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‘Cottage industry’? Bigger is not always better in general practice

Much in the King's Fund report published earlier this month, Transforming the delivery of health and social care, resonates with what GPs have been saying for two decades. Clinical and non-clinical complexity, along with rising expectations, have squeezed general practice to the point where the pips have not simply squeaked, but have been ground down to molecular level.

But the report makes the fundamental error of viewing the UK healthcare system through the narrow-angle lens of hospital institutions, and concludes that the model of delivery of primary care, which it described as ‘the cottage industry of general practice', must be radically transformed to manage pressure and demand.

GPs sigh wearily when we hear this, just as we balk at the suggestion that if only others could look after the simple cases, we could be freed up for a lifetime of managing multiple long-term conditions in growing numbers of older patients.

With the overwhelming majority of patient care already taking place in primary care and 85% of resources embedded in our hospitals, could we work smarter in general practice? Could we employ more nurses, liaise better with other members of the primary care team, integrate our services with others such as community, social and hospital services?

Yes, we could, and we should, because integration has been the glue of general practice since the term was coined by the profession itself in the 1950s. Two generations of GPs have been trained to identify the need for integration and, through primary care teams, practise it.

Yet since the early 1990s, the system has failed to value it, leading to workforce crises and patchwork solutions based on the bigger-is-better philosophy of Darzi centres, polyclinics and others.

All of these models mistakenly focus on redesigning models of care rather than supporting the organic growth of what we already have. The danger inherent in this report is that it will be interpreted as another panacea, providing a platform for yet another round of political ribbon-cutting and drainage of our scarce resources to global firms of management consultants whose understanding centres far more on self-perpetuation than general practice.

Well, as the old bus adage goes, just when you've been waiting for ages two come along at once. In its new paper, Patients, Doctors and the NHS in 2022, the RCGP offers a more rational approach, recognising general practice has its own set of values, centred around the whole patient's needs, be they medical, socio-economic or psychological.

The report offers a less radical, potentially more successful solution. It highlights the need for more GPs with longer training as central to the development of general practice in the next 10 years – something that cannot be denied. The RCGP brings together elements that are prominent in the King's Fund report and ties them to a rationale that makes sense to GPs.

Integration of services is key, but it should be flexible and defined by factors such as ‘patient need, geographical factors and organisational characteristics'. In terms of flexibility, the RCGP concept of federated practices needs to be tailored to local GP cultures and infrastructure constraints.

A single partnership or company may suit some, but neighbourhood networks of practices, linked by good management and telecommunications support, could offer just as much if not more.

The RCGP paper also addresses clinical complexity and the need for longer consultations, which would lead to more effective interventions and better outcomes. But it does so through the wide-angle lens of general practice, where the presenting problem is just the ticket to explore what really are the underlying causes of concern and where the whole patient picture is valued.

Can these reports lead to a new valuing of the clinical generalist and a whole-patient approach? With former RCGP chair Professor Steve Field now deputy medical director of the National Commissioning Board, there is potential to finally turn the system's thinking towards making this a reality.