Primary Care Home

This is a guest post by Professor David Colin-Thomé.

A sustainable and transformed NHS is not possible without a sustainable general practice.

A confident general practice must be forcing the pace on necessary NHS culture change. The Primary Care Home is more than only being a care model, it offers a unique opportunity to ensure the foundation of NHS care will remain list-based primary care.

Context

The aspiration and ambition of the main title of this paper is held by many of us in primary care. What is unique in my lengthy working lifetime is its expression by Simon Stevens, Chief Executive from April 2014 of NHS England (NHSE). Since that appointment we have a sustained and increasing support for general practice and a commitment to the NHSE Five Year Forward View (2014): ‘The foundation of NHS care will remain list-based primary care.’

Over the last few years, however, general practice has seen its workload hugely increased and its share of NHS finances actually reduced, despite continuing to provide over 80% of all the clinical consultations in the NHS.

Announcing the GP Forward View (2016), Stevens said he was “openly acknowledging” the problems and acting on them. “GPs are by far the largest branch of British medicine and as a recent British Medical Journal headline put it — if general practice fails, the whole NHS fails. So if anyone 10 years ago had said, ‘Here’s what the NHS should now do — cut the share of funding for primary care and grow the number of hospital specialists three times faster than GPs,’ they’d have been laughed out of court. But looking back over a decade that’s exactly what’s happened. Now we need to act and this plan sets out exactly how.”

Here are some facts about general practice egregiously ignored by Stevens’ predecessors:

• There are an estimated 370 million consultations a year — up 70 million over the last five years.
• A third of GPs say they are planning to retire in the next five years.
• There are 32,628 full-time GPs — a rise of just over 500 in five years.
• The number of GPs per head of population has fallen since 2009 to 60.6 per 100,000 people in 2014.

GP workloads have reached ‘unsustainable’ levels according to a major study published in the Lancet in 2016. The study analysed more than 100 million GP and nurse consultations at almost 400 general practices in England between 2007 and 2014. It found that the average number of consultations per patient had risen by almost 14% for doctors, with patients now seeing their GP almost four times a year. The number of nurse consultations rose by 2.76% over the same period, while telephone consultations nearly doubled. Maybe unsurprisingly one in 10 GP trainee places went unfilled last year.

Despite these unprecedented pressures, more severe than any other in the NHS, this year’s GP survey reported more than 85% rate their overall experience of their GP surgery as good. Furthermore, Care Quality Commission (CQC) ratings for general practice are far superior to care homes and especially that of hospitals despite the latter’s resources having risen as a percentage of NHS monies.

The definite commitment in the GP Forward View to increase resources over the next five years is described by the Royal College of General Practitioners as “perhaps the most significant piece of news for our profession since the 1960s.” Stevens, in a subsequent speech, emphasised his appreciation: “There is arguably no more important job in modern Britain than that of the family doctor.”

There are two other relevant GP policies and extra funding of recent times: the then Prime Minister funded a GP Access fund, known as the Prime Minister’s challenge fund when launched in 2013 — a political not a management initiative. And in 2015 the government has funded a support package for practices deemed vulnerable.

So there we have it. The cynics, befitting their personas, will remain cynical. As for the rest of us, whether working in primary care provision, commissioning in which GPs continue to have a key leadership role, or in supporting practice and other community based services, we need to ensure the centrality and sustainability of these services.

Three luminaries who have taught and inspired me (two being USA citizens where there is no comprehensive GP service) have set a context in which general practice in particular and primary care in general can thrive. The late and lamented Barbara Starfield is to me the foremost primary care academic:

“The well known but underappreciated secret of the value of primary care is its person and population, rather than disease focus.”

(Starfield, 2009)

And

“There is lots of evidence that a good relationship with a freely chosen primary care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs.”

(Starfield 2001)

And from the doyen of health care improvement:

“…the soul of a proper, community orientated, health-preserving care system.”

Berwick DM. A transatlantic review of the NHS at 60. BMJ 2008;337: a838.

And if we ever get too far ahead of ourselves:

“…claiming territory unable or unwilling to occupy.”

Julian Tudor Hart, retired South Wales GP: A new kind of doctor. 1988.Merlin Press.

Preserving, developing, enhancing a sustainable general practice. More Donald Berwick:

“Every system is perfectly designed to get the results it gets.”

While welcoming the commitment to general practice in word and deed by the NHS Chief Executive, real doubts remain about the capability of the NHS to deliver sustainable general practice given the prevailing culture that has produced an underinvestment in that service. It strikes me that ultimately only general practice itself, with as much support as it can muster, can change that culture.

General practice is essentially about being a provider, important though commissioning is. Indeed, collectively the provider that undertakes 80% of all NHS clinical consultations of proven high quality — consistently high quality and outcome (QOF) scores and more comprehensively evidenced by the Commonwealth Fund reports of 2010 and 2014 — and for low cost — currently 8.5% of NHS monies. To summarise, the NHS provider that, in fact, offers the highest value.

So what do we need to systematically offer with a minimal unwarranted variation? More Starfield: “That aspect of a health service that assures person focussed care over time to a defined population. Accessibility to facilitate receipt of care when it is first needed, comprehensiveness of care in the sense that only those conditions that are too uncommon to maintain competence and rare or unusual manifestations of Ill health are referred elsewhere. And coordination of care such that all facets of care (wherever received) are integrated.”

Building on Starfield’s seminal works, a model for general practice: First point of contact care. Continuous person and family focussed care. Care for all common health needs. Management of chronic disease. Referral and coordination of specialist care. Care of the health of the population as well as the individual. Chambers and Colin-Thomé (Doctors Managing in Primary Care – International Focus 2008)

All practices, small or large, rural or urban, successful or vulnerable, need to deliver on those services for their patients. They may deliver by working either singly or by co-operating with other practices. If a multi practice, each practice may by agreement only deliver some of these services themselves, with the proviso their patients will receive the full range facilitated or provided by the larger organisation. Variation in funding will need to be decided locally. The role of the larger GP organisation has become enormously significant in the modern context.

General Medical Practice’s heritage, strength and popularity with its patients has been earned by being local to its community and offering continuity of care. These virtues must be preserved but further enhanced by being also part of a larger organisation. Hence the popularity of GP Federations, first mooted by the Royal College of General Practitioners in 2007, some of whom cover large populations and the care models on offer in the Five Year Forward View. It is estimated that currently three quarters of English general practice has joined large scale GP organisations. To fulfil the potential of general practice as a local provider and as a service that can shape and transform the NHS, it must be concomitantly ‘small and large’. Small as an essential element of local social capital and large to be of strategic importance.

My next blog will describe my concept of the Primary Care Home and place it as essential to fundamentally reshaping, and hopefully transforming, the NHS. It enables a sustainable, motivated general medical practice, an alternative to hospital centricity and a challenge to the stultifying adoption of the ‘New Public Management’, which is no longer new and seems not to have fostered good management, let alone leadership.

. . .

Continue reading the second of our two guest posts by David: A Way Forward for Community Based Care

Further reading: The National Association of Primary Care — Primary Care Home

David Colin-Thomé

Indpendent Health Care Consultant, Honorary visiting Professor of Health Policy and Management Manchester Business School, Manchester University. Formerly GP Runcorn for 36 years, National Clinical Director Primary Care Department of Health England, and Honorary Visiting Professor of the Centre for Public Policy and Health, School of Health, Durham University. For more information, see www.dctconsultingltd.co.uk