What Next for General Practice?

Last week, I had a sixth form student spend the week with me. She is hoping to go to medical school and is gaining the necessary work experience ahead of her applications. It was so great to be able to share with her the variance of my work and the great privilege it is to be a GP in the community. On the first day, we saw people with all kinds of problems, often interlinked or overlapping. She was amazed by how well I know my patients, not just the conditions they have, but them as people and the complexities of their lives. At Ash Trees Surgery, the practice where I am a partner, we run personal lists, in which we as GPs always see the same set of patients, supported by 2 other doctors, for times when one of us is not around. It gives us the opportunity of building fantastic therapeutic relationships with the people we serve and we get to know them really well. Our patients love it, we love it, and it has been a ‘traditional model’ of General Practice in our local community.

 

However, things are changing (not immediately in our case, but faster than perhaps we would like), and we (as GPs) and people generally, are going to have to get used to it, not just in Carnforth, but across the whole of the UK. I’m not writing this blog post as an idealist, but as a pragmatist. There are many things I wish were not changing, but we are reaching a point at which the scales are tipping and things simply cannot remain as they have been. Many GPs know this already and are making bold and difficult decisions to try and work differently, but many of us keep harking back to yesteryear and wishing we could turn the clocks back.

 

The issues facing us are stark:

 

1) We simply will not have enough GPs within the next 5 years to carry on working in the ways we have done. 40% of current GPs will be retiring within the next 5 years or moving into other work. (http://www.telegraph.co.uk/science/2017/07/30/nearly-40-per-cent-gps-plan-leave-nhs-within-five-years/).

 

2) The promise of 5000 more GPs will simply not come to fruition and certainly not in the time frame needed. Actually, a plan is afoot to replace some of the GPs with ‘Physician Associates’, people who have a science or allied degree, who have then done a conversation course and can do some (but certainly not all) of the work of a GP. They will also neeed supervision by GPs. Health Education England are having to cut GP training in order to make way for this new breed of health care workers (yet unproven). The Royal College welcomes the development as a support, but not a replacement of GPs. (http://www.pulsetoday.co.uk/your-practice/practice-topics/education/gp-training-cuts-necessary-to-allow-hee-to-develop-physician-associates/20034643.article#.WUrZgli-YHU.twitter)

 

3) The new generation of GPs, do not want to become partners and therefore the old partnership model will soon become entirely unsustainable. The results of a recent survey, carried out by Pulse of GP Trainers about the future careers aspirations of their trainees is pretty stark:

Only 6% said their trainees wanted to go into partnerships;
49% said their trainees wanted to become locums;
28% said their trainees wanted to go abroad
30% said their trainees wanted to find a salaried post;
4% said their trainees wanted to change career.

 

So, in summary, the older GPs are retiring, we’re not recruiting enough new GPs and those we are recruiting, simply don’t want to work in the ways we have been used to.

 

The Five Year Forward View has been trying to encourage us all to reimagine General Practice and how we might hold true to the values of this bedrock of the NHS, whilst adapting towards the future that is coming. I think we have some options, and GPs need to think clearly and carefully about which direction they want to head in. But even more importantly, the people of the UK need to recognise that change is afoot and GPs are simply unable to work as we have done previously. The demand is too great and the resource simply is not there to carry on as we were.

 

The first option, is for GPs to bury their heads in the sand and hope that all this might not be true, to become more entrenched in their position and wait for things to be done to them. I believe this will be harmful for General Practice itself, as it will mean a decrease in resources, an increasingly burdensome workload and significant burnout. But I also believe it is detrimental to the NHS as a whole. We neeed to break down the barriers that have divided us and work more holistically across what is a very complex system. Waving the flag of traditional General Practice is admirable in some ways, but I think it might prevent us from stepping into the future that the nation now needs from its NHS.

 

The second option is for GPs to federate with other practices, keeping hold of some of what they love, (a perceived sense of autonomy, the ability to run their own business, to stay part of a smaller team) whilst benefiting from sharing some functions like training, recruitment and maybe some staff with other practices. We have done this in Morecambe Bay (thanks to the Stirling work of Rahul Keith, John Miles, Lauren Butler, Richard Russell, Graham Atkinson, Chris Coldwell et al).  However, the federated model has to be given true commitment and financial support or it will accomplish very little. Practices cannot go back to competitive mindsets or taking care of their own needs first. It requires a bigger heart and a more open mind with genuine behavioural change.

 

The third option is to form super-practices. We have two in our area now (Bay Medical Group in Morecambe – > 60000 patients  and Lancaster Medical Practice >50000 – also both part of our federation). There are some huge advantages in working “at scale”, but it is not easy and certainly not a smooth transition. GPs have to learn to trust each other and be willing to have difficult conversations around buildings, drawings, policies etc, let alone learning to work differently. But more than that it is very hard to learn how to deliver really good General Practice in a personal way, whilst trying to reconfigure the team and establishing a really good culture. However, this model definitely allows new ways of working to be more easily acheivable, if given appropriate OD support. Some recent work done in Gosport and showcased by the King’s Fund showed that perhaps only 9% of people who phone asking to see a GP actually need to see a GP. The reality is that people have become used to seeing their GP, but often they could be seen and treated more effectively by a pharmacist, a nurse, a nurse practitioner, a physiotherapist, a mental health worker, a physician associate or a health coach. Perhaps GPs need to let go, whilst patients learn to trust the expertise of others? How do we transition to this kind of approach without losing that amazing knowledge of a community and complex social dynamics, often held by a GP? How does a Multi-Disciplinary team function effectively for the best care possible for patients in such a dynamic? We are in danger of losing something very precious, but can we somehow hold onto it in a different way?

 

The fourth option is to allow a “take-over” and become a more active player in an Accountable Care Organisation. The take-over approach is not straightforward, but I’m not sure it is as terrible as it appears to many GP colleagues. What if an acute trust set up a separate company, lead by a GP as medical director, who understood and held the true values of General Practice in his/her heart (as they have done in Yeovil – https://www.england.nhs.uk/blog/paul-mears-berge-balian/)? The company, run by General Practitioners, holding true to the core delivery of General Practice, without all the difficulties of running a business, HR issues, estates, etc etc but with all the benefits of shared IT systems, easier access to scans, no duplication of work and direct access to services without all the current clunkiness, not to mention protected admin time! What if the salary was right and the dross was removed? What is it exactly that would not be appealing about this? It is interesting to me. Only a couple of years ago I would have been utterly opposed to this idea, but having given it thought and time over several months, exploring the possibilities involved, I’m in the place of thinking that the benefits probably outweigh the negatives both for GPs and our patients.

 

What we need right now is for us all to accept that the NHS, as we have known it is no longer functioning in a way that meets the need of the population we seek to serve. We know we need a greater emphasis on prevention and population health (I have blogged on this many times before and will do so again!). We also know that the system itself is vastly complex and is in need of major reform and reconfiguration. We need this not only for the people who use the NHS, but for those of us who work in it and are in danger of serious burn out. I hope with all my heart that General Practice does not drag its feet and prevent the revolution that is needed. Our case for more resource and more recognition of the fabulous work we do will only gain favour, if we also show that we are willing to be a part of the whole and a part of the change that must ensue.

 

 

 

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A 3 Fold Approach to Population Health

Here in Morecambe Bay, we are trying to develop a strategy around Population Health – by that we mean we want to take a much broader view of the health needs of those who live in this area, ensuring that we try to tackle the disparities we see in the health of our population. In my opinion this needs a three fold approach.

 

Firstly, we need to get our own house in order. We know there is work

© www.stevenbarber.com – Dr David Walker

for us to do as a health system when it comes to ensuring we’re proactive with people’s health. With the resources we have available, we need to ensure that we are treating preventable conditions as well as possible and use the best evidenced-based approach to the care we are delivering. That is why, the excellent Medical Director of UHMB, Dr David Walker, with his vast experiencing in Public Health, is helping us focus on making a significant difference to preventing Strokes (CVAs – Cerebro-Vascular Accidents) across the Bay this year. We are making a concerted effort to ensure that all our patients are getting the necessary pulse checks, blood pressure checks, blood tests and appropriate medications to monitor and manage conditions which can lead to devastating consequences if left untreated or mismanaged. Within this, we are encouraging people to know more about the conditions they live with, understand them and take responsibility to ensure that they are caring for their own health.

 

Secondly, we are working with people across the Bay to live more healthy lives. We continue to see more and more children running a mile a day and hope that this will soon become the Morecambe Bay Mile, in which it becomes the norm for everyone who lives here to move a mile a day. Our sedentary lifestyles are hugely affecting our health and we’re wanting to encourage all business owners and leaders to ensure that staff have time to be active every day. On top of this we’re starting to work with schools around healthy eating and involved in projects with supermarkets to enable people to make more healthy choices in the face of fierce advertising. We’re also working with high schools around mental health issues and seeing many community initiatives springing up, run by the community for the community, which will improve the wellbeing of all. All of this is backed by our ‘Flourish’ work in our hospitals and ‘Let’s Work Well’ in the community, in which NHS staff are leading by example in changing the way that we work and live.

 

Thirdly, however, we need to dig deeper. We keep trying to put a sticky plaster over the great pus-filled abscesses that are the leading causes of ill health in our country. Traditionally we have paid much of our attention to dealing with the symptoms of ill health, and whilst thinking about the root causes, we have simply not putting anyway near enough time, energy, or resource into tackling them. The reason for this is two fold: firstly, health and social policy is directed far too much by the political cycle and the short term gains that can proven in small time windows – so we keep tackling symptoms because we can then prove how effective we are!; secondly, in truth, we don’t actually know how to tackle some of the issues and those of us in leadership roles are far too clever and proud to admit that we don’t know how to fix them and that we need to find a new way together, with the communities of which we are a part.

 

I was having a conversation with Cormac Russell the other day, via twitter, and he gave me this beautiful quote by Ivan Illich: “I believe it is time to state clearly that specific situations and circumstances are “sickening”, rather than that people themselves are sick. The symptoms which modern medicine attempts to treat often have little to do with the condition of our bodies; they are, rather, signals pointing to the disorders and presumptions of modern ways of working, playing and living.”

 

The reality is that many of the determinants of our health and especially of the health inequalities we see in our society have little to do with the availability or quality of services. No, the biggest factors affecting the health gap in this (and every) area are poverty, housing, loneliness, hopelessness and adverse childhood experiences. If we’re not careful, we end up thinking the real issues are waiting times in the ED, difficulties discharging people from hospital, breaking the 18 week target for hip and knee operations and ensuring there are enough GP appointments at weekends. We must not look at the symptoms and believe that if we tackle these surface issues then we will automatically have better health outcomes for all. Here in the Bay, we are trying to be brave enough to take off the sticky plaster and gaze into the festering wounds in our society, so that we can begin to really do some deep debridement of them and allow real healing to ensue.

 

That is why my team are focusing on hosting conversations that matter across our communities and seeking to co-create a social movement. Using the ‘Art of Hosting’ we are holding spaces open in which rich conversations can happen. “We don’t just want people to be more healthy and well – many people don’t even know what that means”, as an amazing woman called Gill, from the West End of Morecambe told us recently, “No, we want everyone to be able to experience life to the full, whatever that means for them”. We can’t do this simply by having good clinical strategies – we need something far more holistic and it will involve all of us.  We need to start our conversations together with appreciative inquiry. What is already going well? What can we learn from here? Knowing what is good, however, is not enough – we must go further, dig deeper and get to grips with some extremely difficult issues.

 

When it comes to Poverty, here in Morecambe Bay, we are trying out new economies (like time banking) and having challenging conversations. The Poverty Truth Commission is causing is to really listen to those with lived experience of poverty and learn to co-create and co-commission services, rather than presuming that the ‘experts’ know best.

 

When it comes to homelessness, inspired by the work in Alberta Canada (https://www.goodnewsnetwork.org/find-out-how-this-canadian-city-has-eliminated-homelessness/) and the Manchester Homelessness Charter (https://charter.streetsupport.net/) – we’re beginning to explore ‘housing first’ for Morecambe Bay, but imagining what it might be like with extra support in place from a caring community like ‘The Well’ in Morecambe and Barrow (https://www.thewellcommunities.co.uk/). I’m so pleased that Dave Higham is provoking this conversation for us here and I’m excited to see where a conversation between those with lived experience of homelessness, poverty and addiction, along with some of us in the public sector, might take us. There’s a challenge to all of us in society – we like the sound of these kind of things, but not in our own backyard….our values must begin to align with our actions. Love without action is not really love.

 

And what about loneliness and hopelessness? More than ever, we need connection across the generations, turning off our screens and actually being together as humans. In Morecambe we are seeing the launch of the new Morecambe Fringe in September, bringing people together around Comedy and the Arts. More Music are doing incredible work with young people. There are amazing community initiatives right around the Bay. We have loads of festivals connecting people across the district. And what is the role of business here? We need businesses to think abut what kind of enterprise we could see emerge for the youth in our area. Are there more opportunities for mentoring? We have left many of our young people to boredom and with few aspirations. With the help of Stanley’s Youth Centre and the great heart of Yak Patel, we hope to host many conversations with young people to really listen to what it is we could create together to break these problems and build community and hope.

 

What are we together going to do about the huge issue that is child abuse? We don’t have answers, but we do have questions – and we need to keep asking them. We know that the mental and physical consequences of abuse are utterly devastating and we find it hard to talk about because it affects so many of us. But our interventions are happening too little, too late, and we are missing the vast majority of cases. Our services simply cannot cope with the volume and serious case reviews tell us the same lessons nearly every time. So what? What are we going to do differently? There are definitely things that the public services can do better – but not when our resources are being stripped. What is especially terrible about the cuts to services in our most deprived areas is that ACEs cause poverty, homelessness, isolation and ill health! As a team, we take this really seriously and will be hosting discussions in our schools and local communities about how we raise happy, healthy children. Where is help needed? We’ve become so focused on grades and outcomes in schools…..but do we teach people what to do with their anger? Do we focus enough on values? Are there enough parenting (the hardest job in the world) classes – and if so, are they hitting the mark? What do we need to do differently? We know the situations in which children are more likely to suffer – so what? Have we become so focused on getting people into work that we’ve forgotten just how important parenting is? And if we know that ACE is such a massive issue, are we really making the right choices in terms of what therapies we’re making available for those who have suffered them?

 

Is it the role of those of us in healthcare to get involved in these discussions? YES! It is the role of all of us in society. Together, we must reimagine the future. We all know that prevention is better than cure, but our short-termism is stopping us from finding the kind of positive solutions that will really make a difference. In face of downward pressure from hierarchical powers, it is tough to make brave decisions to invest in the future, rather than cut our way to balancing the books. But if we really care about the health and wellbeing of our communities, then we have to stop the sticking plaster approach and clean out the gangrenous wounds in our society. We have to deal with the root and not the fruit.

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