Primary care and the role of the GP
Transcript of my speech at the Scotland Policy Conferences Keynote Seminar on 30th April 2015 at Crowne Plaza, the Roxburghe, 38 Charlotte Square, Edinburgh EH2 4HQ
I want a chance to speak to you really about how General Practice is trying to meet some of the challenges that have been mentioned by Anne, I think we’re very well placed to do that; some of the barriers that we are finding to pick up that baton; but also, some of the progress, specifically some of the things that the RCGP Scotland is planning to do to make this work, and to see this realised.
Anne talked about changing cultures, I think culture is all to do about values. I’m very glad to say that the value of integration is absolutely within the DNA of general practice. It’s all about transforming patient care, so that it is truly patient centred, and tailored to individuals. And, actually, I was absolutely struck by how similar our four characteristics of primary care are to the “What Matters to Me” list.
The first one I would state would be about contact; a general practice is the default place, the first point of contact for the vast majority of patients seeking access to healthcare for the first time.
It’s comprehensive; it’s not just about seeing the person and their presenting complaint, but seeing them in their whole lived experience. And, it’s the ability actually to deal with the mental health problems as well, you mentioned this with the problems with comorbidity. GPs are uniquely placed to deal with some aspects of medical, social, and psychological, obviously with the help of all of the rest of the primary care team, and I’ll come back to that later.
And, it’s about continuity. We’re there from cradle to grave, we value the long term relationships with our patients, although we struggle sometimes to live up to that. And we’re importantly, the guardians of their full medical records, which is increasingly becoming crucial to the way health and social care is working. And, some of the ability to share our data with emergency care summary, and the key information summary, is really leading the way for us to actually get the information that people need out there.
And, lastly, it’s about coordination. Critically, we’re able to oversee care being provided by multiple providers, and we also seem to act as a “system failure service” for the NHS, when anything goes wrong, we usually hear about it.
So, what about progress so far? Much of the activity so far has been about legislation, and about setting up new models of delivery. And, I’ve got quite a lot of familiarity with this in Highland, where we’re obviously slightly ahead of the game, although we seem to be following a different path to the rest of Scotland. It does seem to be a very complicated and difficult process, but it does appear to be making some progress in streamlining services. The process has not really sought much input from general practice so far, which has been a bit disappointing. But now, perhaps, as the institutions are starting to be bedded down, we can really start to come to fore with what we bring to the table.
Everywhere else is setting up joint integration boards, unifying tasks and responsibilities, but really the next step is about this idea of a robust locality working. This is very much described in the “All Hands on Deck” document of 2013, as being of vital importance. GPs need to be central to this, partly as senior clinical decision makers, but also providing clinical leadership for the organisation. In fact, each GP practice has been asked to nominate a GP lead for integration, but how those leads have been used has been very variable, and many of my colleagues say that they haven’t been called upon in any way at all.
The next thing I want to talk about is about networks and primary care teams. A lot has been said about the primary care team, I don’t know what that is. It’s not just my practice team, it’s not just the district nurses and midwives, it now extends into pharmacy, podiatry, optometry, Macmillan, third sector, voluntary sector, social work- it seems to be ever increasing. It’s pointless to think of all of that as one team. The team is what happens for that individual patient, it’s far more useful to think of that as a network of care providers, and for each network, for each individual patient, we draw down a team to work with that patient.
So, we really need to think about a “network literacy”, if we’re going to get this right. It’s absolutely fine to be individual organisations within that, but it’s absolutely crucial that we’ve got a clear idea about what our role are, and what your roles are, so that, we understand each other, and crucially we get that communication bit right between the two of us. Overall it is actually about meeting the needs of the patient for any individual in a way that we have to. It will require a certain amount of flexibility, and this has been part of the problem with some of the approaches of managed clinical networks. They work fine for single diseases, but actually the reality of people’s lived experiences makes that so much more difficult. Crucial to that network literacy is the interfaces between the organisations, and that’s one of the key projects that the Royal College of GPs is taking forward.
The next thing is about some of the barriers to GP involvement. Now, it’s fascinating to think that, actually, the barriers when you start to list them, are exactly the reasons why we’re embarking on this endeavour in the first place. We talk about the “grey tsunami”, actually Ranald Mair’s point is absolutely right, about patients spending shorter times in care homes. That’s had a direct effect on us as GPs, we’re almost providing hospital care to patients in some of these care homes. So, the demand has been huge on the care home sector to upskill and provide that care, and it’s been hugely demanding on the other community services, not just GPs, but also district nurses and the rest of the community, to support that endeavour, and we need to get that right.
Funding has been static or falling, despite what some politicians say, as far as the percentage funding to general practice. I won’t rehearse the figures, apart from I will, it’s gone from 9.8% down to 7.8% of the NHS budget, which seems a bit bonkers, when we had to increase our consulting rate by 10% over the same period. And, actually, we’ve increased our consultation length over the same time too. It’s having a big effect on workload, and it’s becoming evident in a workforce crisis, that I’m sure all of you will have read in the papers in the last week or two. The fact that it’s happening here in Edinburgh is a real sign that we’ve got a problem.
So, what about our vision from RCGP Scotland?
The first thing is about interface working, we talked about this as the key part of the network literacy that we’re wanting to take on. As GPs we are a key hub of the NHS, because of our links in that network we have a key role in the NHS. How we interface with the rest of the NHS is going to be crucial. For examples, how we get clinical decision support from our colleagues in hospital, it sounds straightforward, but actually the only formal ways of getting help from a consultant is by admitting them, referring them into an outpatient clinic, or writing a letter, each of those takes time and is costly. We’ve got lots of work rounds to do with email and phone, but all of those have problems. We want to streamline that, so that actually GPs can get the advice they need, when they need it, to keep people at home.
But, actually, we’re not just recipients of advice, we’re also the givers of advice, and we’ve undertaken some pilot work with the Royal Pharmaceutical Society, on actually what happens when patients go to the pharmacist and need additional help from their GPs. Fair enough to say, “you need to see your GP”, but that becomes an urgent appointment, and the patient arrives with nothing, we have no ability to learn from the professional advice that the pharmacist has given already. So, we’re developing an SBAR form for communication and to streamline things. We need to start thinking about this across the sector, across the whole health and social care sector, if this is going to be right.
It’s also about quality improvement, and we’ll hopefully be developing some quality improvement methodologies for practices to use, to look at their interfaces and see how they fit within the NHS. I suspect that a lot of the things that we learn will have relevance across health and social care, and we’re delighted to start to get some real interest in the work we’re doing. The Scottish Academy of Royal Colleges have lent their support, and we’re now looking for partners from other Royal Colleges to make this work.
The next thing is about GP practice clusters. Now, it seems a bit, sort of, insular for just GPs in these clusters, but actually we need some way that we can get together, and have our interface with health and social care, and plan the services. We hope that GP practices can come together in groups, covering between 20,000 and 50,000 patients, not only to be closely involved with the planning of future healthcare provision, but also to work on our interfaces. And to focus on some of the ideas of quality and governance, which is going to be values based, rather than some of the narrow definitions of quality that we’ve seen with our present contract. There’s going to be a new definition of quality, which is going to be peer based and values driven.
And, finally, the other thing is, I’m afraid we are going to be seeking investment. If we’re going to see 2020 vision appear, if we are going to be stepping up to the role that’s being asked for us. We have actually been stepping up since 2006, there’s been clear evidence that we just soaked that up. But, if we are going to get beyond this workforce crisis that we’ve got at the moment, we need some really creative ideas, and we really look forward to working with Scottish Government to see how we can make that happen.
So, it’s a long way to go, my advice from a GP who works in the Highlands is that, don’t look for early changes with this integration work, it’s going to be hard work. The changes will happen, but they may not be as quick or as dramatic as we expect, but let’s all go through it together.
Thank you very much.