What a grim year 2015 was. A new Government (same Health Secretary); a new vision for the NHS (same money). But let's not dwell - new year, new start!
For all of the challenges that we face in general practice, it is still the most rewarding job in the NHS. And my New Year's resolution is to make sure that the campaign to save general practice for London shows people that what they have is worth fighting for. Protecting the good, not just fending off the bad that may yet come to pass.
Late last year we saw the junior doctors' focus attention on their work for patients and call on patients, politicians and fellow practitioners to work with them. As their issues return to focus, there's a lot we can learn throughout the profession from their indefatigable campaigning. Whilst we know that GPs are experts in caring for the whole person, and a patient's trusted companion through all that life throws at them, we sometimes need to make the case for this and get patients onside so that we can work together to future-proof community based general practice and primary care for the future.... Before it is too late.
Having patients onside doesn't mean giving in or always saying yes. As an expert clinician sometimes we have difficult messages for our patients. I was recently speaking with a patient who had been "gaming the system" to help her to sustain an unhealthy abuse of anti-anxiety medication. This patient praised to the rafters the GP who cancelled her scripts, made sure no other local GP would write new ones, and got on with addressing the underlying psycho-social factors involved in her condition so that she was able to receive care and treatment, rather than simply giving her what she wanted and sending her on her way. Each and every GP and practice nurse will have their own stories about how their care and interventions have made a difference to the lives of their patients with the holistic approach that only GPs possess.
Yet the crucial services needed for professionals and patients to access the very care which would address those underlying psycho-social factors, are both undervalued and actively being disinvested in by government and its agencies obsessed with a purely medical model of health. A model which by its nature segments and fragments care into a limited number of pathways for a defined list of purely clinical conditions, ignoring underlying causes and those conditions which don't fit this narrow range or suit the lens. What's effective in consumerist industries does not work when you're trying to tackle the underlying and wider determinants of health and wellbeing that are hitting those who, in growing numbers, can't afford other solutions.
To quote Wikipedia's definition: "Market segmentation is a marketing strategy which involves dividing a broad target market into subsets of consumers, businesses, or countries that have, or are perceived to have, common needs, interests, and priorities, and then designing and implementing strategies to target them".
The bio-psycho-social GP model of health and wellbeing is the very antithesis to this philosophy - unless of course you want to see a USA-style market provision of general practice in the UK, with USA-style consequences for access and levels of care. We've already seen segmentation play itself out over the last decade with the cost burden of social care shifting onto users - something that health economists, politicians, management consultants and commentators would do well to consider.
Make no mistake, we are rapidly heading towards a model where, under the politically sexed up guise of Challenge Funds, Vanguards and now Accountable Care Organisations (successors to the mostly failed Health Maintenance Organisations of America), Foundation Trust -led conglomerates of teaching hospitals, not famed for their devotion to the principles of general practice and the holistic bio-psycho-social model of care, are being encouraged to build empires providing narrowly specialised NHS services at ever-greater scale, volume, and cost - both financial and human.
It is a model where, at best, lip service is paid to tackling health inequalities and wider determinants of health, and even then in rhetoric such as personalised care and integration which turns such issues into commodities ripe for the picking. A model where all the attention and incentives remain focussed on the wrong end of the system - beds in hospitals and A&E attendances - as if they are the holy grail to conquer rather than concentrating on improving housing, nutrition and lifestyle.
The Government has the power to turn this on its head: deal with the 50% of A&E admissions that are triggered by alcohol; incentivise local councils to control numbers of fast food outlets on our high streets, and; scale back the consumerist agenda and commodification of health and scale up the primary, social, community and mental health services to meet genuine needs where they first begin, with the patient's or service user's agenda, not the system's.
Last year millions of patients came through the doors of general practices in London. And with an average cost per patient per year of £131.24 a head to provide GP access to nine million Londoners, giving them world-leading healthcare for less than the cost of a month's travel from Zones 1 - 3, that's an awful lot of bang for a considerably smaller buck than any other provision out there!
So let's make 2016 the year of positivity about what general practice can and does excel at - coordinating patient care, taking a holistic approach, and being the local and accessible point of entry for citizens in need of health and wellbeing services. And let's also make it the year we flex our resilience muscles and speak up for ourselves and our patients: pushing back on ever increasing bureaucracy that detracts from patient care; saying no to Crackerjack commissioning where more and more activities are bundled together into contracts with fewer and fewer staff to deliver them; and being confident and clear about what our professional vision for the future is.
At the end of January London GPs will be attending the GPCs Special Crisis Conference to agree actions for the year ahead. I will be part of the London delegation and I urge colleagues from across the Capital and the rest of the country to hold firm to the core values and competence of general practice:
- deal competently with patients
- provide person-centred care by relating to your patients as individuals
- use problem solving to tolerate uncertainty and marginalise danger without medicalising normality
- adopt a comprehensive approach to manage co-morbidity and coordinate care
- understand and utilise the physical environment of your practice population and the interrelationships between health and social care
- adopt a holistic approach by understanding and respecting your patients' values, cultures and family beliefs, and how these will affect the experience and management of illness and health
The key tenets are not just the remit of the GP, or even their practice staff, but of the health system in which they operate. Every contract, structure and training programme should begin with a commitment to the provision of excellent and patient centred care.
We know that there are some serious challenges to providing enough staff to meet demand across all roles within practices. And our recent workforce survey (which we will share at the end of the month) is not easy reading. But if we are honest and open about what is not working, and if we are all committed to retaining and developing general practice for the benefit of patients and communities, then this could be the year it all changes. Here's hoping!
The following six areas are concerned with the tasks you will undertake as a general practitioner in delivering care to the patients in your community.
1. Primary care management is about how you manage your contact with patients, dealing competently with any and all problems that are presented to you. (This area of competence is not limited to dealing with the management of the practice.)
2. Person-centred care is about understanding and relating to your patients as individuals, and developing the ability to work in partnership.
3. Specific problem-solving skills is about the context-specific aspects of general practice, dealing with early and undifferentiated illness and the skill you need to tolerate uncertainty, and marginalise danger, without medicalising normality.
4. A comprehensive approach is about how you as a general practitioner must be able to manage co-morbidity, co-ordinating care of acute illness, chronic illness, health promotion and disease prevention in the general practice setting.
5. Community orientation is about the physical environment of your practice population, the need to understand the interrelationship between health and social care, and the tensions that may exist between individual wants and needs and the needs of the wider community.
6. A holistic approach is about your ability to understand and respect your patients' values, culture, family beliefs and structure, and understand the ways in which these will affect the experience and management of illness and health.