It is good press if a fellow GP appears to be urging his peers to do more for less – but that is not my view. GPs should not have to be digging into their pockets to prop up an NHS that has failed to invest sufficiently in general practice and primary care. On the contrary, I believe that GPs should be receiving a far greater share of resources for doing proportionately more as commissioners and also as extended providers of improved health and services.
Those improvements have failed to materialise historically because of a singular failure by previous governments and commissioners to make the necessary investment in general practice and primary care. The result has been a trebling of specialists during my professional lifetime, while the number of GPs and the size of their lists have remained relatively static.
Meanwhile, activity and workload in general practice rises year on year. Much of the work previously done in hospitals (such as childhood asthma, much long term disease and the treatment of deep vein thrombosis) is now carried out in general practice. GPs are not paid according to patients seen or hours spent. We have, effectively, a ‘block contract’. Conversely, the hospital system continues to be paid per unit of activity. It is not sustainable.
General paactice faces greater opportunities and risks than ever before. Its strengths lie in its flexibility and the provision of holistic continuing personal care . It does this very cost effectively. That is why the personal list has survived (in spite of many challenges in recent years – as fellow GP leaders will know).
That is why clinical commissioning is itself now predicated on the GP list – effectively turning the NHS on its head and moving the centre of gravity of decision making on health and services away from Whitehall and to ourselves. Unequalled opportunity or poisoned chalice? GP opinion is divided on which but the greatest deciding factor will be how we react .
We now hold all the keys from designing health services as commissioners to helping our patients decide which to use when they are with us in our consulting rooms. We could not be in a stronger position to describe the future NHS landscape. Issues such as private/public, market/integration or done in hospital/done in the community are very much in our court. We would have no say if clinical commissioning did not exist.
As providers of services, the opportunities are equally great but the window of those opportunities will be short. That is, we need to make a strong bid, and fast, for the role of general practice as provider of extended services and as a major player in local health.
It was my remarks on the latter that led to torrents of abuse from my fellow GPs, when it was implied that I thought we should be digging in our own pockets to improve local health. In my own practice, we do provide funding for a health facilitator and other health projects, which have delivered a return on investment through fewer appointments and referrals, and as importantly, through improved higher quality of life for often patients who are often vulnerable and lonely. My point was not that others should follow this example but that general practice should be enabled to take on a far wider local health role, and be properly supported and funded by CCGs to do so, and backed by local health and wellbeing boards.
Integration at practice level
GP practices and our independent contractor status are very vulnerable in a world of global markets, a society committed to consumer choice and European law – on the one hand and the changing face of general practice itself with an increasing part time workforce, no longer responsible for out of hours and with erosion in some areas of the doctor/patient relationship – on the other. In these circumstances, takeover of general practice by the big corporates becomes a real danger and possibility. Very small changes such as allowing sale of goodwill (which many of us have resisted behind closed doors) or increased profit margins would rapidly tip the balance.
Being prepared for this new world will require that ingenuity and adaptability for which general practice is famous. Already GP practices in many parts of the country are recognising that there is ‘safety in numbers’ and forming associations of practices, local provider organisations (e.g. limited companies or social enterprise) or merging altogether. Some are already providing extended services and others are preparing business cases to do more.
The trick for GP principals and their practice managers will be to maintain good personal and continuing care as generalists, while diversifying by extending services offered by practices (often jointly) particularly for those with long term disease and the frail elderly. We must lead the integration of services at practice level and in primary care as we have, historically, been the sole integrators of care. We will need to do this with caution, holding the ring and heeding the words of Lord Hunt, the first chair of RCGP that integration was what the cat offered the canary.
It may sound exhausting and it will be. Less so with good managers and with the right relationships between local GP practices. Less so also with the support that NHS Alliance will be offering GP practices that want to be in control of their future. Staying as we are holds the promise only of increasing vulnerability and diminishing income. Grasping the opportunity will provide the stability and sustainability that general practice now needs.
A major decider in all of this will be the level of morale, confidence and trust at the frontline of general practice. This is not helped by the current standoff between government and BMA. GPs and practices need reassurances, particularly at this time, about stability of future income. These might then generate a more confident profession that can then take on its new leadership role, which will protect the best of generalism but also create new community services and healthy communities. These are the only answer to long term NHS sustainability.
Dr Mike Dixon is the chairman of the NHS Alliance and a GP in Cullompton, Devon.