Today our NHS faces unprecedented challenges. And some big choices if we are to offer the kind of care we must to an ageing population.
Making the right decisions will demand courage, determination and most of all leadership – nationally, but far more importantly, from doctors and nurses locally.
Inevitably, post-Francis, the focus has been on hospital care. But today I will argue that improving primary and community care is equally important – and perhaps the more urgent priority, because it is from this that so much else follows.
In particular, I will make the case that we have allowed ourselves to lose sight of the concept of the family doctor – the sense that GPs are there to be a champion for their patients rather than simply a gateway to “the system”.
But mine is an optimistic argument. I believe that every patient is the only patient. And I will say that strengthening personal relationships in modern care holds the key to many of the challenges we face if we are to look after our growing elderly population with dignity and respect.
AN AGEING SOCIETY
We should be clear about the scale of the challenge.
One in four of the population has a long-term condition – many of them older people. Within the next few years, 3 million people will have not one, not two, but three long-term conditions. By 2020, the number of people with dementia alone will exceed one million.
We cannot treat chronic conditions on this scale with the systems, responsibilities and incentives we currently have in place. Too often care is reactive and disjointed, with mistakes caused as a result and in a way that endangers patient safety. Too rarely are our vulnerable older citizens looked after with a joined up care plan that pre-empts problems before they arise.
Now for the avoidance of doubt let me clear who I do not blame for this – and that is the professionals in the NHS, whether doctors, nurses, GPs or community practitioners.
Last year on a broadly flat budget, the NHS did 400,000 more operations than in 2010. There were a million more admissions to A & E. GPs now provide in excess of 300 million consultations every year.
All NHS staff are working extremely hard in the face of rising demand for their services, and they are working possibly harder than they have ever worked before. In fact, they are the ones who tell me how much better things could be organised – and it is conversations with them on the frontline that have informed my thoughts today.
Everyone agrees that hospitals should only be a last resort for the frail elderly and that – for someone perhaps with dementia and other complex conditions – A & E departments can be extremely confusing places. But what alternatives do we offer?
– Too often GP surgeries where it is impossible to get an appointment the next day;
– Same day appointments but only if you call at 8 o’clock in the morning sharp and are lucky getting through;
– Too often long waits on the phone to get through, sometimes at premium rate numbers which were supposed to be banned in 2009;
– Difficulty in registering with another practice if you move home, or aren’t happy with the service you are receiving;
– Out of hours services where you speak to a doctor who doesn’t know you from Adam and has no access to your medical record;
– District nursing services are excellent, but can be very hard to access; and
– Urgent care centres whose role is little understood by the public.
Hardly surprising then, that people turn to hospitals and that across England our 150 A & E departments are the busiest in their history.
Something we all know is simply not sustainable.
BETRAYAL OF GENERAL PRACTICE IDEALS
And if it doesn’t work for the public, it doesn’t work for GPs either.
They feel rushed off their feet with a daily list of duties that can make it extremely challenging to develop trust with patients and exercise responsibility for their care – the very reasons that motivated them to join General Practice in the first place.
Things were by no means perfect before 2004. But it is clear now that in that year some changes were made to the GP contract which fatally undermined the personal link between GPs and their patients.
The new contract said that GPs were no longer responsible for their patients all the time, but only during working hours Monday to Friday. So at a stroke the need to think holistically about a patient’s entire needs was removed – although to their enormous credit many practices still make superhuman efforts to do this even under the new structures.
The result of that historic mistake is that GP practices are now remunerated not for looking after people as individuals, but for complying with a myriad of targets and requirements: the Quality and Outcomes Framework; Quality and Productivity; Direct Enhanced Services; Local Enhanced Services; Local Incentive Schemes and others too.
All of these targets are designed for important reasons: boosting immunisation, managing blood pressure, early diagnosis, HIV testing, extending hours and so on.
But taken together, the result is we reward GPs not for putting patients first, but for the number of biomedical boxes they tick when someone walks through their surgery door. “It’s like the patients have their agenda and we’ve got ours” as one GP told me.
And with every target or process comes bureaucracy and paperwork. Updating different computer databases, chasing up test results or diagnoses or scanning in letters from hospitals. One GP practice I visited recently actually had a post called “head scanner” because of the volume of letters they receive, that have to be scanned in and linked to a patient’s medical record, a function that takes around 6 hours every day.
The consequence? We have turned GP practices into largely reactive places – sometimes with the feel of a mini A & E department – where the daily challenge is not keeping a watchful eye on the health of people on their list but simply keeping a head above water in the face of queues outside the surgery door, large call volumes, long appointment lists and mountains of paperwork.
And the proactive work of a family doctor – checking up on a frail older patient recently discharged from hospital, phoning someone who is depressed and living on their own to see how they are, looking up when someone suffering from recurrent back pain last came to see them – is too often forgotten or left undone.
OUT OF HOURS
Out of hours services are perhaps the prime example of where things have gone wrong.
We have had teething problems with the new 111 service. They were not acceptable and we are sorting this out. But those problems have rightly focused public attention on the variable quality of out of hours GP services.
No one is suggesting that GPs should go back to being personally on call during the evenings or weekends – they work hard, they have families and they need a life too. But should the quality of out of hours care for people on their list really have nothing to do with a GP? And is it right that most out of hours providers can’t even access your medical record even with permission?
Which is all part of the same problem.
Patients in hospitals are under the care of accountable clinicians. The consultant responsible doesn’t do everything him or herself. But if something goes wrong, you know where the buck stops.
But when a vulnerable older patient needing follow-up and ongoing support leaves hospital, who is the accountable clinician?
As a member of the public, I would like that to be my GP.
I’m not talking about one person personally providing every element of care for a vulnerable parent or grandparent. Clearly, there will often be important roles for geriatricians, district nurses, social workers and others.
And we can debate whether in certain cases the accountable clinician might not be a GP – just as in hospital sometimes the individual responsible consultant can change based on the needs of a patient.
But at any stage, a patient, or his or her family, should know where the buck stops.
That there is someone whose job it is to know how someone is, ensure good care is in place, and make sure there is access to good advice both in and out of hours. Someone who helps our most vulnerable older people navigate their way through the complex and sometimes scary world of health and social care.
BACK TO THE FUTURE?
Reclaiming the ideal of family doctoring in the 21st century means making sure clinicians are accountable for people who are unwell – whether inside or outside hospital.
It means responsibility for more proactive care. Just as intentional rounding has transformed nursing care in hospitals by heading off problems before they arise, so proactive case management can help keep people healthy and happy at home rather than having to be rushed to hospital in an emergency.
But it does not mean mandating a single model for primary care from the centre and seeking to “roll it out” irrespective of local circumstances. The NHS has tried that many times before with very mixed results.
In fact we need quite the opposite: bold experimentation with integrated care models where our focus is on outcomes rather than inputs and processes, something that Norman Lamb was talking about here just last week when he announced his integration pioneers programme.
Indeed if we do that I am convinced we have the keys to unlock global best practice right here in Britain, where from last month commissioning now lies in the hands of GPs. But we need to go much further, actively combining the best traditions of NHS primary care with the transformative power of modern technology – not just for the benefit of clinicians but also to help patients to manage their own conditions.
And just as we as ministers ask for this innovation from doctors, they can legitimately challenge us: on the need to remove the barriers that still exist to joining up care, something we are addressing in the Vulnerable Older People Plan; on the need to ensure that enough new doctors are joining General Practice; and on the need to ensure that Primary Care is able to get the resources necessary to prevent and head off serious illness in a way that has often been talked about but never delivered.
Finally, getting this right will need a complete overhaul of how GPs are assessed by the CQC. Too many GPs feel that the current registration system feels like yet another tick box exercise.
As with hospitals, we need to reform inspection so that it makes a holistic assessment of what General Practice is for. Inspections need to look at clinical outcomes, patient care, access and safety. But most of all – just like in hospitals – inspections need to look at whether the practices are putting the needs of patients at the heart of their work.
So I am pleased to announce that we will this year appoint a Chief Inspector of General Practice to help drive up standards of excellence in GP practices across the country through clear, open and robust assessments of how well each practice is serving its patients. Working inside the CQC, the new Chief Inspector will work alongside the Chief Inspector of Hospitals and the Chief Inspector of Social Care.
This will involve working together to make sure that primary care, hospitals and care homes are all playing their part to provide a seamless, joined up and integrated service for people with complex needs. The Chief Inspector of General Practice could have an additional responsibility to assess the degree to which this joining up is actually happening.
Many of the problems I have articulated today are what I have heard from GPs themselves – and we need to involve them in designing effective solutions. So let me finish by saying what a GP once said to me.
“The strength of general practice is the trust between me and my patients. I need my patients to be able to trust our relationship even when the surgery is closed. I have to be sure that there are plans in place to look after them, to avoid problems rather than just deal with them. This relationship which spans the highs and lows of life is why I became a GP.”
These ideas are not going against the grain of what GPs want. Nor are they trying to turn the clock back to an ideal that probably never really existed as much as we imagine.
But even as technology changes so much, some fundamentals must remain constant: the importance of people, of relationships, and of accountability.
If we are to succeed, we must rediscover the concept of personal responsibility for the care of our most vulnerable – something that most GPs have always felt should be at the heart of their profession.
Family doctoring in a 21st century environment with all the opportunities presented by a networked world.
But never losing sight of what the NHS has always stood for: a society where we can grow old with confidence and security that when it comes to ill health there will always be someone there for us when we need them.