With fewer doctors choosing general practice as a career, and more of those who do finding it difficult to see a future in the NHS, the onus is now on GPs to rebuild our own professional self-esteem and confidence.
Some GP leaders have declared in these pages that the independent contractor model of general practice is defunct. I believe it still provides the best way forward – but only if we actively start to reclaim and reshape it.
For those of us in medicine who share the values of whole-person, patient-centred care embedded in communities, the way forward is obvious: change NHS and public cultures to value generalism at least as much as specialist care.
To do that, we would need to turn every part of NHS planning on its head, changing the commissioning mindset that values excessive specialism over sustainable generalism. It’s a hard task, but given the long-term proposals set out by NHS England last year in its Five Year Forward View, we must at least try.
Change has to begin with GPs. We must use our voices to persuade commissioners to invest in patient-centred, community-based services run and managed by those who understand how primary care, community, social and mental health services can deliver the best care.
Hospitals do not know how to do this, so it makes no sense for them to manage or operate these services. Let hospitals do what hospitals do best – provide specialised diagnostics and care – and let communities organise services around themselves. This is the horizontal integration model – the ‘in-community model’, if you will – whereby as many of patients’ needs as possible are met within their communities.
Care should be seamless, navigated and coordinated by GPs, with good communication across the boundary between communities and hospitals.
This is close to the multispecialty community provider (MCP) model described in NHS England’s plan, although with subtle differences. MCPs are described as ‘extended group practices’, ‘federations, networks or single organisations’ that would employ consultants, senior nurses and other specialists to work alongside community nurses and social workers, among others, shifting care out of hospitals.
The more worrying alternative model in NHS England’s document is integrated primary and acute care systems (PACS), or vertical integration with hospitals employing GPs. Put simply, this means the hospitals run everything and you work for them.
Hospitals would for the first time be allowed to open their own GP surgeries with registered lists and integrate directly with primary care services (for those familiar with international healthcare, this would be similar to how accountable care organisations work in the US, Spain and Singapore).
Hospitals are already making moves to start these organisations all around England. Pulse recently revealed GPs were being offered £100k positions to work with them.
But GPs have far more in common with social and mental health services. We must use CCG co-commissioning to rebuild community services around practices or networks of practices. Patients need a horizontally integrated network with their health and wellbeing at its heart.
This will mean taking control of our professional future, being prepared to challenge what does not fit our values and finding the headspace to talk with colleagues about more than just surviving the next few weeks. It means GPs using our power as CCG members to galvanise the CCG governing body to support these endeavours. Ultimately, it means not taking ‘no’ for an answer.
As members of our CCGs we have the influence to act. As guardians of general practice we have a duty to do so.
Dr Michelle Drage is chief executive of Londonwide LMCs.