We need to make sure we tackle all the social determinants of health, including obesity promoting fast food - and GPs must get the time and resources to play their part in such holistic care
Over recent years we have gradually witnessed the closure of churches, pubs and other constants in our communities. For many people the GP is one of the few people left providing continuing support in our lives, alongside our families.
Primary care, with all its variability, is also one of the most cost effective health systems in the world. So, while in need of modernisation to meet modern challenges, it is worth preserving.
This has been recognised in the forward view, which steps outside tradition to focus on preventative medicine and care in the community. It also acknowledges that more of the same - hospital and specialist care - is not going to solve worsening healthcare among many.
More forward view analysis:
‘Chicken shop mile’
Where I practise in Tower Hamlets, the difference in life expectancy between rich and poor is 11 years. You’ll reach old age 20 years earlier so a 50-year-old will have the same number of consultations in primary care as a 70-year-old living in a wealthy area.
At the start of life, at five-years-old, half have severe tooth decay and vitamin D deficiency, cognitive development is 10 per cent below the national average and 11 per cent are obese.
By the age of 11, obesity rates have doubled and, in reality, the problem has become just part of a spectrum of malnutrition among the majority of children.
‘At five-years-old, half of Tower Hamlets children have severe tooth decay and vitamin D deficiency’
This, of course, is not helped by the 42 chicken shops per secondary school - Mile End Road running through the heart of Tower Hamlets is known as “chicken shop mile”.
General practice, therefore, has three tasks. To be the vanguard and leaders of preventative healthcare; to move substantial amounts of care into the community; and be a key part of commissioning holistic health services. The government and NHS England have set a clear goal of bringing primary, secondary and tertiary commissioning back together.
Focus on care pathways
The NHS delivers a maximum of 15 per cent of healthcare so if you want to improve people’s health, you need to tackle all the social determinants of health including employment, education, the environment and our creativity.
Put simply, if you educate and employ, you improve health. So why not have the housing association worker at the same reception desk as the GPs?
At the Bromley by Bow Centre in Tower Hamlets we offer 100 different projects under one roof, from cooking and gardening groups to tackle social isolation to adult learning programmes (literacy, numeracy and IT).
We also offer advice on social welfare, legal issues and money management. All the neighbouring practices now connect patients via social prescribing to nearly a thousand different voluntary sector projects in the area.
This April, Tower Hamlets Clinical Commissioning Group is likely to take on full primary care commissioning and, in the not too distant future, we will get back most specialist commissioning.
‘The forward view gives a clear direction for prevention and primary care’
We have a fantastic team of managers and clinicians commissioning holistic healthcare with many early successes, recognised by HSJ as CCG of the year award 2014. The sadness is that all of this could have been achieved without the chaos of the Health and Social Care Act.
The good news is that the focus has shifted towards care pathways, designed for a population and fundamentally changing the role of the hospital.
The vast majority of diabetic care has shifted into the community with the amazing support of a diabetologist who gives advice to GPs via mobile phone, visits practices for teaching sessions, and now sees only complex cases in the hospital. A fantastic success for patients.
Yet we cannot state strongly enough how the spiralling workload combined with the reductions in resourcing for primary care in the last seven years (with the addition of minimum practice income guarantee, alternative provider medical services, and personal medical services reviews) are having an enormously destabilising effect on primary care in areas like ours.
GPs are now completely focused on keeping their practices afloat, coping with the ever rising level of demand, and therefore struggling to take on all these new tasks.
On top of concerns over resources is the burgeoning cost of regulation. One chief executive of a hospital estimated that he faced 80 different inspection regimes a year. I see my local hospital managers overwhelmed with managing inspection teams and taken away from the crucial day job of improving patient care.
The path set out by the five year plan gives a clear direction for prevention and primary care. A tough rationalisation of regulation with a shift of focus to development rather than judgement must be added to this.
Sam Everington is a GP at Bromley by Bow Centre in east London
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Forward view analysis: Stop ‘chicken shop mile’