The Future of Primary Care

OK – we are talking General Practice here, as most of us know it.  I was at one of Roy Lilley’s Health Chats last night at The Kings Fund in London.

All friends together...

All friends together…

Roy Lilley was our Paxman for the session. He floated questions, hypotheses, challenged, derided, abused and cajoled Claire Gerarda, (past chair of RCGP) James Kingsland (President NAPC) and Mike Bewick (Deputy Medical Director, NHS England). And an audience of GPs and many other interested parties…were exercised to intervene too.

But there was positivity in the title…assuming we do have future need. The title wasn’t about the future of the GP, or even General Practice. It was about primary care.  Here are my madly biased highlights ….it was all so full on and frantic, that I am sure everyone there heard different things, depending on their individual need and their own biases. Ears are tuned differently.

Roy wouldn’t invest if he was presented this model on Dragons Den.   The main question was “what will Primary Care look like in 2020” ( a 20:20 vision if you will!).

...and my second point is...

…and my second point is…

Roy is provocative, as is the need of the occasion. Even if we don’t believe he believes it, at least people have to defend their position. Suggestion first, possible actions later, and my bits in (parentheses) in the main: Here’s the visions: (Claire, James, Mike: 3 from each)

  •  Still be – gatekeeper (good value – 8% of budget, 80% of contact). Saves money and stops you doing stupid, e.g. “cancer tests on demand” – What? What for? Why? (worried well can cost a fortune!) We will still need translators of undifferentiated symptoms.  The world wants and is aiming for a primary care led health service.  Why do we want to go the other way?  (Government hates the BBC too…)
  • Get rid of independent practitioner status?  (James disagreed)
  • It won’t be like now – I won’t be working from Hurley Clinic – it will be more Lambeth Primary Care Organisation
  • Primary Care Multi-Specialist team, mainly in the community still
  • Will still be personalised care – efficient care system, not disenfranchised
  • PBC will re-replace CCG! (Full circle, history repeats – pendulum always swings fully in change management – need to stop the extremes…)
  • 300 000 needed for efficient commissioning
  • Health and social care need to be together and seen as holistic (like it used to be?)
  • Let the technology breathe – near patient testing, ambulances containing clinical expertise, change our heads!

And here’s some of the other highlights (for me): Questions are Roy’s, in the main.

  • “Wny not just have it in Tescos?” –  (because we can’t trust them to run their own business…) You don’t understand Roy: It’s not where is it – it is what I do that matters.  It’s about continuity of care.
  • We see symptoms, not diagnoses.
  • Very elderly – maybe need a new model of holistic plus social care (and maybe get rid of poly pharmacy – every older person on 5 drugs max??? No need for medicines to counter side effects – how stupid is that?)
  • There is no one size fits all.  Darzi (he never mentioned Poly Clinics…) may fit the London model, but elsewhere? (Two NHS’s – London and the rest of England / UK?)
  • “What about just moving you all to A&E?” Research shows you become an A&E consultant – over investigating, because it is there.  Not Family Doctor anymore…and we feel that is still the essential
  • More hospital specialists and other experts (e.g. Specialist Nurses in Diabetes and Stoma, as examples that already happen – just stop calling them outreach clinics.  Your expert is her in the building!)
  • No GP surgeries are in special measures – fact (whatever Daily Mail would have us believe)
  • Health services around the world are unaffordable without being GP led
  • We need to take away some of the perverse incentives of some targets

More heat than light?  More questions than answers?  For sure.  But maybe one of the things that needs to change is the attitude towards change.  For example, we do need to have access to our own data (Look, everyone who was there last night is also a potential patient.  Don’t you want to know your own data? And not to have to convince a receptionist that you should have access because you may know more than your generalist GP (it’s in the title) knows, if, for example, you are a Biochemist?)

Claire said something fundamental early on. “There is nothing so beautiful as going to visit a dying patient in their home. I am a generalist not a specialist. I want to see and help the sore throats the depressions and the like. And to see the dying patient.”

Holistically and psychologically, everyone wins in that close encounter. The bean counters may say “someone else should do that, not good use of your skills”. I’m sorry. It is. For the dying person. For their family and friends, and for the GP. I don’t care what it looks like. I want it to feel like Claire described.

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