Missing from Stevens’ Five Year Forward View

Much has been made of Simon Stevens’ Five Year Forward View #5YFV and it seems to have achieved an obedient following across much of the party political and NHS political spectrum. I can’t comment from knowledge on much of it which is outside my area. So why run the risk of criticising Tarzan?

“General practice, with its registered list and everyone having access to a family doctor, is one of the great strengths of the NHS, but it is under severe strain.”

We get the diagnosis, and the box on page 18 has all the right words about supporting general practice with a bit more good stuff.  But the real meat is saved for the next section, what he wants to promote are new models, “Multispecialty Community Providers” MCPs.  As in, “I’m feeling sick as a dog today, I know, I’ll call my Multispecialty Community Provider”.

Smaller independent GPs are brushed off with a couple of lines, while the MCPs get two pages of aspiration, case studies and support for change.  Even the RCGP is wheeled in to support.  So where is the evidence?

Over 95% of patient episodes are resolved in general practice.  Even the single handers, who don’t have the breadth of team and facilities of larger practices, are resolving over 19 in 20 visits, within the practice.  That in itself is an astonishing fact, in plain sight, and shows the level of skill in our GP body.  Secondary care is not irrelevant to them, of course, but it’s a much smaller part of the work than Stevens seems to imagine.  To my simple mind, when you have that degree of competence,  localism and spread you preserve and support the hell out of it.  The rest of Europe, note, wants to be more like the NHS.

The ink was barely dry on the #5YFV when HSJ publishes the commission report showing “Integration will not save money.”  Oh dear.  Are we going to learn from that evidence, or just plough on with policy, regardless?

The evidence for the effectiveness of the NHS current GP model is far more extensive than I can cover here.  A nice swipe at Atul Gawande in the Reith Lectures yesterday said it all, from Dame Sally Davies.  He said hypertension was the leading cause of death.  She counters that may be so in the US, but in the UK with its universal and effective general practice, hypertension is well managed and not the leading cause of death.  So our system is good enough to change the big numbers.

The evidence can be summed up in two small words:  access and continuity.  Take a look at the new Health Foundation report on Improving Quality in General Practice.  Access and continuity are all over it as what matters to patients.  Patients want to be able to contact their doctor easily, and to have a choice of doctor.  Let’s look at BMJ, peer reviewed, published May 2014, “Which features of primary care affect unscheduled secondary care use?  A systematic review” by Sarah Purdy et al.  That means, what does the research say about keeping people out of hospital, probably the biggest movable number impacting on the NHS budget, which should be top of Stevens’ and everyone else’s list.

The answer is continuity: explained in full, relational continuity between patient and GP.  That is our best hope, the thing we need to back to the hilt, measure it, design for it, organise around it.  If we don’t it will continue to wither, to suffer under pressure and neglect.

The word “continuity” does not occur once in Stevens’ Five Year Forward View.

Harry Longman

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