The current debate about the future of primary care and general practice seems to be focused on size. By clubbing together, GP practices should be able to deliver greater efficiency, meet the growing expectations of patients, government and regulators, and ensure financial sustainability. So, a lot of effort is going into working out what organisational forms are most suitable.
It’s not that size can’t be beautiful, but if current trends and predictions relating to our ageing population, long term conditions, ongoing austerity and the like are borne out, securing a long-term future for primary care will take much more than simply ‘bulking up’. It will also require ‘bulking out’. Primary care will need to go well beyond the boundaries of the ‘medical model of health’ and look much more seriously at the social reasons for, and solutions to, the illnesses people present at surgery.
One ‘problem’ is that the NHS has become a victim of its own success. As the best health care system in the world, medical advances over the last 65 years have been astonishing, keeping people alive for much longer with conditions that would have once sent them to an early grave. But these medical improvements mask enduring differences in health outcomes between better off areas and poorer communities. Unfortunately, social progress has not kept up with the medical advances and is now, in fact, in reverse making life for people living in poor areas more difficult and stressful than it has been for decades. People are becoming more exposed to things that have a negative effect on the wider determinants of their health, such as financial problems, unsuitable housing, hopelessness and generally feeling out of control of their lives. And this is having a negative effect on their actual health.
So, the average GP is currently experiencing a rise in demand both from people wanting to live their lives well, well into old age despite having one or more long term health condition and from people living in highly stressful and unhealthy situations. Looking for more tools in the medical model toolbox is not going to scratch the itch. And charging people £10 per consultation is a crass and defeatist way of reducing demand and will only serve to increase health inequalities and mortality further.
Why is the NHS not looking outside its narrow medical focus at what else can be done to improve their patients’ lives? There are plenty of people outside the surgery door who do have ‘social model’ solutions to people’s health problems and who could help to make GPs lives easier. Housing providers have them by the dozen, some of which I have been drawing attention to, but they are often ignored by GPs and CCGs. To housing professionals, it is incomprehensible that health professionals wouldn’t want to engage with them over their efforts to address people’s mental health problems, to prevent older people from being admitted to hospital in an emergency or to divert people who seek frequent GP advice to more suitable forms of advice and support. As one tweeter put it, following one of Simon Steven’s recent speeches … “Why is NHS so resistant to making use of support offered by voluntary and 3rd sector?”
GPs must move away from believing they are the only ones who can solve people’s health problems if they are not to be overwhelmed by a tsunami of demand. At least half of the future for primary care rests on its ability to access tools in the ‘social model’ toolbox to address non-medical issues faced by individuals that will eventually compromise their health – whether they are old or just poor. This might not be the day-to-day job of a medically qualified General Practitioner, but could be achieved by forging relationships with community partners and working with them to develop a ‘social model’ toolset. Community-based organisations are already doing it but in a way that is not connected to General Practice or primary care … they could do it much better and more comprehensively if GPs and CCGs would acknowledge their value, listen to their ambitions and ideas and work with them to shape the range of health and wellbeing services in their locality. At the moment, they are left second guessing how they might best support health colleagues.
But we are where we are. The immediate question is … will ‘scale-up’ of general practice help to achieve this? Of course it could … if scale up brings with it a greater capacity for GPs to do engage with community-based organisations, do the strategic thinking and and develop the local collaborations necessary to develop a fully functioning ‘social model’ health system in in their locality.
I haven’t yet heard this much-needed narrative coming through in the ‘scale-up’ debate, but there are early signs and I am hopeful that it will before long.