The Scottish Government is to be commended on its commitment to general practice that has allowed the Scottish Primary Care system to retain its ethos of universal accessibility for all its citizens. The fact we have our own contract this year suggests greater independence and control in future, which can only benefit patients. It is becoming increasingly apparent that general practice north and south of the border bear no resemblance to each other, and that patients north of the border are the beneficiaries of this philosophical schism.
That said, if the contract is such a winner why then do I feel that I’ve been condemned to another 10 years of hard labour in the GP gulag, where we have a contract that does not reflect our exponential workload? I particularly want to know, what’s in the contract for me and other colleagues working in areas of high deprivation? Our patients become multi-morbid at a younger age and remain hard to reach patients irrespective of the number of letters, leaflets and phone calls encouraging them to attend for numerous physical and psychological screening tests.1 How do I provide the time for patients who do attend not with their single system complaints but rather inconveniently, for the purposes of chronic disease monitoring, regularly blur the edges of their health and social well-being?
The contract does not reflect the qualitative aspects that are core to providing holistic care and that there seems to be an endless unravelling of ‘the mysterious secrets… of the art of general practice’ that can reflect our true workload.2
Furthermore, within the context of swinging health and social care budgetary cuts is an expectation that more can be done in the community, that complex patients can easily be managed at home whilst there is no possibility of shifting money from secondary to primary care.
Resource the holistic approach
General practice is being driven by a public health agenda that has access to our patients through the medium of primary care’s IT systems and regards our patients as a ‘population laboratory’.3 In the rush to categorise, bureaucratise and incentivise the doctor-patient relationship we have ignored the many socio-medical dynamics that don’t suit the traditional bio-medical model. This diminishes our profession and gives us a contract that does not recognise what GPs do, nor values what they are good at – pragmatically working through patients’ multiple problems.
The contract should not be guided by political agendas – telling a patient to exercise more, for example, means little to their health if they cannot first afford their food or heating bills. What of child health and working with vulnerable families? This aspect of GP care has almost been eradicated. And wouldn’t it be great to have an attached social worker resourced to every practice?
There remain major challenges ahead to our contractual obligations if health and social care are to better integrate around children and elderly care services. Integrated care is a political imperative that is being monitored closely, but we will not improve on existing performance unless the contract can be be tailored. Future contracts must reflect changing health needs as much as they can, engage a broad range of GPs in its evolution and stay mindful of the way the NHS is developing.
Dr Anne Mullin is a GP in Glasgow and a member of the Deep End practice group.
1 Mercer, SW, Guthrie B, Furler J, et al. Multimorbidity and the inverse care law in primary care. 2012. BMJ 344, e4152.
2 Heath, I.The mystery of general practice. 1995. London, Nuffield Provincial Hospitals Trust.
3 Shaw, S. E., & Greenhalgh, T. (2008). Best research—for what? Best health—for whom? A critical exploration of primary care research using discourse analysis. Soc Sci Med 66 (12):2506-519.