I care for people not organs, with a continuity that simply cannot be replicated in secondary care…We change lives and we save lives. Dr Mawer
The feeling of being connected with people, understanding their complexity, respecting our equality and our differences and giving something that they value has been the recipe for a deeply fulfilling life. Dr Rhugani
These are two quotes from GPs encouraging others to follow their path into general practice through the Twitter hashtag #WhyGP. The hashtag is the brain child of Dr Dominic Patterson (@DocDomP), GP and GP educator, seeking to create “an island of positivity in a sea of negativity” exemplified by the daily headlines about rising numbers of GP vacancies and high rates of GP burnout and stress.
It is a pity, however, that the hashtag is not #WhyPrimaryCare. The shortages of GPs are matched by equally serious but less well publicised shortages in primary care nursing. Like their medical counterparts, nurses in primary care can have deeply fulfilling roles.
Earlier this week I was privileged to spend the afternoon shadowing an advanced nurse practitioner working in a primary care team in Lewisham. Having observed her at work, she too could argue that she changed lives and saved lives. I saw her delight as, through her support, a hard working builder who clearly enjoyed his food and drink had managed to get his blood sugar under control. I saw the skill with which she persuaded a grandmother, now having to care for her vulnerable daughter and her daughter’s child, to try therapy rather than drugs to manage her anxiety. I also saw the high degree of trust vested in her. People came into her office bowed over, palpably anxious and stressed, yet left standing straighter with a smile on their face.
As a member of the Primary Care Workforce Commission whose report ‘The future of primary care: Creating teams for tomorrow’ has just been published, I was left under no allusion as to the scale of the workforce challenges faced by primary care, but at the same time – given appropriate support – the huge opportunities. A story we use in the report is the experience of the Group Health Cooperative in Seattle. The early part of this story bears an uncanny resemblance to the recent history of primary care in the NHS. The latter part is similar to the path we advocate in our report.
In the 2000s, Group Health, in an attempt to improve performance and save money brought in a range of measures to improve access to GPs. They laid off nurses and reduced consultation times. While the doctors saw more patients, those patients also made more visits to A&E. The doctors became burnt out, and many reduced their hours or retired early.
Recognising that they had a looming crisis, Group Health redesigned care on the principles of the patient-centred medical home, with more attention paid to personal relationships and continuity of care with individual healthcare professionals, better team working and better coordination of care. They reduced the number of patients per doctor and increased appointment times. They recruited medical assistants and clinical pharmacists. Nursing roles were extended to include outreach work. They shifted much of their work to email and phone contacts.
The result was not only a significant improvement in staff morale and patient experience, but also a reduction in use of hospital care – delivering overall savings to Group Health.
The path chosen by Group Health aligns well to the Five Year Forward View and proposed the new care models. However, recent talk of ‘scorecards’ and the continued emphasis on access rather than continuity suggest no let up on a more rigid performance focus from our political masters. It is a focus that could be hugely counter-productive.
Strong primary care is the essential foundation for a sustainable NHS. Jeremy Hunt, who seems happy to learn the lessons from the Virginia Mason Institute in Seattle, would do well to learn the lessons from their nearby neighbours, Group Health.
imison C (2015) ‘#WhyGP: Should it be #WhyPrimaryCare?’. Nuffield Trust comment, 4 August 2015. https://www.nuffieldtrust.org.uk/news-item/whygp-should-it-be-whyprimarycare