So much is now defined as “medical”, requiring and getting a medical intervention, that the system is overwhelmed. In this essay, Tim Howard argues for why the role of the GP needs to be clarified (and subsequently better resourced) such that they can effectively treat key medical issues, whilst directing more deep-rooted problems to the appropriate institutions.
A SWOT analysis of General Practice in England today might read something like this:
- Strengths – historic reputation: used to be a much-loved national institution, the jewel in the crown of the NHS.
- Weaknesses – currently in a state of dysfunction, with a dissatisfied clientele, a lack of clarity about its future, and a workforce that is disunited and demoralised.
- Opportunities – to re-create itself as the functional bedrock of the NHS, attracting the best doctors to it as a career choice, and providing an essential service that meets the needs of patients (though their needs are not necessarily the same as their wants).
- Threats – that unless it grasps the opportunities now available to it, that it will dwindle and die, and the NHS and the public health will be the worse off.
What has led to the present state of dysfunction, with patients frustrated by what they perceive to be an inaccessible service, dissatisfied doctors, overspill patients filling A&E departments, and GP morale at an all-time low? These are well-known, but here is a brief recap: repeated reorganisations; lack of status; relative reduction in resource compared with the rest of the NHS; an overwhelming deluge of demand from a public that has been trained to think that there is a medical cure for all societal and social ills, as well as the ones caused by disease.
But we will achieve little by looking backwards at these and complaining. We are where we are, and we will only salvage general practice, especially where it is most needed – in deprived areas – by coming up with workable suggestions about how to make it function properly again. As the headline on James Kirkup’s Times article declares: ”Generous GP pay isn’t working for patients”. So if money isn’t the solution, let’s consider what is, or at least, might be. Here I suggest a few changes and activities that might, just might, rekindle the flame of general practice, and make it the beacon it once was.
First, and most important, we should define what we want it to be. General practice has become a victim of its own success, welcoming anyone to come to it for a cure. So much is now defined as “medical”, requiring and getting a medical intervention, that the system is overwhelmed. Emotional needs, now defined as “mental health”, come to the GP. Homelessness comes to the GP. So do poverty, anxiety, stress, relationship problems, bereavement, unemployment, fitness to drive, the (in)ability to work, and so on and so on.
Following murders in Plymouth in August, ministers have suggested said that gun licencing should come to GPs too – as if a general medical training gives a GP insight into who is going to lose their temper and shoot someone. All these and a myriad of other things come to the GP. So he or she feels overwhelmed, and so works part-time or retires early.
GPs are, after all, only trained in medicine. They are not trained to become the repository for all the angst of society, even though many of them feel that this is what they have become. And of course, in deprived areas with lots of societal problems, there are more of such problems that come to the GP, who feels overwhelmed sooner, and retires even earlier, leaving a void.
So the first task should be to define what is, and what isn’t the role of the GP. We should then start to train the public – as well as the politicians – what the limits of general practice are. Second, give them the tools so that they can do the job. GP partners are small business-owners who hold a franchise. They are given about £160 per head per year to provide everything – staff, premises, equipment, and a service. (That equates to a large Starbucks coffee a week.) Their pay is what is left over – the profit. So there is an inverse incentive; spend less on your staff and earn more. Buy less equipment and provide a poorer service and your take-home pay increases. This is the exact opposite of common sense contractual practice. It worked for the 50 years when general practice was a lifetime vocational calling. It doesn’t now, when many of GPs hold mobile portfolio careers and growing numbers work part-time in order to give families equal priority with patients. The Quality and Outcomes Framwork has driven up clinical standards, despite protests from some diehard GPs, but it needs expanding and quantifying. The principal log-jam is not quality, however. It is resource. It is no good appointing 10 more GPs to a large practice if you still only have 2 receptionists answering 4 phone lines. Patients still will not get through.
So politicians should accept that the Carr-Hill formula and the global sum allocation are archaic financial tools. Ministers should sit down with GPs and work out a method of resourcing them which permits them to deliver the service they should. Of course this will need more money, but you get what you pay for. At present the public pays peanuts for general practice.
Third, target money at need. If we genuinely want to tackle deprivation, incentivise GPs to work in areas of greatest need, which are only rarely nice places to live. Like everyone, GPs want the best and nicest for themselves and their families, so accept that and work round it. The old fashioned model of GP partnership is defunct in deprived areas. So we must work out how to get GPs to work in a more mobile way. We pay medical and dental students generously to get them to join the Armed Services for short service commission as medical officers; why not do the same for GPs? The offer might be: work for 5 years in an area of high deprivation and we will pay off your student loans and give you an income as a student. It works in other walks of life; why not GPs? It is irrational to think that a funding formula that supplies GPs in Kensington and Bournemouth will work in Grimsby or in the Pennines. What is it about centralised command and control that stops it being flexible and reactive? Aldi and Tesco can make it work in both Surbiton and Grimsby; why not the NHS?
So leaders must break the vicious circle of top-down regulation and control. Instead they should target medical resources where it is most needed. But do not rob Peter to pay Paul. This must be new money, not just a reduction in one area to make good in another. (This applies to all medicine, not just GPs. The law of diminishing returns is alive and well in all intensive care units in the country.) Work to improve flexibility of GP service and manpower, rather than to impede it, as at present. And never forget that money talks. Incentivise GPs throughout their career to work in nasty places as well as nice ones.
Fourth, do not appoint more GPs, appoint more paramedical staff. Nurse practitioners, wellness practitioners, physiotherapists, occupational therapists, pharmacists, volunteers – the whole gamut of skilled and unskilled workers who deal far better with the common presentations to general practice than the GP herself. Why see the GP with backache? The physio is far better at managing it. Very few unhappy people need antidepressants, but GPs are trained in the disease model, not the lifestyle model. Most unhappy people presenting to GPs need a lifestyle or wellness adviser, not a pill. To medicalise all life’s vicissitudes is a sure way to overwhelm any health service, and that is what is happening now. So broaden the team, not the number of doctors.
GPs can no longer be the repository of all medical and social wisdom; they should become the leaders of teams. They will conduct an orchestra of health care professionals, while at the same time acting as reference points, appraisers, organisers and employers. This model already exists in the UK, and it works. Its only impediment is the inertia of regulation, and the archaic strands of employment practice that lead to district nurses being employed by a different authority to practice nurses, counsellors by a different authority to psychiatrists, social workers by a different authority to care workers, and so on. Bring them under one roof; allow them the flexibility to work to a single common goal on a shared patient group, and give them clear leadership. The present dysfunction can be ironed out.
So another key task is to break down the barriers between those providing services for the same patient group, allow them to work together, and recognise that their skills are often more appropriate than that of a GP.
Fifth, artificial intelligence is far more effective and rapid at spotting significant change that warns of impending disease. The old ‘hunch’ of the experienced GP should be superseded by the algorithm that analyses vague symptoms and inconclusive results far more quickly and effectively. A single GP may have to process 200 tests a day. To interpret these in the light of symptoms is a recipe for error. Programmes exist and are now used that do this task more quickly and more safely. They need clerical staff to input data, but the savings in doctor time, patient safety and improved outcomes show that they are the only viable way forward. The move from the old fashioned cradle-to-grave personal GP will be – has already been – replaced by the “wellbeing team”. This hub will welcome all, well or ill, and direct them to the most appropriate service; dieticians for the obese, emotional care for the bereaved, psychosexual support for the impotent, a GP with specialist training for the menopause, and so on. Only those who need medical input will see the GP; most (perhaps 60% presenting to general practice) will be triaged out to a more effective service.
So the final priority for policymakers must be to work to develop this model. It is functioning to a degree in some areas, and it is the best, perhaps the only way to drive up health inequalities. Without this holistic service, general practice will continue to collapse under the pressure of unlimited demand, the areas of most deprivation collapsing first.
In conclusion, we must stop tinkering at the fringe of inequality in health outcomes. Government should acknowledge that this inequality exists and that it is huge. The practical solutions are there, as described, but there is deep inertia about facilitating them. We all know that just appointing more GPs in Middlesborough won’t cure the epidemic of obesity there, any more than appointing more bariatric surgeons will. We do know that having a lifestyle coach working with the most at-risk families may make a significant difference to their eating and smoking habits and life style. Bizarrely, we have abolished health visitors, the only trained health educators in primary care, and we will live with the consequences of that for a generation.
Why not acknowledge the need for social, not medical guidance, grasp the nettle of poverty-driven behaviour, and tackle health inequality at source – in the home and community? Use general practice as a hub, combine it with the defunct remit of Public Health England. And above all, do not, whatever you do, offer an all-encompassing medical solution to a social and environmental malaise.
Tim Howard was a GP in a large practice in Dorset, and was a GP Trainer, member of several Health Authorities, and enthusiastic innovator. He became deeply involved in reorganising health care delivery in primary and secondary care and in medical ethics. He retired from clinical work to become an associate member of the GMC, involved in medical regulation, and rose to become a chairman of GMC Tribunals, and then the first medical member of the newly formed Medical Practitioners Tribunal Service. Now retired, he remains involved in the ongoing debate about health care delivery and standards. He celebrated retirement by taking part in a round-the-world sailing race.