How do we make clinical roles both cost effective and satisfying?

As part of our redesign of the community health and social care system in our area we are trialling the Buurtzorg model of community care in the most rural part of our CCG.The “Dales Project” will integrate health and social care in an area where we struggle to find carers, and staff spend a lot of time in their cars driving along slow rural lanes from patient to patient. The model is compelling. Having care delivered by self managed teams of highly qualified nurses who work closely within individual communities has been shown to improve the experience of care for patients AND reduce overall spend on care. You can read more on the RCN website at:

http://www.rcn.org.uk/__data/assets/pdf_file/0003/618231/02.15-The-Buurtzorg-Nederland-home-care-provider-model.-Observations-for-the-UK.pdf

Interestingly it also improves job satisfaction for staff. We are running the pilot for 18 months at least. It will be interesting to see the outcomes.

I found myself thinking about the staff aspect. It seems the staff in The Netherlands feel they do a more enjoyable job, providing more holistic care to patients rather than simply delivering the “nursing role”. Maybe there are lessons from that we might usefully apply to other areas of the NHS. Why are people not wanting to be GPs? Community nurses? Is it that as we skill-mix roles to squeeze the most cost effectiveness out of the system, we inadvertently design roles that no one wants to fulfil? Does working at the top end of your competency make the role too stressful and difficult to sustain into the longer term?

When I was a young GP I did my vocational training in a rural practice in Derbyshire. The practice fulfilled a wide role in the community, we regularly visited elderly isolated patients, delivering not just their medicines but provided an important social focal point and even delivered their groceries if necessary. Those long gone regular visits allowed us to help sustain people in their own homes, working with the glue of the local community to support and cherish those frail people. We would now have been called their care co-ordinator. When I first came to Catterick we syringed ears, took blood, did all our own on call. I remember examining a little boy with ear ache on Christmas Day in our living room. We knew our patients. Was that time wasted? Certainly they were roles that could be and are now fulfilled by other people with different training and who cost less than a GP. But did we lose something along the way? I remember a patient who I saw occasionally over the years for relatively minor things, all of which could have been delivered by someone else. But then one day she came to confide in me that her husband who had dementia had been assaulting her. She had told no one. She was a retired officer’s wife. You didn’t complain. She told me I was the only person she could tell because she knew and trusted me. Another patient developed motor neurone disease and they felt able to discuss with me the most personal of issues around their disease because of the relationship we had established over years of managing their hypertension and sharing stories of our children’s exploits. I very much treasure those memories and that way of working. I worked long hours on-call every other night and every other weekend but it felt good. Now the job is much more challenging, fewer hours of highly intensive work. Is the “decision density” of the modern GP role just too much to sustain for 30 years?

Our CCG has the best patient satisfaction for general practice of all CCGs nationally. People often ask me why. The GPs here still provide predominantly medically-led small practices where personal continuity of care is still alive and well. It is changing as it is everywhere, is it one of those things you don’t know what you’ve got till it’s gone?


Is our rush to define roles where everyone works to the top of their pay grade, to maximise efficiency for the system actually designing jobs that no one wants because they aren’t satisfying, are too stressful and don’t work on a human level? If the model from The Netherlands shows this is a cost effective nursing model that also delivers better satisfaction for both patients and staff should we just pause a little and reflect before we rush headlong into more skill mixed roles for primary care too?