The future of general practice

It is 11:30 am and you’ve just finished morning surgery. The patient with financial worries and her child are playing on your mind. You’d asked if you could seek advice on how to help her, so you walk upstairs to talk to Emma from the Early Help Advice Hub. You’ve found that she’s been a great source of information and discuss the impact of the patient’s financial trouble on her ability to care for her child. Ten minutes later it is agreed that the threshold for a social care referral isn’t quite met, therefore an Early Help Assessment is appropriate. You call the patient later that day to gain consent and action the referral . Debate surrounding the future of general practice is usually rooted in the context of the primary care workforce (Primary Care Workforce Commission, 2015); the introduction of new roles and developing practitioners with a new skill-mix (Baird et al., 2018). Such solutions are rooted in the medical model of health. I share the ‘Marmotian’ view that health care is just one dimension of improving individual and population health. Currently, GPs often consult with patients who cannot be helped by our services. Furthermore, we are often unable to effectively signpost patients or help navigate them to services that can support them (O’Connor, 2017). Consequently, I believe the future involves working as part of a collaboration of services – delivered optimally by co-location. Provision of these services will be based on the geographical location of patients and include amenities already provided by local authorities – housing, social care, public health. Other allied health care services will also be part of these collaborations, for example health visitors, district nursing and community mental health. Co-location of services does not equal integrated care. The former simply provides services from the same location, the latter requires streamlining of referral pathways, sharing of information and the development of patient care plans using collective knowledge. The value of co-location is in the spontaneous and closer communication between professionals. Good communication fosters a mutual and deeper understanding of the knowledge and skills of each service and reduces conflict (Hinds and Mortensen, 2005). This understanding is a necessary pre-requisite to effective integrated care. Service reconfiguration alone, however, fails to tackle the defining issues for general practice of the last decade – workload and workforce. Most suggested new models of care require additional staff, staff who are not currently forthcoming (O’Dowd, 2018). Therefore, it is not hyperbole to state that any and every future vison of general practice perishes if workforce issues are not effectively tackled. The scale and complexity of the challenges are enormous – multi-morbidity of patients (Salisbury et al., 2011), causative factors of rising early retirement (Moberly, 2018), patient expectation of access and treatment (Baird et al., 2016), improving access and wait times to psychological services, the impact of similar workforce challenges in district nursing, etc. Technology will be a part of the solution to these challenges. GPs broadly think it will help with administration of work – rather than direct clinical care (Blease et al., 2018). However, the impact for policy entrepreneurs is arguably most significant. How many GP appointments are available nationwide today? How many have been cancelled prior to today? General practice in the UK is currently unable to comprehensively answer such questions. Complaints from GPs of being overworked can be interpreted as an opportunist call for a salary uplift, rather than a genuine distress signal. Data evidencing patient demand, for example average length of time from booking to appointment, is helpful in reframing surveys of GP burnout into politically advantageous formats. After all, waiting times for appointments are what our patients talk about and consequently what politicians are most likely to understand and respond to. Promoting solutions to these issues in the policy arena requires the development and championing of GPs, and other advocates of general practice, who can understand and navigate the policy process. GPs who readily accept that the delivery of health care funded from general taxation is inherently a political issue. GPs who accept that the production of evidence, though helpful, is not often the defining factor in influencing policy (Cairney, 2016). GPs who are prepared to form alliances with other groups and campaigners to advocate for services that influence the workload in general practice, for example community mental health services.