary care services
More work, including prescribing, done by non-medical team members
More options for employing salaried and part time doctors
More options for funding improvements in premises
Potential for increased collaboration with pharmacists, optometrists, dentists, and other primary care professionals
More funding for services which cross the interface between primary and secondary care
Potential fundholding for certain kinds of inpatient care without having to take on total purchasing
Potential pooling of prescribing budgets for primary and secondary care
Potential pooling of budgets for health authorities and local authority social services
When primary care is defined broadly as health care delivered outside the acute hospital sector, general practices are not the only potential beneficiaries of the reforms. The white papers imply that general practice will be strengthened; yet, ironically, general practice will comprise a smaller proportion of primary care than now. This would not necessarily be bad for patients or for general practice. Changing contractual arrangements and breaking down traditional boundaries between disciplines and organisations could, as the government suggests, result in services that are more responsive to local needs. The challenge will be to retain the traditional strengths of general practice–namely, continuity of care and clinical generalism provided by a core team.4 This poses a dilemma which is exemplified by the BMA's approach to core and non-core general practice.5 The following examples illustrate some of the possibilities.
A practice wishing to develop a service for people with learning disability
The Abbey Practice in Chertsey, where one of us (TK) is a partner, illustrates how a practice might take the initiative to pilot an imaginative and flexible service tailored to fit local needs. The practice has been considering for some time how it might improve the health care offered locally to people with learning disability. For more than 20 years, partners from the Abbey Practice have worked as clinical assistants providing medical cover and annual medical checks for people with learning disability in Botley's Park Hospital, which is due to close later this year. As a result, former residents of the hospital are usually registered with the practice, which now has 94 patients with severe learning disability (IQ less than 50) living in 10 group homes in the Chertsey area.
Most people with learning disability have increased needs for physical as well as for psychiatric care; most commonly these are neurological, ophthalmological, dermatological, and orthopaedic problems.6 7 8 These problems could be managed in primary care by generalist physicians,6 but patients often have undetected needs for care, especially reduced hearing and vision.7 Protocols based on meta-analysis and expert consensus suggest how to provide primary care for these patients, including screening for the known complications of the clinical syndromes associated with learning disability.8 9 10 Among elderly people with learning disability, 80% take long term treatments such as psychotropic, antiepileptic, laxative, and diuretic drugs; these drugs should be monitored and reviewed regularly.11 However, while most general practitioners accept initial responsibility for the medical problems presented to them by such patients or by care staff, many do not accept that they should be carrying out proactive care, health promotion, or regular screening for visual and hearing problems; they feel that such patients should be under specialist supervision.12 Most general practitioners have received little training in dealing with learning disability and are not interested in more training.13 Some argue that delivering adequate primary care to people with learning disability needs increased resources given the need for more visiting, longer consultations, extra screening and health promotion, and special experience in the particular physical and behavioural problems that such patients present.5 14
The practice would like to develop a new, truly integrated, and properly funded service for people with learning disability, with increased teamwork as outlined in box. The white papers would allow the changes in local contractual arrangements that are needed to develop the service. Such a pilot could be funded with new money from both the £2m health authority development fund and from the £32m hospital and community health services growth fund. The objectives of the service are listed in box.
Box 2–Proposed pilot for integrated primary and community care service for people with learning disability
One practice holds the district contract for extended primary care for people with learning disability in group homes
The extended team includes general practitioners (a named doctor for each home), psychiatrists, community nurses with limited rights to prescribe, physiotherapists, occupational therapists, care staff, a dentist, an audiologist, an optometrist, and a chiropodist
Written protocols are agreed for general medical care, including health promotion and annual medical checks, and covering minor physical illness, epilepsy, urinary incontinence, and challenging behaviour
Regular team meetings take place
Primary care and secondary cares budgets are pooled and include all costs of prescribing and hospital care
Box 3–Objectives of the learning disability service pilot
To increase accessibility and acceptability of care, through:
Increased continuity and more proactive care
Regular visits to the homes by doctors, nurses, and other community therapists
To increase communication between all the professionals involved, and:
Increase and improve support to home care staff
Simplify the tasks of prescribing drugs, dressings, incontinence supplies, and appliances
To reduce the number of unmet needs for care, especially:
Vision and hearing problems
Complications of specific syndromes–for example, congenital heart disease, atlanto-axial instability, and thyroid problems among people with Down's syndrome
Evaluation of such a project would be essential and could be funded through a joint bid by the practice and trust to the NHS Research and Development programme. Evaluation would include process measures such as number of contacts between professionals and extent of diagnosis, investigation, and treatment of problems gathered through auditing patients' medical records. Outcome measures would include reductions in unmet needs for care and satisfaction with the service, gathered through surveys of patients and carers. A quasi-experimental design could be used, comparing the outcome for patients of the pilot service with a comparable district elsewhere. The health authority could ensure that evaluation of the pilot was carried out according to recommended guidelines.15
A community trust contributing to extended primary care in the inner city
Working with general practice to strengthen primary care may be difficult for NHS trusts delivering acute services, particularly if this threatens to lead to a big shift in resources. Community health trusts should find this easier. In areas where general practice is well organised, with a large proportion of established fundholders or multifunds, the role of community trusts in primary care may be relatively small. In other areas these trusts and general practices will have to form strategic alliances to fulfil the objectives of the white papers. For example, inner city areas have smaller practices with fewer facilities, yet these practices have to meet greater demands associated with socioeconomic deprivation in the local population.
In inner London, primary care development plans set up after the Tomlinson report16 focused on three areas: getting the basics right, extending primary care services, and expanding the interface between primary and secondary care.17 Wandsworth Community Health NHS Trust in South London, where one of us (SH) is medical director, exemplifies a community based organisation committed to working with general practitioners, many of whom are singlehanded, have restricted facilities, and find that newer and more specialised services are difficult to obtain for their patients. In Wandsworth in the past three years all practices have had access to new and extended primary care services (box): chiropody has expanded into a foot health service including biomechanics and podiatric surgery; services for patients from ethnic minorities now provide health promotion, dietetics, and dental health promotion; and a community based continence service has been introduced.
Box 4–New primary care facilities introduced by Wandsworth Community Trust
Foot health services including biomechanics and podiatric surgery
Primary care physiotherapy and occupational therapy
Psychiatry services for younger disabled people
Bilingual speech and language therapy
Mobile dental unit and dental health education
Primary care for homeless people
Dietetics and health promotion for people from ethnic minorities
Potential for expanding specialist skills
To advance the shift from secondary to primary care, however, more ambitious liaison work is required at the interface. Specialist nursing, therapeutic, and medical skills are needed. Three more initiatives in Wandsworth illustrate the potential for this.
A multidisciplinary therapy centre has been established for residents with severe or chronic physical disabilities. It serves a potential client group of approximately 1500 people with physical disabilities and their carers. The main causes of disability among the patients attending are strokes, Parkinson's disease, multiple sclerosis, head injuries, and rheumatoid arthritis. There is a dedicated transport service to help clients and carers to attend the centre. Staff also go out to see them in their own homes and local clinics and practices. A user group of clients and carers also has advisory members from local voluntary groups such as Community Care Alliance. The centre also offers neurological and psychiatric care, and a salaried doctor provides general medical care and liaison with the clients' general practitioners. Initially, referrals came mainly from secondary care (on discharge from hospital) but self referral is possible, and more referrals are now coming directly from general practitioners.
The white paper will allow the Trust to enhance its partnership with general practitioners by employing salaried doctors to cross practice boundaries. Experience within the London Initiative Zone Educational Incentives scheme, employing young vocationally trained doctors on short term salaried contracts, has shown this to be a feasible and popular means of providing additional clinical support to enhance rather than damage general practice.In 1996 one such scheme employed recently trained academic assistants to provide locum cover for Wandsworth general practitioners attending weekly daytime education and audit meetings.18
Intermediate care schemes incorporating early planned discharge and avoiding hospital admission19 also show how community trusts can work with large numbers of general practices to complement the core primary care team. The case study in box illustrates one kind of intermediate care: hospital at home.
Box 5–Case history illustrating a hospital at home scheme
An Afro-Caribbean woman in her 80s had a moderately severe stroke. She was not known to community services other than her general practitioner, having previously refused support from social services. She had diabetes, high blood pressure, and gradually declining mobility. On referral to the community trust's rapid response team she was assessed at home over a period of four hours. Space in the home was reorganised to set up equipment, which included a pressure relieving mattress and aids to mobility and washing. Nurses and healthcare support workers visited up to six times daily for two weeks, and the night nursing service attended for 10 days. This care was combined with social support from friends and neighbours. The neurophysiotherapist from the trust's therapy centre visited and advised a programme of exercises which were carried out by the visiting staff.
The patient progressed steadily, and her mobility was improved further by the chiropodist. After three weeks the patient was independently mobile. Her care was transferred gradually to the usual services, with her general practitioner and the district nursing services monitoring her diabetes and hypertension. The patient had avoided going to hospital and the likelihood that hospital staff might have considered her home situation too risky to return to.
Implications for general practice
Initiatives that enhance the roles of general practitioners and other members of the primary care team may increase job satisfaction and help to tackle current recruitment problems. Changes in funding arrangements could benefit practices financially and pay for work shifted from secondary care.5 There is a risk, however, that the white papers will threaten the central role of the general practitioner in primary care (and even the existence of general practice) if elements of general medical services are parcelled up and divided between other providers. The history of the deregulation of public services in recent years shows that traditional roles can change dramatically, especially when new, cheaper, or more efficient operators tender for services. At the very least there will be more salaried and part time practitioners and fewer independent contractors in the future.
The government has stated that pilot projects should not create inequity of resources for patients of different practices. But inequity is inevitable, at least temporarily, because not all patients with relevant conditions in a district will be covered by pilot schemes. If voluntary pilots are successful then pressure will increase to implement service developments more widely, as was the case with fundholding.
Pilot projects that cross the interface between primary and secondary care should strengthen primary care in the broad sense, with community health services offering an important bridge between acute services and general practice. However, such joint initiatives will blur the distinction between generalist and specialist roles and could threaten the important gatekeeping role of general practice.20 Referrals to specialists may increase, whether from community professionals other than general practitioners or through self referral. Some of these referrals may be inappropriate and inefficient, and the resulting extra expense might even cancel out any gains made by integrating services. Referral rates will need to be monitored closely.
Perhaps the most intriguing opportunity is the potential for pooling budgets for health and social services. This would ringfence social services funds for residential facilities for patients with long term physical and mental health problems, which would remove some of the financial considerations that affect admission and discharge to hospitals and residential homes. Those currently responsible for these budgets will have concerns about this. Certainly, agreeing the relative contributions from health care and social care budgets would be problematic.
Above all, it is essential that the development of new partnerships and services is not allowed to undermine the obvious strengths of general practice. Patients value the approachability and accessibility of general practitioners and the continuity of care afforded by registration with a named doctor.21 Registration clearly assigns professional responsibility for primary medical care and defines the target population for preventive interventions such as immunisation and screening. Whatever benefits the new service developments bring, the registered list is a vital feature of British general practice which must be preserved.