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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Primary care is heading in the right direction – but will it get there in time?

Filed Under (Clinical Commissioning Groups, GPs, Reform of the NHS) by Paul on 14-03-2014

A year ago the main change happening in primary care was the move towards trying to finds ways to increase the size of the basic organisational structure.

1948 had seen Nye Bevan, for a whole range of very good reasons caused by the political reality, shy away from creating a salaried GP service. Having famously stuffed the mouths of consultants with gold, he gave GPs the right and the power to run their own businesses.

The real world of political achievement gave him little room for manoeuvre. Creating the NHS was not a matter of drafting the arrangements that you wanted. It took very hard bargaining with implacable foes running the medical trade union – the BMA.  Only commentators with no feel for the reality of political achievement could criticise Bevan for the compromises that he had to make to get the NHS show on the road.

One of those was to grant to the nation’s GPs the right to organise themselves as small businesses having control over their own organisations. Unlike other small businesses however, GPs have a guaranteed state income and a guaranteed state pension. A privilege denied to small shopkeepers and painters and decorators who have to operate in a real, competitive market to make their money and their pensions.

So in 1948 hospital consultants became workers with the right to moan about the management, and GPs became small businesses with the right to run their own organisations.

This split creates all sorts of problems for integrated care (about which I will blog next week), since the problem is not just about getting generalists and specialists to work together, but the much more difficult task of getting those who work for large organisations (consultants) to work with those who run their own show (the GPs).

So the 50th and 60th anniversaries of the NHS came and went with GPs still running their own show and the vast majority of them running very small businesses while over the previous 50 years nearly all other industries had undergone a considerable increase in the size of the unit of delivery.

Customer preference had used markets to turn small grocers into supermarkets. Customer preference had used the same markets to change nearly every industry with large numbers of small outlets into bigger organisational units.

Since consumer preference was not driving primary care to change, their organisational structure stayed where it was.

The problem was that medicine needed larger organisational structures to deliver all of its potential benefits Primary care needed to be actively involved in carrying out the many more diagnoses and interventions that at the moment take place in hospitals..

I, along with many other people, cannot get a blood test at my local GP surgery. Instead I have to go to an international hospital to get something that should be available in my street from my GP.

A year ago there was a greater recognition of the problem of size in primary care than had existed in the previous 60+ years. Most parts of the country were talking about the creation of federations and building sets of relationships between GP practices and one year on this trend has if anything accelerated.

Most people see this talk of federations coming in part because of the creation of CCGs. CCGs have brought GPs together for the purpose of commissioning, not providing. However most of the activities that GP leaders of CCGs need to talk to their fellow GPs about concern variations between the way they practice as providers of care. Therefore creating larger CCGs has inevitably raised a string of questions about scaling up GPs practices.

CCG leaders have experienced what every leader in the NHS has experienced for the last 60 years – primary care is vital but very disorganised. It will only really be able to fulfil its role if it takes on much larger organisational forms.

And it is this that is behind the strong move towards federations.

However there are two real problems with this set of changes.

Firstly because it takes on some very ‘hallowed’ experiences (the right to run their own organisation), this sizing up of primary care will not happen quickly. Taking on several thousand organisational leaders and persuading them to give up a lot of the power they have to run their own organisations will not be a speedy process.

Secondly this change is voluntary. GP practices that choose not to do this will not lose their registered lists or their income. In all other industries that have scaled up the failure to grow meant that you either had to work much longer hours to make the same amount of money (small corner stores) or be taken over – often the only way you could stay in business. These drivers have not been built into this change process in primary care.

In short GPs will do this at the pace that they want to, not the pace that their patients need. This means that it is done at the pace of the producers of the service rather than the consumers.

One other change with GP practices continues apace. As I noted above Nye Bevan failed to create a salaried GP service, resting power instead in the hands of a small business structure with partners. For 50 years Bevan’s compromise created a career path which saw GPs seeking to become partners in order to run established organisations.

This is now being changed – not by fiat from Whitehall – but from the new career choices that new GPs are making. For a variety of material reasons new GPs are not choosing to tie themselves to this old organisational structure. They are now choosing to become the very people that GPs 50 years ago did not want to become – salaried staff.

Newer GPs, instead of yearning for the long term relationship with a locality that partnership gives, are opting for the greater freedom provided by being salaried staff. This is partly caused by the change in gender of new GPs, with the larger number of women wanting to be able to shift their work patterns around prospective family responsibilities and partly because the relationship between place and security that was behind the creation and continuity of this model 60 years ago has changed radically. Professionals want to be able to move around and being tied to a locality through a particular organisational relationship does not give the freedom of movement that being salaried provides.

This means that the organisational structure of NHS GP service provision is primarily being changed by the wants of the new workforce.

The problem for patients is that they need larger scale primary care now and not in the 20 years it will take to work these changes through.

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