Enough of this merging nonsense

The future of primary care seems inextricably intertwined with other NHS services, but Dr Katie Musgrave questions whether it has to be this way

As we have been plodding along, trying to keep our heads above water, there are plans to ‘integrate’ primary care, whatever that means – and rising to the surface of these plans is the Fuller Report, led by chief executive designate of Surrey Heartlands ICS Dr Claire Fuller.

I listened with interest to the oral evidence given to the Health and Social Care Select Committee in their work on ‘The Future of General Practice’ this summer. This was one of the more encouraging debates I have heard, with the committee chair Jeremy Hunt giving Dr Nikki Kanani, Dr Amanda Doyle, Matthew Style and James Morris a thorough grilling. 

One comment made almost as an aside by Mr Style – the director general for NHS Policy and Performance – stood out. He said: ‘There is a strong consensus across the profession, across the NHS, about the vision that Dr Fuller has set out for the future of primary care.’

Is there? Have we as a profession been consulted about Dr Fuller’s vision? Is there a strong consensus? Or is this simply more nonsense from the bowels of NHS England that will further demoralise and fracture our service, until we really are at the point of no return?

Over the past few years, we have been promised salvation in various forms.

First, there was multi-disciplinary working. Using a team of professionals would reduce our workload and make our jobs more sustainable.

Then there were remote consultations. These would be efficient to deal with patient enquiries without the need for an appointment (and would definitely not drive inappropriate demand). 

Scaling up general practice would allow special interests to flourish, streamline back-office functions, and allow innovations to be rapidly disseminated (these would definitely not demoralise staff and lead patients to feel they were engaging with an anonymous machine).

Extended access would relieve pressure from weekday services and allow patients to book an appointment at a time to suit them (and would definitely not spread a thin workforce even thinner). 

And PCNs were introduced to allow us to collaborate closely with other practices (but were definitely not a vehicle by which to incentivise the sharing of appointments, staff and estates – with the end goal of encouraging practice mergers).

Promise after promise has been made, but please take note: none of these proposals have worked. They have not touched the sides of the crisis in general practice, and, arguably, they have hastened its demise. We have been too busy dealing with the introduction of PCNs and the associated shifting sands to look at how to build a service that can survive in the coming decades.

So, now we have the Fuller Report, presented with all the fanfare that NHS England can muster. It builds on the PCN model and proposes:

‘At the heart of the new vision for integrating primary care is bringing together previously siloed teams and professionals to do things differently to improve patient care for whole populations. This is usually most powerful in neighbourhoods of 30,000 to 50,000, where teams from across primary care networks, wider primary care providers, secondary care teams, social care teams, and domiciliary and care staff can work together…’

But why 30,000 to 50,000? Has this figure been plucked out of thin air? Surely the scale and model will vary depending on the rural or urban nature of a population.

The other particularly interesting aspect of the report is the proposal to integrate the urgent care system (and separate this from chronic illness management). That is, to deliver same-day care across the scale of a PCN, ultimately including out of hours and 111:

‘In the face of rising demand, we need to move to a streamlined and integrated urgent care system… We need to enable primary care in every neighbourhood to create single urgent care teams and to offer their patients the care appropriate to them…

‘Critically, we need to create the conditions by which they can connect up to the wider urgent care system, supporting them to take currently separate and siloed services – for example, general practice in-hours and extended hours, urgent treatment centres, out-of-hours, urgent community response services, home visiting, community pharmacy, 111 call handling, 111 clinical assessment – and organise them as a single integrated urgent care pathway in the community that is reliable, streamlined and easier for patients to navigate.’

Do you see what is planned? Yet, as we all know, patients do not come to our service with a banner announcing: ‘This is an urgent problem and need not be viewed through the lens of continuity.’ I would argue that every patient benefits from a degree of continuity, and that at the very least, we must not design continuity of care out of the system, which is exactly what the Fuller Report does. 

Understanding a patient’s background, context, previous consulting behaviour and past medical history, as well as establishing a trusting relationship, is fundamental to safely providing good quality care. Of course, some of our workload must be reduced – drop in mental health cafes, better family planning access, children’s centres and the like. But to suggest that urgent care should be delivered across a population size of 30,000 to 50,000 patients is frankly insane.

I do not write these words glibly, or without reflection. A wholesale move in the direction outlined by the Fuller Report will lead to increased secondary care referrals, overprescribing, increased rates of reconsultation and reduced patient satisfaction. This would likely finally bring down the NHS.

If merging hasn’t worked, we must not merge, merge and merge some more. As GPs, we know the value of what we do – and we must defend it before it has gone for good.

Dr Musgrave is a newly qualified GP in Devon and quality improvement fellow for the South West