General practice is making a leap in the dark
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5698 (Published 28 October 2016) Cite this as: BMJ 2016;355:i5698
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In their editorial Professors Marshall and Pereira make important points about the value of ‘effective general practice’ and the danger of the current ‘ad hoc’ changes, but they fail to acknowledge that ‘the baby’ has become so emaciated that it’s already slipping down the plughole. General practice isn’t leaping, or doing anything else at all, the changes are happening to it by default.
The editorial lists access, holistic care, managing risk and a focus on prevention as the qualities that make for effective general practice yet how can that be the reality of the many practices today, of whatever size, that lack clear leadership and are staffed increasingly by salaried and locum GPs.
Larger organisations may not always be the answer but successful healthcare organisations, big and small, know that their success is generated by facilitating their frontline staff to provide good care including continuity and a productive relationship with their patients.
What we need is a proactive review of the role general practice should be playing in the 21st century NHS and then a redesign to get us there. Surely this is what our professional leadership should be focused on?
Competing interests: No competing interests
Professors Marshall and Gray make a convincing case that new models of working risk throwing the baby of General Practice out with the bath water of health service reform. In my role leading a Local Medical Committee in the East Midlands of the UK my team and I witness many of the unintended consequences of implementation of change. Too often we hear local health managers voicing the mantra 'the current model of General Practice is broken' - my view is that the current model is actively being broken. In Leicestershire in the last nine months we have had four sizeable GP partnerships hand back their contract - the latest one which serves nearly 6,000 patients was handed back just six days ago.
Every day I speak with individual GPs who say they cannot sustain the work they do - they are reducing their clinical sessions, retiring early, emigrating and burning out. In September Leicester's Deputy Mayor hosted a 'Primary Care Crisis Summit' and it was clear from a wide range of participants that patients and carers want continuity of care above all else. I concur with the authors that a strong commitment to evaluating new models is necessary. If the prime motives of implementing reform includes control of costs, getting a 'grip', a belief that big is better and possibly to create a predominantly salaried GP service rather than reliance on an independent contractor model then we have to remember that a demoralised workforce may be a secondary victim. The prime victim of reforms in many areas will be the risk of new models not giving patients the quality and service that they want and need.
Competing interests: No competing interests
Changing models of health care delivery by general practitioners could be the result of changing expectations of the people at large, whereby a patient feels not satisfied with the available treatment at the primary care level when diagnostic facilities are available at the doorstep, especially in urban areas. The awareness of people regarding health problems, available infrastructure, facilities in the health facilities starting from the primary to secondary and tertiary care level has led to higher expectations from primary care doctors. The GP, on the other hand, has limited resources and cannot meet the expectations of the people at all times. This can be frustrating on the part of the GP, and it might have an effect on the quality of care provision to patients. However, there are several diseases where the GP can play an effective role, epecially providing immunization, taking care of minor ailments, and providing health promotion measures for prevention and control of diseases.
In the context of developing countries such as India, primary care physicians have minimal resources to take care of patients’ needs and, hence, referral to higher health facilities becomes a routine affair even for certain minor ailments. This leads to overcrowding in the higher health facilities, and physicians in the higher centres cannot provide quality time and care for patients. In some hospitals such as Kasturba Hospital under Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha in Maharashtra, India, screening of patients for those needing referral care is done as the first step and then specialists take care of the referred patients. This reduces the burden on specialists and hence leads to the provision of adequate and quality care. However, this model cannot be implemented everywhere depending upon the availability of space, manpower and facility in health care settings. The screening component is done by primary care physicians and it is found to be appropriate and acceptable. Thus, GPs can still play an important role in health care delivery provided that the appropriate structure of health care delivery model is developed. We need GPs since the population is large, and we cannot provide adequate number of specialists for the population.
Competing interests: No competing interests
Re: General practice is making a leap in the dark
Professors Marshall and Pereira Gray’s Editorial (1) was welcomed by a group of us in Derbyshire, South Yorkshire and Bassetlaw, where unfortunately, like GPs around the country, we are not seeing the resources promised in the ‘General Practice Forward View’ (2) reaching frontline services as yet. Cited by Professor Mathers as “one of the most important events for general practice since the GP Charter of 1966”(3), the NHS England led ‘vision’ style report pledges a 14% real terms increase in investment in primary care by 2020/21; this fits with the emerging ‘Sustainability and Transformation Plan’ (STP) model which aims to increase care for patients in their own homes with substantial increased investment in community services.
However, despite the GP Forward View bringing hope by acknowledging a chronically under resourced and increasingly demoralised GP workforce, we are disappointed to report that the only extra resource received in our regions so far is a woefully inadequate £800 - £2000 per practice for ‘resilience’.
On a positive note the STP have brought professionals from different arenas together for the first time; the local and regional enthusiasm, hard work and compassion for our patients and communities is heartening despite the current climate of austerity.
Sadly though many frontline GPs have not heard of the STP, let alone know what this acronym stands for literally or in practice as the NHS is yet again reorganised. This is perhaps due to lack of transparency of these documents thus far or heavy clinical workloads, which lead little time for reflection on NHS England reform.
We are fearful that the severe disconnect between the ‘vision’ of the ‘GP Forward View’ and ‘STP’ with the reality of funds not reaching General Practice could be catastrophic. The bed closures aimed for by the STP to ‘close funding gaps’ will lead to savings but at what cost ultimately to patient safety if funds to do not reach community services to replace them? GP and community services need the ‘Sustainability’ funds for training, infrastructure and staff before the service can be ‘Transformed’ to close any funding gaps.
References:
1 Marshall M and Pereira Gray D. General practice is making a leap in the dark. New models of working risk throwing the baby out with the bathwater. Editorial. BMJ. 2016; 355:15698
2 NHS England. General Practice Forward View. 2016. https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf [accessed 14.11.16]
3 Mathers N. General Practice Forward View: a new charter for general practice? Editorial. BJGP 2016; 66, 651. 500-501.
Authors:
Dr Liz Walton NIHR Clinical Lecturer, GP and RCGP Co-Ambassador for Derbyshire
e.walton@Sheffield.ac.uk
Dr Mark Torkington
GP and RCGP Co-Ambassador for Derbyshire
Dr Kathryn Markus, Chief Executive Derby and Derbyshire LMC
kath.markus@derbyshirelmc.nhs.uk
Dr Ben Jackson
GP, Clincal Teacher and RCGP Ambassador for Sheffield
ben.jackson@yh.hee.nhs.uk
Dr Ben Milton
ben.milton@northderbyshireccg.nhs.uk
Clinical Lead and Chair, NHS North Derbyshire CCG.
Competing interests: No competing interests