We know the population is growing, aging, getting more unwell with more complex illnesses that require more complex interventions/treatments and is demand/expectations growing too fuelling the problem?
We know GPs numbers are falling, we have less doctors per head of population than a lot of developed countries and this is perhaps due to a combination of early retirement (pension issues), lack of medical school places, lack of retention in the profession once qualified and perhaps poor workforce planning or perhaps more sinister a co-ordinated plan to break the power/influence of doctors.
We know there is a huge push to move work from hospitals to primary care, this has been going on for ages partly as hospitals become more and more specialised. Presumably someone must think that care done in primary care is either cheaper or better? Else why the shift?
We know GPs are feeling burnt out and many are thinking of leaving for that reason alone.
There is a growing feeling that the introduction of the Additional roles staff, while a welcome injection of new money into primary care and an experiment in skill mix, hasn’t worked as well as it would have been liked. The staff aren’t as experienced as needed and their training is taking up a lot of the time they free up. There are now shortages in some of the key staff and private companies have got involved increasing the cost. Also some silly rules around these new roles need changing but no one seems to be changing them (who can issue fit notes etc)
So can we do without the GP or their role? In some quarters there is a feeling that you cant simply look at what a GP is seeing and replace the consultation with a specialist in that presenting disease. GPs do more than one thing at once and the patient benefits from seeing a generalist.
Professor Barbara Starfield’s work seemed to prove the usefulness of a generalist at the front door to a health system, improving quality and cost effectiveness of the system. This seems to be borne out by studies of Accountable care organisations in America that apparently tend to invest in primary care and population health in the form of screening/vaccination etc as a way of reducing in hospital costs and improving lives. Yet we are moving to an ever more specialist model, which has been proven to be inefficient and poor value!
Segmentation as part of a population health approach is a current buzz word. People are trying to identify discrete population groups that would benefit from intervention as a way of targeting resources in an efficient way. For example, patients who are likely to fall in the next year for OT/physio intervention, or patients at high risk of developing diabetes to send on weight management courses. Often these groups are identifiable or manageable at a supra-practice level and can be dealt with by a new team. Some require each practice to do the work but there is an elephant in the room – clinical quality varies from practice to practice which ill mention again later.
Our local hospital Chief Executive has segmented hospital patients into wide groupings; pts attending A&E, out pts, in patients etc. and has identified certain groups he feels shouldn’t be in hospital e.g. end of life as a way of creating a work plan. I wonder if we could apply this approach to patients that GPs see as a way of looking at what we do.
A not exhaustive list might be 1. Acute minor ailments that are usually self-limiting. 2. New presentation of disease that could be minor, could be chronic or could be life threating, this links to 3. patients currently being investigated, 4 patients needing referral or 5 awaiting being seen by a consultant for a discrete episode of care, 6 patients under one or more consultants for complex/chronic illnesses that cant be managed in primary care alone, 7 house/home bound, 8 end of life/palliative care, etc.
Is it time to ask some fundamental questions? What do we want GPs to be doing? What are they good at? What can only they do? What is the most cost-effective thing for them to do? What can they drop doing?
Rather than every other speciality using General practice as its overflow – what can others pick up? Why do health visitors and midwives sent patients to the GP for simple prescriptions that surely they could issue if only they were allowed to? Why do ANPs and Physios send patients to GP to do fit notes or X-rays? Why don’t we spend some of the SSRI drugs budget on talking therapies – as a lot of GPs will state they only prescribe because patients can’t get therapy. Some simple rule changes to who can do what and moves of money might make big differences but who is doing them?
People talk about, is the future of general practice salaried? Is it Super-practices? Perhaps what we should be asking is what services need to be done, at what scale and what is the best model to deliver them?
Where does a practice approach work? Where does a town approach work? Where does an area approach work? Form might follow function.
We know that a lot of practices have seen the potential benefits of merging into a bigger organisations. Whether all have realised them is a good question. We know that some are very resistant to this for a variety of reasons inc geography, culture, personalities etc. Should we be forcing all to merge or have those that will done it already? Has anyone really evaluated whether bigger practices give better care?
We know that small practices often do better in patient satisfaction surveys. This may be that they can be better at patient continuity or perhaps they care about it more? Is it that large practices attract GPs who want a more portfolio careers and therefore continuity suffers or is there something wrong with large practices?
Should we look at the segments and say minor ailments could be a separate service run at town/or bigger along the lines of walk in centres or out of hours. In a neighbouring town all the practices in the pm take turns in doing the on-call leaving the others free to concentrate on chronic disease – has this been evaluated?
Do we say that palliative care could become a community service with some Macmillan nurses, some specialist GPs and hospice teams all employed centrally to deliver a service across a PCN or area? Existing GPs who particularly enjoy this work could opt to work in that service for some/all of their time. Of course we may feel that palliative care is one of the things to keep at a practice level. I’m not saying which should be what or indeed that one solution fits all – a combination of geography and existing relationships/services might influence the choice, I’m saying we should be asking the question.
For example chronic disease management – is this more important to be done in primary care than seeing colds? Would improving chronic disease care deliver much more in the way of savings and longer healthy lives than dealing with an endless queue of self-limiting illness? If it would, why does is always appear to be second in priority to book on the day work?
Revisiting the variation topic – there is some evidence that there is unwarranted (on a patient demographic point of view) variation in quality from practice to practice some of this may be due to workload or other factors. The right care data and other such evaluations seems to suggest huge savings are to be made in the long term by treating disease well but we de-prioritise it over coughs and colds worried they may be cancer why aren’t we tackling this?.
Should CDM be done by a specialist service cross PCN? Local labs wonder if they rather than GP practices should take on drug monitoring – should the diabetes team take on all diabetics. They may argue that they would be more consistent across a patch and all patients would benefit to the same level? Of course, I’m not pretending that all hospitals give the same level of care either or even good care.
Services is another hidden variance. Why do some practices do ECGs in house same day, some it’s a 4 week wait to go to hospital? Some do minor ops? Some do bigger ops? Some have onsite diagnostics some don’t. Some do wound care, travel clinics, HGV medicals some don’t. Some have 1500 patients per GP some 2500 is this right? Are we measuring this? are we comparing? Why aren’t isn’t their guidance on what general practice is?
Could community services take on some segments. Should we have bigger A&Es that have walk in centres? Do we need to invest in rapid result diagnostics as a large cohort of patient’s get seen while waiting for tests?
Also, what do patients want from their GP? This may vary from area to area from city to country. Of course, the Oregon experiment suggested that patients get it wrong too, but they should be involved.
There may be a presumption that the only way we can redesign what practices do to deliver a consistent and ‘segmented’ service would be to set up an NHS run salaried service, however we know from a productivity and cost point of view that this would be a disaster, so the question is – how can we progress this debate and come up with the right answers within our current General Practice model?
Dr Neil Paul is a GP; a Partner in a large practice in Sandbach, Cheshire; a PCN Clinical Director, and a Director of Howbeck Healthcare. Howbeck Healthcare provides support and services to practices, PCNs, and Federations.