The unrecognised – and under-celebrated – core of our successful NHS has been the role of general practice. Their registered list of patients has enabled continuity of care, continuity of patients’ records and long-term relationships that build mutual trust. Fortunately, NHS England’s Five Year Forward View has recognised this, with calls for further investments in general practice, as well as more integrated care.
A modern, forward looking, sustainable and thriving general practice of the future will certainly build on the success of the past. It will also take advantage of having registered lists and integrated care with other providers to have the best place-based commissioning and provision. This would help us provide the most intensive complex integrated care in the least intensive community care setting. We would also be moving from hospital-based care and investment to out-of-hospital based investment.
But let’s be crystal clear about the current context: general practitioners have been put through the wringer. They’re tired – the average working day is often 12-13 hours. And they’re tired of being an afterthought of the NHS.
For decades our politicians and our public have talked about the hospital service as the health service. The evidence also suggests that the government invests preferentially in hospital care and specialists, as compared to general practice. But it is in general practices that 90% of patient contact happens, despite less than 8% of the NHS’s budget being invested there.
This gap between rhetoric and reality has damaged general practices, negatively impacting its workforce and their ability to provide the best care for their patients. There has been loss of income year on year for the last seven years, at the same time as increasing patient needs and complexity of conditions.
When I suggested that general practice must continue to evolve to meet the needs of the future to some of my fellow general practitioners over a Sunday lunch, they were in agreement, but they were also sceptical. One suggested that ‘GPs are far too busy doing their day job and looking after their patients to waste their time on fanciful un-resourced grand visions for the future’.
They continued, suggesting that GPs weren’t just tired, but that they were also frustrated and jaded. The consultants were concerned that hospitals will be asset stripped and the care will suffer – this despite promises of reducing pressures on the hospital system that have not been met. And they had seen more reform programmes and visions of the future from the NHS leadership than they could shake a stick at.
Ultimately, we all agreed that patient needs had outstripped clinical capacity.
So how can we marshal a tired, frustrated and jaded group of workers into a future that meets the needs of a growing and ageing population?
First, we need to increase our capacity to test new combinations of ideas, investing in out-of hospital care infrastructure, workforce and design.
We need to invest upfront in organisational development, tolerate and learn from intelligent failure and have faith in our dedicated professionals in community and primary care.
We can then create the local general practice at scale that combines specialists and generalist nurses and doctors, third sector, pharmacy, social workers, local government and others.
These successful thriving organisations will be as diverse as our populations; this should be our campaign.