Focus on… Growing primary care

One of the key ways to expand the capacity of primary care at low cost is to provide clinicians with tools that enable them to do more.

There are tools you can use to instantly increase your diagnostic skills-known as diagnosis decision support tools. These tools allow you enter signs and symptoms and instantly see a list of possible causes. This immediately widens your differential as the knowledge base draws on thousands of diagnoses and also enables you to refer more appropriately.

One study carried out by a US medical school on its final year students using the Isabel tool (http://www.isabelhealthcare.com) found that their diagnosis skills increased by over 20%

The Impact of a Diagnostic Reminder System on Student Clinical Reasoning During Simulated Case Studies
Carlson, Jim MS, PA-C; Abel, Marc PhD; Bridges, Diane MSN, RN, CCM; Tomkowiak, John MD, MOL
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare:
February 2011 - Volume 6 - Issue 1 - pp 11-17
doi: 10.1097/SIH.0b013e3181f24acd

Final year med students aren't really a good enough comparator. As a GP decision support software doesn't really help much (and I have tried it) mostly it isn't not knowing what the diagnosis is or what should be done but rather having the time to provide it

The comment about NHS bureaucracy stifling innovation is spot-on. GMS2 was supposed to be administered with a high degree of trust but we all know now that it was not true. The present round of NHS reforms similarly started with a promise to let go of the reins but as we go on we see that the ropes are being replaced with spiders` silk - much less obvious but ten times as strong! If politicians want an innovative NHS then they have to de-politicise the service and realise that all change costs money and centrally-directed change costs much more.

<i>The current assumption is that moving activity out of institutional settings into community ones is bound to save money. But this is likely to be true only if the shifted activity requires marginal change to staff and facilities – in other words, the system doesn't need to erect new buildings or employ new staff </i>

A shift in activity from secondary to primary care without any increase in primary care (staffing) capacity is really just another exhortation model asking us to work harder, do more. This won't do. The car is driving as fast as it can, the pedal is on the floor. To do more we need a different car. We need system change.

It is possible to describe overall cost reduction to the NHS by increasing primary care capacity.....but to save overall costs this MUST be accompanied by a reduction in secondary care infrastructure (staff and buildings). Duplication costs.

Service reconfiguration is a huge challenge.

Closing hospital departments is not popular with patients and politicians. Even reversing the current unsustainable secondary care staff expansion is going to cause problems. Training fewer consultants, for example, means that some middle grade rotas will not be sustainable without service reconfiguration.

In an "any willing provider" environment the greatest danger is in fact growth of secondary care capacity and what Elliot Fisher and Jack Wennberg call "supply driven care". Our current road is towards a secondary care driven system, not a primary care led NHS.

What is needed is a shift in the way that we train the NHS staff of the future. Unless we train the future NHS workforce in a primary care context and with a primary care orientated curriculum we will simply recreate expensive secondary care delivered in a community setting. Reform needs to begin with workforce education and training with a strong primary care voice into Health Education England and the Local Education and Training Boards..