Hunt: good diagnosis, wrong treatment

SAM_8851There was something highly refreshing in Jeremy Hunt’s speech last week on primary care.  His diagnosis is well informed, and we know from a tweet that he spent time on the phones at Hurley practice in Kennington.  He talks about family doctors in terms of  strengthening relationships with patients.  This is a version of medicine very different not only from Lansley but also recent Labour administrations, who have seen medical care as a commodity, a series of disconnected transactions between patient and operative.

By gum have they put those notions into action, from the 2004 contract onwards, with the separation of OOH, the QOF regime, the 48 hour access targets, WICs, NHS Direct and 111.  Every single one of these policies has undermined the personal responsibility of GPs for their patients, all at vast cost, much of it incalculable.  They have sown the wind, now they reap the whirlwind.

The result, as I think we all know, is a 50% increase in A&E activity, hospitals bursting, letters from college chairs and hospital chiefs calling for action in cliff-edge crisis terms.  It is sad that while Mr Hunt says he doesn’t blame the professions, he is seen as engaging himself in pitched battles with the GPs.  This is the one group best placed to make a difference because they, more than any others, can affect demand.  Reducing demand is the single best strategy for A&E, while so many cunning schemes attempting to do so have failed (eg 2011 Nuffield report).

GP-patient continuity is paramount

GPs know that many if not most of their consultations, and all the most complex ones, involve that special therapeutic relationship.  It is this which makes them, despite everything, the Man U of Britain’s most trusted professions, in a league table propped up by politicians.  Their training and practice does not allow them to reduce it all to transactions.  The word for what Hunt identifies as their strength is continuity.  In study after study, this has been linked with patient satisfaction, GP professional satisfaction, lower emergency and elective demand on the wider healthcare system.

Now sadly we come to Mr Hunt’s treatment.  He wants them to spend less time on box ticking.  Let us clarify this crude term as unnecessary non-clinical work.  We all agree on that, and the tales I hear from GPs daily underline how much of it there is.  So why on earth does he propose in the next breath a Chief Inspector of General Practice?

An inspector asks the question, “What’s good enough?”.  He or she has to allow almost all the current establishment to pass in order to avoid chaos, so he has to think of things to measure which are easily measured, and on these set standards which are easily met.  Do you really think that being inspected and proving you have met standards will be accomplished without yet more non-clinical activity?  A few practices will be failed with a great hullabaloo.  There are two failures, I read, under the current CQC process. But what, pray, will this do to improve general practice?  Has anyone noticed how the hospital inspection and failure regime has improved hospitals? Me neither.

An inspection regime does much more harm than failing to improve quality.  It casts the whole enterprise under leaden skies.  The game becomes, “Be good enough, don’t get caught” and precious energies are devoted to this end.  For most people, there is simply no time for the question “How good could we be?” and innovation is stifled.  A few pioneering souls will innovate anyway, but very likely find their efforts produce the wrong numbers because the measures are designed for compliance, not excellence.

“What’s good enough?” is not good enough.  Ask “What works?”

I’m an engineer and I can assure you that good engineering companies have long since abandoned inspection as the route to improved quality, in anything other than a backstop role.  No, they are busy improving their systems and processes.  The engineering question, which anyone can ask, is “What works?”.  This makes us curious, and makes us measure things of interest to outcomes, leading inevitably to the next question, “What works better?”.  No standards are needed, because innovations keep arising which change what people can do and shift expectations.

Let me illustrate from general practice.  Some years ago the government set a standard that all practices must offer an appointment with a GP within 48 hours.  This caused enormous frustration for patients as most found they were not allowed to book more than 48 hours ahead, there was a rush for slots as soon as they came available, and continuity dived as patients saw whoever was on that day rather than the GP who had seen them previously and understood their problem.  Hunt, commendably, has seen this at first hand.  The public were duped into accepting it as the price of modern medicine, a rapid but impersonal service, rather than as the inevitable result of an ill-conceived policy.

Here is a different way from two practices with deprived, high demand populations.  Elms in Liverpool measure their response time so they know their patients are speaking to a GP within a median of 15 minutes, a cool 200 times faster than that government “standard”, and with no loss of continuity.  Along the M62 at Clarendon in Salford, they achieve a median of 30 minutes but with continuity improved 15% over the last six months to 85% (ie the chance of seeing the same GP on multiple occasions).  They aren’t finished, this is a journey and I don’t know what improvements we will see next, but I do know they are self motivated to go further.  Now just imagine our Chief Inspector going to BMA House to present these as the new standards.  He’d be hurled clean across Tavistock Square.

Mr Hunt, you have the right notions of GP care and continuity.  Let them do the job by removing all the targets, policies and structures which have got in the way.  You can make the sun come out for general practice, and it’s about time.  Don’t impose a Chief Inspector on them.  You have plenty of Chief Medical Wallahs of this and that.  What you need is a Chief Engineer of General Practice.  I’m sitting by the phone.

Harry Longman


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