Changing primary care: The baby and the bath water

A lot has been written about primary care recently. Everyone who is anyone appears to believe it requires a major overhaul. I have always been a bit of a change junkie. I love the adrenaline that goes with shaking everything up and starting all over again. We were the first practice in the north to have a nurse practitioner, in fact we had to train our own because there weren't any courses in the north then. I ended up designing a course at York uni because of that in the following years to fill the gap. I believe in skill mixed teams working around the needs of individuals And I worked hard to keep the holistic part of general practice alive that I think is so fundamental to uk general practice. Alive despite a bigger team. I have worked to change health care and mould it to meet the challenges of life today and yet all the talk of radical overhaul makes me uncharacteristically anxious. I am wondering why.

It think it has to do with losing the relationship that builds over years between a GP and their patients. Lots of small encounters. Most of which could probably be done by someone less qualified but which build a human bond of trust and knowledge. I know it has all but disappeared in many places. People see different people with different skills each time they go and mostly I don't suppose they mind much. A member of my family had a sore eye this week. He made an online appointment and saw a doctor the next day. He hadn't seen her before but wasn't bothered and was treated effectively So does it matter that we no longer have that relationship between a patient and" their" doctor? I wonder sometimes if the phrase "you never know what you had till it's gone" will be the epitaph of general practice as we know it.

Let's look at the facts. Patients value primary care. Satisfaction rates are really high. Most other private or public services would love to have the kind of satisfaction rates GPs have. Primary care sees 90% of all NHS contacts every day and treats 90% of those without sending them anywhere else. Yes people struggle for appointments sometimes. There is real clinical variation that we need to confront and improve. Primary care is under considerable strain , but as Clare Gerada talked about that is because of real funding pressure which has resulted In a decrease in investment whilst demand rises.

Before we rush to new models based on the sound bites of important people who actually know very little about how the service works day to day can we first answer some simple questions. What is primary care for? What do we as a nation really value about the service now that we don't want to throw away in the rush for change?

My view is that primary care is : 1. A front door into urgent care. 2. Deals with minor illness 3. Manages complex long term physical and mental problems 4. Is a safe place for people who don't know where else to go for support and advice.

Now , you could take each aspect and give it to new service that deals with just that. There is already evidence from around the country of GPs running urgent care services alongside more traditional primary care. Let's stop and looks at them before we decide is the right model. In Bassetlaw such a service exists. Patients and staff like it but it hasn't solved the problem of demand in A&E round the corner. Minor illness services were available in Darzi centres and many of them are closing.

One of the joys of being a GP and I think one of the most important motivators for maintaining a work force in primary care is the on-going relationship with patients. Perhaps rather than analysing each patient contact and asking who else other than a GP could do that, we need to see each contact as part of a long term relationship forming the platform upon which you build what is needed when it is time to deal with big significant illness when trust and human factors become a huge part of the transaction between patients and their doctors. Each GP I talk to has their stories. I have mine. The young woman terrorised for years by the husband who planned for 4 years to leave him by educating herself and scrapping together savings from her housekeeping, her flight when he was posted away, her necessary complete break from her family and friends who had helped him find her during previous escapes. And I was the only person she confided in. She didn't trust anyone else. And a postcard 2 years later to tell me she and her kids were safe and happy. She didn't have a medical illness. And perhaps she would have found someone else if she had not found me. And perhaps it didn't matter and she would have done it without me but I like to think seeing her every few weeks for those 4 years gave her a safe place to express her fears and formulate her plans.

Or being able to pick up something unusual because you know the patient: the very eldery woman who had been a patient at our practice for years and came because she had had a little “wobble”. Very little to find clinically but she just wasn’t her usual self. If she had been assessed by people who didn’t know her they might have just thought she was mildly senile, we knew she wasn’t right. She had a cerebral bleed, not related to a fall but to a bony metastasis in her skull eroding a blood vessel.

I have could go on.

GPs also manage risk better than any other group of clinicians I know. Every day they make decisions using only the tools they have in their heads and their bags to filter the serious from the " got some time to sort this one out". Until you have done the job you don't really get that. Going home and thinking through that one nagging case of the day and wondering if you got it right. You can't send everyone on. The system wouldn't cope. It is our job to get it right every time. If we get it wrong we are rightly criticised. If we get in right no one notices. But that is the job and I am not complaining. I am just saying it is more complex than most think it is. May be can’t afford this model any more. Maybe we have to accept something different.

But before we change everything can we somehow have a real discussion about what primary cares job is, what we care about keeping, learn from what has been tried around the country, and really trial and evaluate new ideas before rolling them out.

Can we think about evolving primary care rather than revolutionising it? We all know that 70% of major change initiatives fail to deliver their stated objectives. ( I remember David Nicolson told me that when they first announced CCGs)

And try just this once to keep the baby whilst throwing out the bath water.