I don’t know about you, but in the unfolding election campaign I see an unhealthy lack of debate and challenge on how the NHS should work. The parties argue about money, and that only at the margins, but the opportunity for improvement lies in function, not form, and no party has understood.
Now see this week’s Lancet editorial “A manifesto for health”. “To achieve health… we must think more about issues such as education, food, alcohol, housing…” It highlights inequity as the greatest determinant of ill health, and does not shy away from the need to tackle it. Do read, for the largest vision for health you will see this year, and all on one page.
As a contribution to this vision, our manifesto zooms in on primary care, where we want three principles upheld, a service that is responsive, relational and professional. Why are these counterintuitive and countercultural?
Responsive: despite all the patient-centred rhetoric, the dominant ethos is supply led. GP time is in slots, for patients to take them up. When they are gone, tough. We divert, ration, manage, fob off, whatever it’s called, because the supply is used up and your demand doesn’t fit. The fundamental shift is to become demand led, understanding, predicting and working out how to respond to demand. The counterintuitive finding is that free and faster service is less work.
Relational: the bedrock of the NHS is the registered local list, having access to a doctor you know and trust. It is a crucial driver of clinical outcomes as well as patient satisfaction. Yet it is under threat from many sides, most of all the mistaken belief that a transactional model is cheaper. (see how GPs are now being drafted into NHS111 centres) Some see this as inevitable, we see it as a set of policy choices, which means that systems can and must be designed to promote relational general practice.
— A test: have you, as a health professional, ever attempted for yourself or a relative, in whatever small way, to get around the system? Either to get faster access or a choice of doctor? If so, you would want that access and choice for all patients, as a matter of course, wouldn’t you?
Professional: not only medicine but all professions have an ethical duty to provide disinterested advice. Yet QOF and myriad other schemes have sought to pay GPs for specific actions which may not be in the best interests of patients (note the hastily withdrawn £55 dementia diagnosis bung).
These are bound to colour judgment and undermine the relationship of trust. At the same time GPs groan under the bureaucratic burden which monitors all the schemes. Patients and GPs should unite against them. By the way, we’ve just learned from this Manchester study that QOF has shown no benefit for life expectancy.
So there’s my pennyworth, the three R’s for primary care: responsive, relational and professional. Some things are more important than spelling. My mother would be shocked.
Founder, Chief Executive
GP Access Ltd