The model of the community physician needs to be based on a holistic patient offer and clinical collective accountability − starting with a new GP contract, writes John Rooke
My grandfather qualified as a doctor in 1940, spending his early years in the army, then as a GP in a small village in Dorset. His role in the newly established NHS was to care for local people, whether they happened to be in the consulting room, community hospital, nursing home or hospital. As a lone GP with 24-hour responsibility, with input throughout the care continuum, this model offered unrivalled continuity of care. He was more of a community physician than we would recognise of a general practitioner today.
‘The independence of general practice is celebrated, particularly by those who sought out this medical specialty for this reason’
Fifty-two years of growing demand and expectation later, Alan Milburn’s NHS Plan still did not alter the fundamental construct of the providers of care established in 1948. Moreover, it introduced new rules and standards through pay, investment, access and choice. This plan sought to address the morale, recruitment and pay in general practice through a new contract.
Posterity does not always capture the success of this contract as the antidote to these problems but focuses on the loss of out of hours responsibility and the increased link between clinical care and remuneration through the quality and outcomes framework.
The unintended consequence of the framework and the 24 and 48-hour access targets was introspection, leading to more in-house appointments at the expense of community duties and to some extent home visits.
The independence of general practice is celebrated, particularly by those who sought out this medical specialty for this reason. These predominantly productive units of healthcare provision offer tailored response to the local scenario; however, this independence has led to increased isolation. This is significantly salient with the difficulty with which partners, such as hospitals and community services, have been able to collaborate with and influence a disparate set of general practices.
Commissioning and provider functions
The Department of Health’s Commissioning a Patient Led NHS set out the separation of the commissioning and provider functions of primary care trusts. While PCTs and GPs were not good examples of collusive oligopolies, this enhancement of the schism between purchasers and provider, coupled with the 2004 change in out-of-hours responsibility, was to further isolate general practice and to fragment care.
‘Our current model of primary care, in its broadest sense, can no longer underwrite an affordable healthcare service in an information age’
I am a bad economist; however, my assessment of the quality, innovation, productivity and prevention (QIPP) challenge for general practice has been 12.4 per cent savings since 2010. The sector received little attention in the QIPP plans of PCTs, with neither investment nor workforce development being prioritised. The conscious expectation of the early QIPP plans was that those with global sums would just absorb the impact of reduced variation in referrals and hospital activity. Four years on, the prospect of a further four similar years seems untenable to many of those working tirelessly in direct access services.
The size of challenge in developing appropriate workforce is exemplified by the gap between the need and effectively meeting it. It is estimated that 30-40 per cent of presenting conditions at general practices are mental health related; however, the proportion of the staff, available each day in the practice, trained to deliver evidence-based psychological therapy is considerably lower. Furthermore, the lack of strategic workforce development has led to paucity of numbers, skills and training for practice and community nurses.
Some say, rightly in my opinion, that British general practice is the envy of the world. My grandfather and father alike have committed their working lives to this profession and alongside their colleagues have given a good offer to the public, with both direct and indirect value for money.
To achieve systematic prevention of illness and hospitalisation requires a radically different attitude to the development of the primary and community workforce to underpin a fundamentally different offer to the public. Unfortunately, our current model of primary care, in its broadest sense, can no longer underwrite an affordable healthcare service in an information age, and a developed country, in today’s global economy.
‘I believe we should begin the metamorphosis of the NHS with a radically new GP contract’
Last year I speculated about the trigger for the paradigm shift in our thinking about how we offer affordable healthcare in the 21st century. I was wrong in thinking that the second Francis report would set our platform ablaze. Perhaps, unexpectedly, it may be the troubled rollout of the NHS 111 service. In the shadow of the 111 go live, the ping pong about the responsibility for GP out-of-hours care conjures images of Nero with his lyre. The out-of-hours issue is a distraction from addressing what should be the beginning of a chain reaction of supply-side reform that redefines the NHS.
The NHS, like most organisations, holds insight into its challenges at maximum. The solutions are less clear or are so diversely articulated to offer collective purpose and inspiration. Among pluralism of strategy, I’ll offer mine. I believe we should begin the metamorphosis of the NHS with a radically new GP contract.
GPs willing to practise in the NHS are now legally bound to their collective, not individual practice level, commissioning responsibility. The remaining barrier, in both process and belief, is that the GPs cannot easily maximise the potential to make or buy. At what price does artificially induced competition come at in our society’s quest for sustainable and affordable health services?
This is ideologically testing when reflecting on similar abilities within local authorities and PCTs for the majority of their tenure. As the Commons health committee inquiry in 2010 found: “Weaknesses remain, 20 years after the introduction of the purchaser-provider split”.
What is needed is a revolutionary new contract that binds GP practices together in larger pseudo self-determined collectives for provision, potentially conterminous and definitely combined with their commissioning units, offers impetus for genuine provider transformation through total collective accountability and performance-related pay for safety, outcomes and customer experience. This, coupled with a new consultant contract directly aligning pay, accountability and contribution to the success of clinical collectives, would be considerably more potent in tackling fragmentation and proactivity in prevention.
‘Those of us using the Francis report as the trigger for transformational change would tell you that there is not much more time to lose’
Akin to the best independent physician’s associations in Massachusetts or the Johns Hopkins Community Physicians in Virginia and Maryland, the alignment of specialists and generalists, through purpose and incentives, supported by an environment of effective clinical leadership and challenge, will create greater sustainability in the local system.
The key difference would be that this collaboration of doctors would be empowered with full commissioning duties. The oversight of this system would be delivered under the watchful eye of a single regulator on outcomes, conflict of interest, quality and value. Binary, I know.
The realistic among you will quickly ask the questions about financial accountability, regime failure, medical training and the trust I am proposing to place on the medical profession. However, it is within a context that all of these issues have and will continue to exist in a tax-funded, free-at-the-point-of-access service, focused on population-based registration with a GP. Only if you change these parameters do you replace this inherent, contextual risk.
Those of us using the Francis report as the trigger for transformational change would tell you that there is not much more time to lose. The risk of inactivity is far greater than the risk of fundamental change to principles we have got used to, such as purchaser-provider split and the prominence of commissioning as the primary solution.
I would hope that total accountability through clinical collectives would support a better response, given space to develop and form, to overcome organic deformities of periodically genetically modified NHS services. Building on the holistic patient offer of my grandfather’s generation, surrounded by the support, organisation and challenge of an accountable clinical collective, may well take us from the last of Britain’s corner shopkeepers to the rise of the community physicians.
John Rooke is chief operating officer at Bedfordshire CCG