The Blog

Let it Flow, Let it Flow...

The patient-doctor consultation is the irreducible essence of general practice. The consultation is the safest of all safe places where I and my colleagues can help patients through the traumas of life, and identify tell-tale signs of physical and mental illness before they have the chance to fully manifest themselves. The sense of reward and achievement that comes from helping anxious, often scared, patients during the consultation is second to none. I'd even go so far as to say that the consultation is one of the few things preventing even greater numbers of GPs leaving the profession in this time of crisis, where demand is substantially outstripping supply.

But general practice does not operate in a bubble. Successful outcomes are interdependent on the success of other services.

So to improve access for patients, the NHS has to improve the flow of patients' journeys not just at the front doors of surgeries, but all the way through to their rightful destinations, most of which are not hospitals, and which by their low-tech nature are not considered sexy enough to be adequately financed by government. This means clearing blockages to clinicians providing sufficient quality time during consultations, and increasing the capacity and availability of community health, social and mental health care professionals.

General practice is under threat. London in particular is seeing a steady and growing wave of GPs and practice nurses exiting the NHS and consequent GP surgery closures. Our own recent survey of over 1300 practices found that up to ten per cent are considering handing back the keys due to workload and stress.

With less funding for practices and community services like district nurses, health visitors, mental health workers and social services, the knock-on effect is that practices get clogged up, GPs and staff are overwhelmed, and tell-tale signs of illness can be missed as practices squeeze more consultations into less real time. Add to this the burgeoning of NHS bureaucracy with its demands for pico-levels of data by yesterday, and the political targets of unproven health value that practices are required to meet, and it becomes obvious why your consultation time is gobbled up by the need to feed the beast sitting on your doctor's desk.

Everybody gets a worse deal when patients wait longer for appointments. Too many GPs and practice nurses in London are running on empty trying to manage these rises in demand. And at the other end, hospitals are discharging more patients to local family doctors; with care needs such as the management of more and more medical conditions and the prescription of drugs that patients would have previously had done at hospital. GPs are sick and tired of having more work and responsibilities dumped on them. Low morale and burnout are common.

So what can be done to help?

We need to clear the blockages by stripping out demands from the NHS system which don't add value, or worse which diminish it, to the patient having the consultation at the time; by prioritising the development of coordination and navigation of care at practice level to support patients - that's you and me by the way - through our erstwhile complex health and wellbeing journeys (ahead of creating even more so-called integrated care or accountable care organisations). And we need to work with commissioners to increase capacity so that the right people are in the right place to provide the right services; and so that IT systems and premises are fit for task and are a help to general practice rather than a hindrance.

The Five Year Forward View should, we hope, introduce some much needed stability. But alongside that vision for a coherent, resourced, and coordinated NHS we desperately need a moratorium on the destabilising GP contract reviews that are further disrupting primary care in the Capital. And a focus on freeing up resources to support clinicians at risk of burnout - reinforcing their professional values and building their resilience and morale.

General practice desperately needs to see an end to the culture of contractual threats, bullying and intimidation that can exist within primary care organisations. We call on commissioners to work with us to support and recognise the challenges faced by primary care; provide ongoing education, training, mentoring, improvement and leadership skills; build resilience culture at practice level, and; to implement local, accessible occupational health support for NHS practice teams.

Critically, we need to work together across the health service(s) to be clear that neither hospitals, nor GPs hold all of the answers. Rather, they are part of the network of "pipes" channelling patients to the best services for them - not the system. All pipes do not have to lead to hospitals, or back to general practices. By working together, commissioners, providers and local medical committees should work with stakeholders and partners locally to promote education and prevention, self-care, and awareness of community, mental health, social and voluntary services. Expanding on such community services as are needed in particular areas by developed and collaborative commissioning.

But transformation can only go so far without investment. To develop truly collaborative services we need to prime the pump; commissioners must recognise the need for sustainably funded services through periods of transition, and must be realistic about how long it takes to develop new services and bring them into full use. And critically, we must be wary of replacing the good with the new. Innovation is all well and good, but continuation of something that works would be preferable. And more beneficial to the patient.