This post is the first of a three part series on the state of primary care by two of CHPI’s founding trustees: practicing GP Jonathon Tomlinson and academic and author Colin Leys. This piece is by Jonathon, and here you can read the second part ‘The GP Shortage’ and the third ‘Continuity of care vs ‘transactional’ care’.
Purpose
Any vision for the future of general practice must begin by clarifying what general practice is for and whether this should remain the case in future. Any proposals should be assessed in terms of how much they support or undermine its purpose.
The Commons Health Committee invited submissions on the future of General Practice in March last year which included one from Professor Chris Salisbury from Bristol, who summarised it this way,
“The purpose of general practice is to provide ‘proactive, personalised, coordinated and integrated care’. General practice is the front-door to the NHS. It needs to be accessible and comprehensive so that most people’s problems can be addressed most of the time. It should provide high quality care which maximises outcomes and patient experience in an equitable way, while minimising costs.”
Many people have an assumption that GPs see two types of patients. Those that they can fix or reassure, and those that they cannot, who need referral. The reality is that only about 10% of patients need referral, about 20% have acute illnesses that they can cure and the rest have complex chronic problems that need long-term, often lifelong care.
A typical GP morning or afternoon surgery for me may consist of between 14 and 24 phone calls booked by patients, usually within 24 hours of the appointments becoming available. Last Thursday morning at 8am there were already several patients in the waiting room trying to make an appointment at the reception desk. Some of them didn’t have phones, or were unable to book online, some were waiting for a pre-booked face to face appointment.
Darren, a homeless man with learning difficulties was pacing up and down wanting to see me. He didn’t have an appointment but I hadn’t seen him for several weeks and I knew that he had diabetes and schizophrenia and can become very unwell and so I saw him before I started my calls. He needed a full physical check-up and was due blood tests which I took while he was with me. I spoke to our practice social prescribing lead, who spent some time with him and organised some additional support and we arranged for Darren to come back in the next day so that I could see him with the blood results.
I looked at the list of patients to call. All but one of the names was familiar because my practice has embedded continuity of care as a core value and organising principle. The patient I didn’t know had left a short message, “It’s for my son, he won’t eat, we need help” Later when I called, I discovered that they were asylum seekers living in emergency accommodation where the food was notoriously unpalatable. As asylum seekers with no recourse to public funds, they had no choice but to eat what was provided, but her son, aged only 2, wouldn’t eat it and was constantly crying and losing weight. I arranged for them to come in for a face-to-face assessment.
Among the other calls was Shirley. Her message said only, ‘Back pain, need stronger pain-killers”. I knew that Shirley was grieving. Her husband died at the beginning of the year and her daughter died from breast cancer shortly before that. Her back pain, from osteoporotic fractures, had been harder to tolerate since then. She would call roughly every 2 weeks and we would talk, one time by phone and the next, face to face. After our chats she would usually say, “You know what doctor? I don’t think I need those painkillers now”. I wonder what treatment she would get from a GP who was a stranger. Ivan says, “I think I have a chest infection” A few months ago he was in a terrible state, addicted to crack cocaine and alcohol and too chaotic to engage with care.
Since then, things have improved. I remember a series of long consultations when things began to change but could not remember what had helped him make the difference. I wanted to see how he was doing, so invited him in to examine his chest. He looked amazing, a glowing picture of good health, barely recognisable compared with the man I knew before. As I went through the motions of a clinical examination, I realised that the reason he had booked the appointment was so that I could see how much he had achieved. We both felt quite emotional – I asked if he would be happy to come to speak with medical students and he said he would love to.
Also on the list were a couple of infants, only a few weeks old, and I arranged for them both to come in for a face-to-face assessment. I knew the parents well and would be able to see how they were managing as well as assessing their children. A fourteen-appointment surgery turned out to be eighteen after dealing with Darren and a couple of other patients who needed to be seen.
About half of the patients were trying to deal with depression and/or anxiety as well as whatever else had caused them to book an appointment, and six of them were also suffering from chronic pain. Several were socially isolated, and their loneliness was apparent even though they described physical symptoms. I referred one patient to hospital with partial loss of vision and I reviewed several patients’ long-term conditions while they came in for something else.
At the end of the calls, I visited a ninety-year-old woman who had fallen during the night and whose face was bruised all over. Perhaps someone else could have visited her, but I have known her for over 20 years and our shared history meant that the visit would mean more than a brief clinical assessment. Although I work in a deprived, multicultural community, the complex mixture of social, psychological and physiological complaints is typical, if less severe, in any GP surgery.
Prevention and population health
General Practice provides proactive, anticipatory, preventive care. This includes planned care for all patients with long-term conditions as well as child health checks and immunisations, antenatal care, and regular reviews for vulnerable groups such as housebound patients or patients with learning disabilities, or people at risk of disease because of smoking or obesity. We provide care for populations as well as individuals.
Most of the administrative work of a practice is dedicated to this work but this rarely gets the attention that reactive care for individuals with acute conditions receives. The range of medications available to treat long-term conditions like Diabetes or COPD has increased significantly in the last few years and patients are living longer with more advanced disease. This means that the work is a lot more complex than it was when I began as a GP over 20 years ago. Organising preventive care depends on management and administrative expertise backed up by effective IT. While IT in NHS general practice is almost universally inadequate, management and admin vary widely and are much harder to recruit for in areas of deprivation. Effective general practice depends on this as much as it does on clinical staff.
Opportunities for prevention and population health come from making it easier for GPs and other practice staff like nurses and pharmacists to access specialist advice when needed. Patients prefer to access care near to home so it should remain in GP surgeries. Continuity of care with different members of the practice team can and should be an organising principle to build trust and confidence. Strategies to recruit and retain good management and admin support should match those for clinical staff. Some of this can be done at scale, but the importance of human relationships between members of staff as well as with patients, should not be overlooked.
Relationship-based care
Proactive care for long-term conditions and reactive care for acute concerns cannot easily be separated. Patients with long-term conditions undergo episodic exacerbations, and acute illnesses happen to people already living with chronic diseases. Many people live with complex multimorbidity – mixtures of different, interacting conditions, for example diabetes, vascular disease and lung disease. Mental illness and social adversity, such as poor nutrition, inadequate housing and deprivation further undermine health. Underpinning effective care for patients like this are long-term relationships with expert generalists who know their personal history as well as their medical history and social circumstances, clinicians who can advocate for them.
For this reason, Relationship-based care is key among the RCGP recommendations in their report, Fit for The Future. Continuity of care is associated with greater patient and clinician satisfaction, greater efficiency and earlier diagnosis of serious conditions including cancer. Continuity can only thrive where there is organisational support to ensure that patients are booked in with the right clinician. In organisations like mine, continuity is the default. In organisations that do not support continuity of care but attempt to book patients in with a clinician that knows them only when it is essential, continuity will be far harder to achieve.
Opportunities can arise, if there is a stable workforce and organisational support, for continuity of care and easy access to face to face appointments for those that need it.
Risks are that without experience of continuity of care, patients and clinicians will cease to value it, no matter how strong the research. With fewer GPs and more additional clinical roles, including physician associates, physiotherapists and specialist nurses, patients will cease to have a therapeutic relationship with someone who knows about them as a person and not just through the lens of a single disease. Trust and confidence in medical professionals will be eroded and levels of satisfaction for patients and professionals will fall. One response to the lack of GPs is a rapid expansion of new clinical roles, including clinical pharmacists, physician associates, paramedics, physiotherapists and more, working in primary are.
Risks include care becoming more fragmented. ‘Taskification’ is the process by which a clinician’s work of caring for a patient is broken down into separate tasks which are given to different people to complete. The problem for patients is that they have multiple appointments with different clinicians who are all strangers. The problem for staff is that nobody feels responsible for the patient, and the risks of delayed diagnoses or treatment increase. The problem for the GP is that they end up supervising several people which takes more time than it would for them to see the patient themselves.
Complexity
Complexity resulting from the presence of multiple diseases and stressors contributing to patients presenting complaints is far more often the case than the alternative – a patient needing nothing more than a diagnosis that can be managed according to a standard protocol. For this reason, GPs who are expert generalists, who know their patients and the neighbourhoods in which they live and the resources and stresses in the community, must remain the primary clinician so that patients can be properly assessed.
Opportunities can come from acknowledging this fact. Management of complexity rather than the treatment of single conditions should be at the heart of GP education. Valuing and making explicit this epistemology (theory of knowledge/ way of knowing) can help to foster pride and identity and re-invigorate General Practice as a career and an intellectual and academic pursuit. Opportunities for patients are a personalised, more humane and holistic experience of care that is tailored to their specific needs and values.
Risks come from incentives used to force GPs and other primary care clinicians to follow rigid single-disease management pathways designed by and for specialists working in secondary care. For patients this would lead to excessive investigations and medications and repeated appointments with a series of strangers who are only interested in one diseased part of them. AI and digital diagnostic tools threaten to do this, with less oversight from a clinician.
The Inverse Care Law
The Inverse Care Law (ICL), proposed by GP Dr Julian Tudor Hart in 1971 claims that the availability of good medical care is least where the need for it is greatest. The ICL also states that this effect is greater the more that market forces are allowed to influence the distribution of care, because it is easier and hence more profitable to care for patients whose social conditions are less of an impediment to good health and engagement with health care. A report from the Health Foundation in January this year showed how funding for general practice in England does not adequately account for the care needs of patients in areas of deprivation. The RCGP Fit for the Future report calls for more funding to recruit and retain staff in under-doctored areas to help address this.
Opportunities depend on a reworking of the funding allocation (the Carr-Hill formula) for primary care so that money matches workload. As well as more money, GPs in deprived areas need a community of practice. This should include peer support as well as specialist back up and opportunities to join others in research or education so that their work is more than clinical consultations.
Risks are that there is no change to funding and that market mechanisms are allowed to disrupt the supply of GPs, worsening the mismatch between the numbers of GPs and the needs of patients as predicted by the Inverse Care Law.
The rise of digital, remote providers is already hastening this as better-off patients with more straightforward needs are dealt with in one tier of care, while more deprived patients with more complex needs are left with a shrinking pool of increasingly burned-out GPs.
Measuring the value of General Practice
The value of general practice is health gain achieved, illness prevented and, holding-work – the supportive partnerships that enable patients with long-term conditions, especially mental illnesses, to keep going. This is hard to measure compared to rescue or salvage at points of catastrophe, such as a heart attack or stroke when patients receive specialist care. It is much harder to count the cost saving of strokes that don’t happen or complications that don’t arise thanks to early diagnosis and good ongoing management in primary care. The recent King’s Fund review of Levers for Change in Primary Care concluded that the NHS is an international outlier in its dependence on top-down financial incentives to drive change. These have been shown to drive activity, but not quality of care or patient outcomes. The review concluded that clinical teams need more freedom to experiment and learn.
Opportunities could arise if there is a critical review of data collection so that we measure only what is genuinely useful to patients and clinicians and stop the arduous and time-consuming data collection that is consuming so much of every consultation. This was summarised in Donald Berwick’s call for medicine to move from our present Era 2 – one of constant measurement, scrutiny, incentives and markets – to Era-3, with a commitment to reducing (by 50% in 3 years and by 75% in 6 years) the volume and total cost of measurements currently being used and enforced in health care.
Risks are that we continue and accelerate the practices of Era 2 with worsening morale, increased costs, and exacerbation of the Inverse Care Law.
Conclusions
General Practice in the UK is in a precarious state, especially in areas of deprivation, and this is prompting a lot of organisations, individuals, and politicians to propose solutions. We need to begin with a clear understanding of the purpose of General practice so that the risks and opportunities of any proposals can be assessed in terms of how they are likely to impact this.
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