Regarding General Practice: An appeal to the new UK Government

Dear Sir Keir and Mr Streeting,¹

We were very pleased to hear that the Secretary of State for Health and Social Care has commissioned an immediate and independent investigation of the NHS with a particular focus on assessing patient access to healthcare, the quality of healthcare being provided and the overall performance of the health system.

Addressing the chronic underfunding of the NHS in recent years is crucial, but in order to make the best use of additional money we must also review the way in which the NHS is managed. No doubt COVID-19 placed an enormous strain on the NHS. However, much of the current low morale, high levels of burnout, and consequent difficulties in recruitment and retention in primary care are the result of a neoliberal market paradigm that promotes a ‘factory model’ of healthcare. This industrial model of care is predicated on increasing control, micro-management, and targets as the solutions to failure to meet demand. As a paradigm, it devalues the importance of personal relationships, continuity of care and of seeing disease within the broader context of people’s lives.

A recent article in the British Journal of General Practice compared this efficiency drive with 19^th century measures to improve drainage by straightening rivers.² At first this seemed beneficial, improving fertility and productivity, but more recently, adverse effects, increasing flood risk and washing sediments downstream, have become clear and the changes are being reversed. Similarly, measures to improve ‘efficiency’ in primary care that superficially look reasonable can in fact just wash problems ‘downstream’ and result in ‘flooding’ of community and hospital services alike. Community, hospital, and emergency services are drowning, and the most experienced and compassionate staff are leaving or reducing their hours, and even taking their own lives.³

As the RCGP emphasised in a recent joint letter from the membership to the new Secretary of State for Health and Social Care,⁴ there is a need for adequate funding of primary health care to make the NHS work. However, ‘re-wilding’⁵ and ‘re-wiggling’² of primary care, valuing and strengthening patient-professional partnerships and collegiality between clinicians is also needed.  This requires measures which support continuing relationships, so that trust develops between patient and professional, and also between clinicians. We were therefore pleased to hear before the election that Labour plans to reward general practices for providing continuity of care, but a change of philosophy is also needed. Self-efficacy rather than dependency  should be promoted in an environment where patients can be confident that support from familiar and trusted clinicians is accessible when needed.  Conversely systems which encourage a customer/provider model of healthcare must be discouraged, as these reward activity and short-term metrics of success rather than good, long-term care. This holds true both for industrial and consumerist approaches to healthcare.^6,7

Humane healthcare also requires subsidiarity; organising healthcare systems at the level of the smallest unit practicable; the practice, hospital department or hospital, instead of monolithic systems that do not account for local variation in need or recognise the shared and diverse values of our fellow citizens. This includes enhancing accountable professionalism.  Professionals need to feel trusted but also responsible for the standard of care they and colleagues offer, rather than to be treated as cogs in a machine.

This requires an end to toxic managerialism.⁸ We recognise that NHS needs good managers; in both primary and secondary care, they are essential members of the team. But their focus should be on building morale and commitment amongst workforce and on the practicalities of cost-effectiveness, rather than implementing systems of targets and protocols without regard for the people who deliver the service and the experiences of service users.

Whilst implementing these values requires changing attitudes, and in some cases, particularly at senior levels, perhaps changes in personnel, structural re-organisation should be discouraged since it is an expensive distraction and often further damages morale.

Measures to improve professional morale and promote continuity of relationships are not just a matter of making professionals or even patients feel better (although that is no bad thing), it has financial benefits. Good morale helps retention and recruitment, and continuity of care improves efficiency (for example by avoiding unnecessary tests and referrals) and outcomes including mortality.⁹

When the Labour Government took over in the 1960’s, their “GP Charter” reforms laid the foundations for the transformation of general practice from a cottage industry into a system of primary care which for more than twenty years was admired as the best in the world.¹⁰  We hope and trust that this government will do something similar to revive general practice and primary health care more widely.

*Editors’ note: all authors are writing in their own capacity and not on behalf of the RCGP or BJGP

References

1. This text is based on a letter signed by 29 primary care clinicians and academics sent to the addressees before the election
2. Sanders T, Rewiggling general practice, Br J Gen Pract. 2023; 73 (736): 508. DOI: 10.3399/bjgp23X735417
3. Khan N, BJGP Life October 6 2022,  https://bjgplife.com/burnout-patient-and-physician-safety/ [accessed 21/7/24]
4. https://rcgp.eaction.org.uk/Joint-Letter-2024  accessed 21/7/24]
5. Heath I. Rewilding general practice. Br J Gen Pract. 2021 Nov 25;71(713):532-533. doi: 10.3399/bjgp21X717689. PMID: 34824063; PMCID: PMC8686424.
6. Toon PD. What is good general practice? A philosophical study of the concept of high quality medical care. Occas Pap R Coll Gen Pract. 1994 Jul;(65):i-viii, 1-55. PMID: 9248307; PMCID: PMC2560367.
7. Iliffe S. The political economy of family medicine. In: From general practice to primary care: the industrialisation of family medicine. Oxford, UK: OUP, 2008:26–27.
8. Toon P (1999) Towards a philosophy of general practice: A study of the virtuous practitioner. Occas Pap R Coll Gen Pract (78):iii–vii, 1-69.
9. Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. Br J Gen Pract. 2022 Jan 27;72(715):e84-e90. doi: 10.3399/BJGP.2021.0340. PMID: 34607797; PMCID: PMC8510690.
10. Gillam S. The Family Doctor Charter: 50 years on. Br J Gen Pract. 2017 May;67(658):227-228. doi: 10.3399/bjgp17X690809. PMID: 28450339; PMCID: PMC5409444.

Featured image by Tom Shakir on Unsplash