Margaret McCartney: Scottish GP contract—responsibility without power?BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5628 (Published 06 December 2017) Cite this as: BMJ 2017;359:j5628
All rapid responses
"Another big issue with the contract is its reliance on advance care planning to reduce admissions despite large uncertainties about whether this is possible. My fear is that GPs will continue to fill the gaps created around work that others don’t take on—and that we may have little choice in what that work is........................
........................But, as proposed at present, we retain responsibility without necessarily the resources to discharge it".
Helpfully, as always, Dr McCartney gets to the heart of the issue. What are we best at and where can we make most impact, especially as we are fewer than previously.
The impact of Advanced Care Planning (ACP) and the Key Information Summary (KIS) are uncertain. The latter has assisted those working out of hours to make better decisions which may affect sending someone towards admission.
I foresee GPs as expert community generalists convening meetings in patient's homes at which patient, carers, DNs, community OTs, and relatives determine priorities and address uncertainties. I have a feeling that consultant geriatricians doing domiciliary visits did this and OTs taking in-patients on home visits as part of discharge planning achieved the rest. The first GP planned home visit would set up the agenda and seek informed consent to the second meeting with other invited attendees. After the second meeting, a plan (ACP) and KIS need to be composed.
Unless GPs feel that others should do the first meeting and compose the summary of the second meeting, that process will take some considerable more GP time than we have previously provided to individuals who are frail and housebound.
Similarly, working in a number (12) of practices in the last year, the majority provide15 minute appointments as standard. That offers rather more scope to deal effectively with the complexity of unfiltered problems.
In the new models of care by expanded teams, continuity of care will mean different things. Bruce Guthrie
(BMJ 2008;337:a867) described:
"Box 1 Three types of continuity of care
Informational continuity—Formally recorded information is complemented by tacit knowledge of patient preferences, values, and context that is usually held in the memory of clinicians with whom the patient has an established relationship
Management continuity—Shared management plans or care protocols, and explicit responsibility for follow-up and coordination, provide a sense of predictability and security in future care for both patients and providers
Relationship continuity—Built on accumulated knowledge of patient preferences and circumstances that is rarely recorded in formal records and interpersonal trust based on experience of past care and positive expectations of future competence and care
and later..............Physician responsibility is a key concept, as identified by Michael Balint in the 1950s. He described the “collusion of anonymity,” where general practitioners and specialists avoid taking responsibility for complex patients who attend both, each assuming that the patient is the other’s problem. Fifty years later, in the face of increasing fragmentation of care, Balint’s conclusion remains true: generalists are best placed to take responsibility for holistic care, coordination, and advocacy for the most complex patients. That generalist is currently almost always a doctor, but nurses and case managers may increasingly take on this role. Despite its neglect in policy, relationship continuity remains vitally important, both because it matters to patients and because it facilitates informational and management continuity when they matter most."
If we cannot make relationship continuity work well, brand confidence in primary and community (social) care will not develop. That is essential if patients and carers are to agree to home management when uncertainty, anxiety, disability and pain require managing.
Have we asked for this or are we inadvertently filling a gap as Dr McCartney warns? Will we have the time and team to do community planning well?
I suspect that current progress with Clusters is slow. So many GPs when they get together look outwards at problems in interfaces and in other's areas of responsibility. Unusual for them to consider their collective practices efforts - access, communication, learning, leadership, quality of records and care. Do any care whether their patients can get through to the practice at 8am? Why are patients standing at the locked front door in the morning in freezing temperatures when there are staff inside who could considerately usher them into the waiting room? Can we learn from each other - does it really make sense to put patients off lists for failure to attend? And so on.........
Of course not all GPs are best at the same things - not all are leaders but most can be trained to lead. Not all teams currently function well as teams and external facilitation could be key. Will health boards have the resources to meet that need?
Competing interests: No competing interests
This is a thoughtful article which makes very valid points about the proposed contract. It's sad not to see these real concerns echoed in any of the official BMA views, in either the journal or the News Review
This graph, which was put together by Dr Gerry Wheeler for RGPAS, shows the disproportionate effect of the contract on rural GPs in Scotland
You can click on practice dots to see how much their income will drop before the proposed "uplift". Very few rural docs have any trust that the uplift will be maintained, despite the guarantees by our BMA betters, who are on record with some extraordinary condescending comments about rural GP.
I'm semi-retired now so not so worried about the effect on my personal working life. But I do have concerns about just how many people it will take to provide my, probably fragmented, healthcare compared to whenIi could assess a patient, do a bedside INR, a blood test and a flu jab, all in about 15 mins, meantime asking after their family and dog and contributing to continuity...
(Perhaps I'm biased by my experience last year when I went for a flu jab in a new practice - I have an ongoing medical reason and am also a health professional but I wasn't on the computer list and so the Practice Nurse, and Practice Manager, whom she consulted, both said "No".)
Like Margaret McCartney, I think the intentions are good but I feel a mark is being missed.
Competing interests: No competing interests