06/06/2017 07:42 BST | Updated 06/06/2017 07:42 BST

New Models Of Care - Form Must Follow Function


The future of London general practice is set for a continuing state of emergency, despite a raft of plans, strategies and forward views anyone who is anyone is still looking for a new model of care which fits with our values, as I told our conference at the end of April.

We have a variety of models parading up and down trying to convince us their outfit will be the big hit of next season, with all eyes currently on the multi-speciality community provider, cut from very limited cloth by Simon Stevens. And that's the problem, we're in an ideas fashion show, being offered ideas formed of fads straight from the blue sky, rather than letting facts on the ground drive real improvement and innovation.

The facts on ground are:

  • Demand in London is growing as the population increases and more people develop long-term illness at a younger age, such as diabetes and heart disease.
  • The GP state of emergency is still in effect a year on from the launch of our campaign to highlight this crisis. 46% of practices responding to our November workforce survey had a vacancy, 45% had at least one GP planning to retire in the next three years. Every week we help another practice that has come to us because they are thinking of throwing in the towel.
  • The GP Forward View, launched on the same day we declared a state of emergency hasn't delivered the support we need. Large sums of money are tied up in overly-bureaucratic application processes or, where the money has been released it, comes with so many strings attached practices can't use it where it's really needed.

So far the solution offered has been to push practices to form large organisations to deliver care 'at scale'. The quest to provide care at scale results in the 'at scale' part taking up all the resource and the 'providing care' part coming in second place, while the practices in your neighbourhood are allowed to fall by the wayside.

A growing number of London surgeries are already working together in federations or networks largely in response to workforce pressures. I see these each turning into some form of at scale care entity sooner rather than later and it's important that we work to define how these practices do this, before others define it for us with 'fake' models of care, at the expense of the values of true general practice.

That's these values:

  1. The registered list - individuals and 'practice' population.
  2. Expert generalist care of the whole patient.
  3. The therapeutic relationship with a consultation as the irreducible essence of care.
  4. Based on holistic, bio-psycho-social care, not a disease-focused model.
  5. Advocacy and confidentiality.
  6. Safe, effective long term and preventative care by promoting access to relationship continuity, balanced with timely episodic care.
  7. Needs based, taking into account the wider determinants of health and the inverse care law, compared to consumerist wants.

Allowing GPs, community services, third sector, local groups, schools and everyone else who can shape health and well-being to work together across boundaries is what we should be doing to enshrine these values in a new model of care. This doesn't need layer upon layer of management, it needs time and sufficient, motivated clinicians. Yet we are already losing what we have on the political and economic alter of spurious key performance indicators and uber-regulation.

At our conference we heard from Dr Nav Chana of the National Association of Primary Care, talking about the Primary Care Home model that the NAPC have developed and are trialling across 15 sites in England. This is the sort of model (note: 'model' not 'organisation') that can fit with our values, because it offers the opportunity for:

  • People to continue to receive GP care in their neighbourhoods.
  • Building the relationships with other bodies need to provide joined-up care via a framework for collaboration, rather than market driven mergers and takeovers.
  • Flexibility and adaptability, avoiding the one-size-fits-none approach of single organisation models.

People in London know their GPs and practices have their backs, let's hope that they don't vote with their feet on Thursday.