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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We Have a Power Problem!

NHS – we have a problem! This blog forms a hiatus in the middle of a 4 blog mini-series about what I call the four rings of leadership (in the context of healthcare). I have been musing on some statements made at the IHI conference in London, Quality 2017, and before I go any further, I want to take a pause to reflect on the notion of power. Helen Bevan says that the number one issue facing our health care system is the issue of power. I would suggest that unless we seriously reflect on power and how it manifests itself in our systems and in us as individuals, then we will never be able to co-create health and well-being in our society.

 

In my last blog, I mentioned an excellent talk that I heard Derek Feeley of IHI and Jason Leitch, the CMO of Scotland, give together about our need to “cede” power, if we are to build safe, high quality, economically sustainable health systems. They contend that we need to move from keeping power, to sharing power and then ceding power. To cede power, means to transfer/surrender/concede/allow or yield power to others. I do believe this is correct. I believe that true leadership is absolutely about being able to ’empty out’ positions or seats of power, so that all are empowered to effect positive change and build a society of positive peace. However, my contention is this: ceding power is not helpful unless we first deal with the very nature of power. Once we have dealt with its very substance can we truly cede it through our organisations and systems to bring increased well-being for all.

 

I have talked many times over the dinner table with my great friends Roger and Sue Mitchell about the nature of sovereignty and power. Sovereignty is a dominant theme within our political discourse at the moment, at a national and international level. It is worth reflecting that sovereignty (the right to self-govern) is utterly intertwined with our understanding of power, and we need to pull the two apart if we are ever to cede the kind of power that can transform the future. If we do not recognise (have a full awareness/deeply know) this, we will continue to inadvertently create hierarchical dominance and systems that become the antithesis of what they are created to be.

 

 

We see the issue of sovereign power at work every day in the NHS. We see it in terms of power edicts from on high, without understanding the local context or issues worked through in a relational way. We see it in the way these edicts are then outworked through leadership and management styles, which are very top-down and hierarchical in nature, eating up people like bread in the process – what Foucault calls “Biopower”. We see it in the way wards are managed and in the way GP surgeries are run. Sovereign power says “I’m in charge around here” and “we’re going to do things my way”. We see it in individuals who choose to practice autonomously without thinking about the wider implications on the system, prescribing however they would like to, without thinking about the cost implications. We see it in the attitude of some patients, when it becomes about “my rights” with an unbearable or unaffordable pressure put onto the system. If we multiply sovereign power, we simply end up with lots of  kings and queens who defend their own castle, creating more barriers, walls and division in the process. Sovereign power is defunct and dangerous and it is this which is currently destroying our ecosystems and wider society. The “I did it my way” approach is rooted in self preservation and ambition and does nothing to help us build health and well-being in society. Sovereign power stands in the way the very social movements we need to see, because Sovereign power is based on fear.

 

Sovereign power has its roots in certain streams of theology and philosophy which have in turn laid the foundation for a way of doing politics and economics based on the supremacy of the state and within that the individual. However, the damaging effects of this are seen on our environment and on community, with utterly staggering levels of inequality, injustice and damage to the world in which we live.

 

If we are to truly cede a power that is effectual in changing the world, then it is not enough to simply reconfigure (rearrange) it, or reconstitute it ( i.e. give it a new structure/share it). First of all, we must revoke it! In other words, we must look ‘Sovereign power’ straight in the eyes and reject it, cancelling it’s toxic effects on our own selves and on that of others. We must change our minds about it and embrace instead a wholly different kind of power. Sovereign power has not changed the world for the better so far, and I hold no hope of it doing so in the future. No, we don’t need Sovereign power and we certainly don’t want to cede it. Instead, we need kenotic power. Kenotic power is based in self-giving, others empowering love (Thomas Jay Oord). It empowers others, not to live like mini-dictators, but to also dance to a very different beat.

 

I used to play the card game bridge, with my Grandpa (he was an amazing man, who invented Fairy Liquid!). In bridge, to revoke something is to fail to follow suit, despite being able to do so. Kenotic power refuses to play the game of Sovereign power. It embraces an entirely different approach. And as many through the ages have found, this kind of power is truly costly, and can even cost you your career or life; but it is the only kind of power that truly changes the world for good. Jesus, Rosa Parks, Emmeline Pankhurst, Gandhi, MLK, Malala Yousafzai, Nelson Mandela, Florence Nightingale and Mother Theresa are just some, who have embraced this ‘self-giving, others empowering love-based power.’ This is the kind of power we need now. We need it in healthcare and in every other part of our society.

 

Kenotic power is vulnerable but it is not about being a door mat. It is like a beautiful martial art, in which we can say “I won’t fight you and you can’t knock me down, unless I let you” In other words, we lay down our rights and power freely, they are not taken from us by force. So, even when energetic attacks are launched against us, this kind of power allows us to move out of the way, allow the attack to pass through and then to come along side the person and help them see another point of view. Switching to this kind of power is far more creative, less combative and far more fruitful in creating a way ahead full of possibilities without the need for making enemies in the process. We must challenge the deep structural belief that our political and economic systems must be built on and can only be held together by Sovereign power. What if we developed systems based on love, trust, joy and kindness, aiming for the peace and wellbeing of all (including the environment?) – what might such a health system be like? It will take a social movement for us to get this shift, and as I wrote in my previous blog: You might call this a re-humanisation of our systems based on love, trust and the hope of a positive peace for all. But this social movement is not aiming for some kind of hippy experience in which we are all sat round camp fires, singing kum-ba-yah! This social movement is looking to cause our communities to flourish with a sense of health and wellbeing, to have a health and social care movement that is safe, sustainable, socially just and truly excellent, serving the needs of the wider community to grow stronger with individuals learning, growing and developing in their capacity to live well.

 

 

I agree wholeheartedly that the most important role of leaders is to cede their power, so that all can truly flourish, where there is a far greater sense of cooperative and collaborative agency within our (health) systems. But if we do not examine the nature of this power, we will only perpetuate our problems.

 
Martin Luther-King said these famous words – they are seriously worthy of our reflection:

 

Power without love is reckless and abusive and love without power is sentimental and anaemic. Power at its best is love implementing justice, and justice at its best is power correcting everything that stands against love.”

 

 

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