In response to the post on 1 October, “GPs, where were you when they stole your profession?”, Dr Helen Haywood writes:
I always read your emails with interest and generally find myself agreeing with your viewpoint – yours seem to be a fairly lone voice when it comes to rationally and consistently pointing out flaws with the state of NHS general practice as it is and the direction it’s travelling in.
I find myself less certain about this message however. Partly because I’m not sure I fully grasp the inputs vs outcomes argument and analogy used. Partly also, though, because of the hint of derision towards the Locum workforce seeming to suggest that these freelance GPs are unwilling to make longterm commitments simply due to the possibly adverse impact on their social life.
I absolutely agree with your depiction of market forces and supply and demand issues with regards to extending GP hours and that NHS general practice cat continue in it’s current form in the face of insufficient and decreasing numbers of GP principals to maintain the GMS and GMS system. I also worry about the apparent lack of willingness to take on partnerships, but would argue that the picture it is not one of simple greed, self-interest and lack of support for the NHS PMS/GMS contract on the part of the non-principal GP workforce who may often, in a PMS practice for example, have found themselves falling on the less satisfactory side of this arrangement not being offered the BMA salaried GP model contract, nor an income anywhere near that of a principal, but expected to undertake much the same workload, albeit not carry ultimate responsibility for the practice. I would go as far as to suggest that partnerships of recent years might consider whether they have some responsibility for the current situation when, for example, they might have chosen, in buoyant times, not to offer profit-share partnerships to junior salaried colleagues. Not only that the contract does nothing to encourage appropriate numbers or length of appointments in relation to the capacity of the workforce or to to deter growing list-sizes in order to achieve balance books or achieve adequate profits. Likewise in the early more lucrative days of QOF, always rising to the challenge of achieving the often meaningless targets without ever stopping to challenge the system and simply say no to such a tick-box mentality which in itself must account for at least some of the current squeeze on appointments not to mention its demoralising effect on professionals.
Although the GMS/PMS contract may be wonderful for balancing unlimited accountability for managing the registered patient who is ill, with unlimited discretion on how to manage them, it does not permit easy change or varied styles of practice within partnerships, expansion of general practice provision in it’s original format, with, for example, no option for GPs to set up new practices or indeed to take over contracts from retiring single-handed practitioners without first going in to partnership with the outgoing practitioner on their terms.
I do share your concerns about the extension of GP hours simply diluting the service and diverting attention and investment away from the core service. I also strongly believe that continuity of care, not only facilitates improved patient experience and outcomes, enables true practitioner reflection and continues professional development, but also helps contain demand and costs, contributing to an efficient * health service and am alarmed about the assumptions being made around the idea that larger organisations will necessarily result in savings. My own experience is that the larger the practice, the less continuity for and satisfaction of registered patients. One way around this is what might be considered to be the old-fashioned own-list approach, but I note with interest how an article in last week’s BMJ highlighted a study suggesting that ‘Having a named GP does not improve continuity of care’ ( BMJ 2016; 354:i5048 ). The results of the study undertaken would not be a surprise to any NHS GP practising at the time given that it simply looked for any noticeable changes in relation to the introduction of the requirement that all registered patients over the age of 75 be offered a named accountable GP from April 2014. This was, of course, introduced without any specification of changes to service offered, reporting requirements or additional funding and will accordingly largely have been delivered with the same lack of conviction or commitment to meaningful change in practice. It is a shame, therefore, that the results of such a study are now quite probably going to be used in the argument against the benefits of continuity. Accompanying the same BMJ, it’s BMA News supplement featured a centre-fold two-page spread entitled ‘Care revolution: inventing the future’ suggesting that the emerging ‘New Care Models’ from front-loaded Vanguard projects, such as the Nottinghamshire Multspecialty Community Provider it focuses on are trail-blazing the way forward for primary care, but neglecting to explain where the £7.3 Million that this project is benefitting from will be found if such a model is to be replicated elsewhere.
Such reporting does beg the question of whether we as a profession as a whole, principal, non-principal, salaried, freelance or otherwise, are content to passively let policy roll out, drive changes and transform the NHS as we know it without opposition and if not why we aren’t more obviously actively involved in the discussion and process. I would agree that we all need to get involved in this debate and echo your questions;
GPs, where were you when they stole your profession?
Are you going to stand up?
Before it’s too late?
Doctor 27 years, GP 23 years, including as first wave salaried combined academic-inner City practitioner London scheme, retainer London, salaried Leeds, principal/partner 9 years Leeds, salaried Leeds again 1 year, now locum GP.