My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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A manifesto ‘to’ primary care or a manifesto ‘for’ primary care. Small change but a whole world of difference..

Filed Under (Healthcare delivery, Patient involvement, Reform of the NHS) by Paul on 10-01-2013

Today I am taking part in an interesting conference organised by the NHS Alliance about the future of primary care. They have asked me to develop challenges to an important set of chapters that clinicians and others are writing about the future of primary care.

Let me share some of the challenges that I will be making.

The first point may appear really semantic but it goes to the heart of a big and real problem. This meeting has sometimes been described as developing a manifesto to primary care and on other occasions as a manifesto for primary care. These two phrases do not carry the same meaning.

Obviously people want to be able to do both. It would make people feel good if they could, at one and the same time, do something that is both ‘for’ and ‘to’. But the words do in fact convey different meanings.

A manifesto for primary care is making the case for the current set of institutions. Of course there will be many arguments for change (I am sure most writers would agree that no one is saying that primary care, as it exists at the moment, will exist in the future). But a manifesto for something still stands for a set of existing institutions and practices and argues their case – usually against others within the NHS family. This is good thing, and if that is what we are doing today then some good things will come out of it. Primary care does need to be simultaneously changed and defended.

But a manifesto toprimary care is written outside of the institutions and practices that it is trying to change. Of course it can be written sympathetically, but it views primary care as something that needs to radically change and will need assistance in making that change from outside – probably most powerfully from patients.

So I am not sure if the conference and the publication are about starting from scratch in defining what primary care means and what it can do – or whether it’s starting from the current base of institutions and moving on from there.

Does this matter?

I think, given the 30-35% increase in demand for health care in the next decade combined with the fact that over that same period primary care will be very lucky to carve out single digit improvement in the number of staff that it has, the current model will not work in a decade from now. That big increase in demand coupled with the small increase in resource will cause it to break.

In fact the GPs I have spoken to over the last 6 months talk about their current practice as being ‘overwhelmed’ by demand. (I have commented before that the analogies they use to describe their experiences are very troubling. They are all water and drowning analogies. There is a tsunami of extra demand from older people. They are being flooded by the demand for mental health services. There is a rising tide of new cases for people with diabetes…. Nearly every analogy it seems contains some real threat from water.) So the current model won’t just break under a decade of pressure of increased demand. GPs report that it is breaking already.

Now of course one response to this could be that what we need to do is invest a lot more money in the current system in order to help it meet the increased demand. But that is what everyone is saying about their part of the current system.

It will not happen. There is no more money. There will be some movement from the current category of secondary care to primary care. But it will be less than 10% growth over the decade.

So a few thoughts about what a different primary care system might look like.

First let’s think about what we mean by ‘primary’. If the word means anything it means first. And primary care is very proud of being the first place where health care starts to happen. It’s true that the GP’s surgery is very different from the hospital (secundus), but defining itself in its main definition as ‘against secondary care’ leads to all sorts of errors about the real experience of health care in our country.

So for example there is an enormous amount of talk about moving care closer to home. By which we mean moving it from existing secondary care to a new place in primary care. All important changes, but these are movements within the categories of a healthcare system that believes that its own categories can define the world.

They don’t.

The main site of healthcare delivery is not the hospital, the GP surgery, or the polyclinic but overwhelmingly is the patient’s home. On any one day an enormously high percentage of total healthcare takes place at home. It’s true that there are 1 million consultations between healthcare professionals and the public every 36 hours. But that is not where most health care takes place.

Why does this matter for writing a manifesto to primary care? Well it may well mean that primary care (the first location where care takes place) happens mainly at home. So what we have to do is radically improve the way in which real primary care (that which happens in the home) takes place.

Perhaps a manifesto for the improvement of self-management and real home production of healthcare would be important.

And of course professionals who currently see themselves as primary care would be incredibly important in that process. They would have to play a major role in improving the efficacy of the home and the community as the real sites of primary care. They would improve the productivity of the patient as the main primary care staff many many times.

But the focus would be very different.

Think for a bit about what it might look like for the way in which we usually think about planning for NHS change.

What would the implications be for workforce development if we saw the main staff in the primary care system as the patients and their carers?

What would be the estates policy for a health service that saw the home as the main site of its primary care system?

What would the development of an integrated care system look like if that system had to include the day-to-day relationships of the main staff involved (patients and carers).

Then there would be a further question.

What do we call the sets of institutions that at the moment we call primary care and how do we change them?

An important question – but of a second order.

Comments:

2 Responses to “A manifesto ‘to’ primary care or a manifesto ‘for’ primary care. Small change but a whole world of difference..”


  1. Very few people with long term – or even short term – conditions are spending their time at home or elsewhere delivering medical care to themselves or their families – and nor should they: there are more important things in life such as work, life and pleasure.
    Nor is it reasonable to expect normal people to train for roles which they are unlikely to ever need – unless or until they need the services for themselves.
    Paul, what are you suggesting in practical terms?
    I agree with your assessment that the system is breaking down – no doubt that is why the Coalition has introduced clause 75 in the Act, and is planning to impose massive changes (meaning cuts) to the nGMS contract for next year – which starts in 2 months time – at the same time as expecting general practice to take over many PCO functions *and* a lot more unresourced hands clinical and administrative work of dubious benefit to anyone.
    Even politicians.

    It will be interesting to see what the audience think of your approach.


  2. Agree with you on consistent messages from GPs – overwhelmed with demand, drowning. Estimates of demand rise over 10 years are plausible. But what does this mean? We will need professional doctors and nurses to deliver the care. It can’t all be delegated to the patient. What we do need, and what we are seeing in a growing number of practices, is a new model of delivery which allows them to be much more productive – yes, 30% more contacts per day.

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