This is my contribution to the Scotland Policy Conferences Keynote Seminar: Next steps for primary care in Scotland held on Wednesday, 21st January 2015 at the Crowne Plaza, the Roxburghe, 38 Charlotte Square, Edinburgh .
I was a GP Trainee in 1991, and I vividly remember being taught that there were 3 studies of the treatment for patients with Myocardial Infarction that each showed patients were better off with treatment at home rather than admission to hospital. I became adept at treating crashing left ventricular heart failure at home, at a time when GPs were most valued for their role in unscheduled care. My goodness things have changed since then.
Thrombolysis and now coronary artery stenting have led to increased survival rates and shortened hospital stays, and GPs are bypassed to rush patients with heart attacks and strokes to hospital. Our main role is now in chronic disease management. Secondary prevention has become ever more involved and ever more effective. Hospital medical generalists have almost ceased to exist. We, as GPs, have needed to step into this role as the community expert medical generalists. Our patients are older and fitter but with increasing multi-morbidity and poly-pharmacy. But as Margaret Hannah points out in her book “Humanising Healthcare” this has come ‘at the cost of squeezing out the time and humanity needed for good care and quality relationships’.
Our role is described by Barbara Starfield’s 4 C’s, the pillars of general practice: –
- 1st point of Contact
- Comprehensive care
- Continuity of Care
- Coordination of care
This role of the GP was brilliantly described by Aidan, a service user representing SAMH’s work at their parliamentary reception last week on the role of general practice in mental health. He described how his GP took on his care on his discharge from the army and worked with him to move from a point of desperation to being an active and creative member of society. She gave him the time to explore the issues, sought out his service medical records and referred him to agencies to find the support and treatment he needed. This was not about her completing the right questionnaire or ticking the right box but about the mixture of skill and care she showed. A vivid demonstration of the RCGP motto, ’cum scientia caritas’, ‘Science with compassion’.
We need a broader concept of quality than simply achieving measurable criteria. We need to acknowledge the importance of having the appropriate skills and competencies, but even more we need to be explicit about our underlying professional values and ensure we demonstrate that our practice is congruent with those values. This approach to quality was described in RCGP Scotland’s documents The future of General Practice in Scotland – A Vision and the core qualities of General Practice are distilled in The Essence of General Practice; work led by my 2 predecessors Ken Lawton and John Gillies. We have a real opportunity to rethink the Governance and Quality agenda for general practice and RCGP Scotland intends to lead this work alongside the GMS contract discussions between now and April 2017.
General Practice has never existed in a vacuum; rather it is a key component of a web of health provision. There is no such thing as a single primary care team but for any one patient a team forms around their care from the primary care network. Our next challenge is to have the “network literacy” to ensure patients receive the care they deserve. General Practice is just one node in this network but the strength and reach of its connections make it a major hub within the NHS. We believe that much can be gained by improving the interface of general practice with others. An example of this approach is the work that NHS Highland has started via its Highland Quality Approach. The chief executive of NHS Highland, Elaine Mead, in a project based at my practice, has shown the huge potential for improving patient care by improving the system of decision support between GPs and Hospital Specialists. This may drastically reduce the need for outpatient appointments and streamline patient care.
But GPs are also providers of decision support and RCGP Scotland is piloting work with the Royal Pharmaceutical Society to improve communication between community pharmacists and GPs. General Practice has been described as the “system failure service” for the NHS. Rather than endless frustration and work-rounds wouldn’t it be better if these problems were acknowledged and corrected? It will be less about planning and commissioning but rather about attending to the snags and significant events at all of these interfaces to allow the complex ecology of health to evolve. This should become a key role of GP locality clusters if they can be supported in this approach.
The RCGP Scotland work-steam on Interface intends to look at: –
- Decision support – both how GPs access it but also how we provide it to others.
- Snags and Significant Events – GPs need a means of feeding back problems in other parts of the service.
- Quality improvement methodology – we are proposing an “Effective Interface” module of QI that could be utilised by practices.
- IT sharing – Recent introduction of the “emergency care summary” and “key information summary” has enhanced patient care when being delivered by clinicians other than the patient’s own GP.
- Developing relationships – Examples of GP and hospital colleagues undertaking work shadowing for short periods illustrate a better shared understanding of roles and can be a more effective means of delivering care.
Fundamentally, however, none of these changes can happen without reversing the funding reduction that General Practice has faced since 2005. Then, 9.8% of NHS resources were spent in General Practice. In 2013 it was 7.8%, with a further fall in the last financial year. Despite this, GPs in Scotland have increased their annual consultation rate by 2 million per year since 2005 – we now have a staggering 23 million consultations each year. A one off, non-recurring, injection of £40 million has been promised in the next financial year. This needs to be made substantive and even this amount fails to reverse the decline in resources we have seen. There can be no justification for this lack of investment and if the needs of our patients are to be met it is imperative that it is reversed if the NHS is to be maintained.
A quote: –
“Without the family doctor as a personal link, not only between agency and patient but between agency and agency concerned with the same patient or family, the advantages of publicly provided medical services must inevitably come short of full realisation”.
This could have been written for 2020 Vision. In fact, it is taken from the Macalister report 1920. I believe it remains as accurate and relevant 95 years on as it was then but to achieve it we need 3 actions: –
- Governance and quality has to be seen beyond the tight remit of measuring and rewarding achievement of single criteria. In its place we need an alternative structure where clusters of practices are responsible for peer led, values driven activity.
- General Practice must be recognised as the major hub in the network of community health provision. This is not about management structures or budgets but requires attention to the interface between all these providers.
- Most importantly resources to the key hubs of community services such as General Practice, Health Visiting and District Nursing must be protected and enhanced until they reach adequate, sustainable levels.
Over the next 3 years RCGP Scotland intends to progress all 3 of these aims and I hope I can persuade you all to join us to help bring about the substantive changes our patients deserve.
Jackson Carlaw MSP:
Now Miles is going to take some questions, I think it’s easy if you just facilitate this from the lectern himself, so if you would in the time honoured way, like to indicate if you’d like to put a question to him and he can invite you to speak; just say who you are when you do, thank you very much. Right, an indication of someone who would like to speak, we’ve got, oh gosh, somebody I recognise, I think it’s Michael Haughney I think.
Dr. Michael Haughney:
I’m a GP in Newton Mearns in Glasgow and Chairman of the Glasgow LMC. I found the piece that Jackson Carlaw just read out from the unprinted book which he’s had access to highly objectionable and insulting, I just wondered if Miles agreed with that?
Dr. Miles Mack:
We’re in a difficult position, I think we’re getting to the stage where general practice is beginning to be recognised but I realise we’ve still got a long way to go. I realise that also just exactly the nature of the problems we’ve got with out of hours cover and how we do that; I can’t see any way that out of hours can continue as an overtime service of general practice, it needs to be formalised and made more appropriate to that. So much as some people would like us to go back to 2004, I don’t think that’s an option, I think we have to be, look to where we’re at, look to what we’re really good at and actually accept that the role of general practice has changed. But actually I think it’s a fantastic job, I think we’ve got the most fantastic opportunity to make a difference to the NHS so people will write nasty things about us but I think the important thing is how we actually start to reverse that and actually bring about a really positive image of general practice that it deserves.
Jackson Carlaw MSP:
Can I say I agree with that, I hoped it would stimulate that very response because it was kind of the reaction it prompted in me but I think it is interesting because it is the debate that I think is underpinning all of this which is where does GP practice go and where does the resource that I think Miles has identified as lacking come from? Yes.
Dr. Peter Kiehlmann:
A GP in Aberdeen and currently a Dementia Lead there. Just to follow on from the discussion about the GP role; I’ve been a GP for 30 years, I’ve been involved in teaching students and GPs over that time and while I think there have been issues about the delivery of palliative care, I think most GPs and the practice teams with district nurses and others are passionately concerned to look after people and give them good quality holistic care. A lot of work has been done to ensure communication both within teams and out of hours and Scotland leads the way with some of the systems that have been set up to ensure information is transmitted between GPs and out of hours services. So that was one thing, but the other thing that hasn’t been said today which was mentioned on one of the slides earlier, and I’d be interested in Miles’ view on this, is primary care premises; there is a real issue with a lack of infrastructure for primary care and I think teams are passionate to work together, to be the hubs, to be the places where we look after our patients, we work with health, with social care, we work with the third sector but many, many places are woefully served by poor premises and with the aging population and the rising population, there’s a real need to really deliver premises now and urgently.
Dr. Miles Mack:
Yes, on the first point about palliative care, I absolutely agree with you, I think it does epitomise the values that we stand for and the reason why we went into this job in the first place. And I think it shows the weakness of some of the single issue type approaches trying to reward that, whether its enhanced services or quality and outcomes framework, so I think there’s a real opportunity for values based approach to actually tackle that. As far as premises is concerned, you don’t need to speak to me about that, we’ve just moved back into our premises after 18 years of planning, which did involve being in temporary accommodation for 9 months. Whether it’s any coincidence, it happened before I started as Chair, I don’t know because I believe that Ken Lawton also got premises just before he did, so it may be a perk of the job, but I can’t believe that because it did take 18 years and I certainly wasn’t planning this job at that time. You’re absolutely right, we are the hub function, I think the business about how we link with other people within that network is crucial, it’s about being absolutely focused on patient’s needs, being absolutely focused about what our own roles are and understanding the other roles of other people and how we communicate. Now there’s probably no better way to improve the communication than sharing a kettle and so the ideal way, if we can have people co-located, it goes without saying that it works brilliantly. If we’re not, we have to make absolute efforts to make sure that communication’s not lost and I take it as I think there’ll be times when we find that effort to communicate is so great that the only way round that is to invite them to co-locate with us. So you’re absolutely right, I know well how long it takes to get premises moved and how desperate it is to do that.
Dr. Brian Robson:
Thanks and good morning Miles. Clinical Director at Healthcare Improvement. Scotland but also just declare I’m on your Scottish Council of RCGP as well of course. So Miles, a patient sitting in the audience here today might very well be forgiven for thinking that all the different professional groups were making their own pitch for what they should do, and actually the patient’s care, whether it’s Agnes’ care or somebody else’s care, is going to be fragmented. Sitting in the Scottish Council I have seen a lot of the discussions and deliberations at RCGP about how professional leaders are bringing themselves together, can you say a little bit more about some of the commitments that RCGP or indeed others have made around bringing professional groups together so that it’s not siloed?
Dr. Miles Mack:
The problem of fragmented care is absolutely crucial and I think this is where we want to build on the whole idea of the interface to overcome this because each part of that network is a separate module and I think we’re having to see that develop and evolve as time goes by. There may well be new professions or people providing new service which is going to get dropped into that network and it needs to evolve organically. We can’t plan how health service is going to be in the 10 years, I certainly couldn’t have predicted we’re doing what we are, when I was a younger GP. It’s absolutely crucial that we work with others, we continue to have meetings with other colleagues; I’m now sitting on the Scottish Academy of Royal Colleges, I think it’s going to be absolutely crucial to involve them in the interface working to make sure that they understand what we’re trying to achieve and to make sure that they can see the benefits of this sort of approach, not just to patient care but actually to our professional satisfaction about actually being able to do the job that we’ve got. So there’s vast numbers of people want to work with us, at times resources are severely restricted in how we do that but there is times when we have started working with particularly we mentioned SAMH and the Royal Pharmaceutical Society which have been hugely successful as ways of breaking done barriers and getting better understanding. I think the challenge is to spread that to the rest of the NHS because what is our strength is business of this hub function, that we’ve got all these links and really strong links to so many people is also our weakness because actually how do we maintain those links, how do we still have that understanding about what the others are doing as they say they change because the point was made about the third sector about so many different providers there, it’s going to be a big challenge to us.
Healthcare Improvement Scotland. Speaking sort of from a personal experience as well as a sort of professional background in terms of improvement and looking for your comments around the role of quality improvement in the clusters, GP clusters, the role of the GP in looking at snags; so from my experience, the fragmented experience of going through from primary care to secondary care, the complaints system tends to be focused at health board level whereas our interactions tend to be at local level in a first instance. So I wondered if you might like to comment on how you see GPs and general primary care having a role in being part of quality improvement initiatives and snagging from the patient’s perspective.
Dr. Miles Mack:
Okay, I’ll take those two bits slightly separately. Snagging I’ve got some experience of because before taking up this job I was the Chair of the Area Medical Committee in Highland which was the one body where GPs and consultants sat together and I realised that that committee’s job was more and more about dealing with snags and trying to fix them, ongoing grumbles that had gone on and we hadn’t really sort of fixed that. We began to get round a system and Jonathan Ball’s taken this on further with this about actually having some form of documentation about how we do this, we’ve developed SBAR form that we can actually start to indicate what’s happened and put it through some sort of process. So this sort of process needs to happen. I do see that locality groups having a role to do that because I suspect if it’s happening in my practice, it’s probably happening in Stewart’s practice in Strathpeffer just next to me. And we do need to join efforts together to make sure that those issues aren’t just getting swept under the carpet, aren’t just having sort of simple work rounds, but actually tackled in a serious way. As far as quality improvement is absolutely crucial to my vision of where we go for the future. It’s about these locality clusters having a clear idea about what their values are and being absolutely explicit about that. And these should be shared with the patient groups as well so it’s absolutely out there. The quality improvement comes in about actually how we demonstrate that our practice is congruent to those values and where it’s found lacking, to use the quality improvement techniques to bring about changes to meet that. So it will be about some peer reference data, I’m sure localities will be very interested to see how their prescribing or their appointment systems work. Either within that locality cluster, is there as much difference as we think there might be and actually how does one locality match with its wider health board area or across Scotland. So I think that some of this data would be crucial, the most important thing is that we want to move quality improvement to be something which is professionally led so these locality clusters are undertaking this work because it’s something that actually they need to do to show that their work is reaching that, is congruent with their professional values. And actually if there are things that are stopping that, there’s actually easy ways to say, this is what we are trying to do, please can you help us to achieve that.
Jackson Carlaw MSP:
Miles, I think we’ve got time for one final question. Anybody forthcoming? In which case… ladies and gentlemen can I invite you to thank Miles for his contribution this morning.