How do we reclaim GPs core role in long-term condition management?

It feels to me like general practice needs a bit of a reboot. Time to refocus on what we could and should do really well- chronic disease management. We are ideally placed to do this with enduring relationships with our patients. However, it seems that with ever increasing demand and expectations, we are consumed with firefighting at the front door, rather than giving proper attention to what should be our core business. 70% of NHS resources are consumed by people living with long-term conditions, so the systems that can achieve good outcomes in an efficient and sustainable way will surely preserve their place in the ever-changing landscape of healthcare.

I believe that the way for primary care to do this is to adopt a person-centred approach. There are lots of definitions of Person Centred Care (PCC), but my take is that it’s all about creating a situation where people with long-term conditions can be active partners in their healthcare. Supporting people to be a resource to themselves and to us. It involves a different approach on the part of commissioners, healthcare professionals and their patients. The Year of Care team describe this as the ‘house of care’.

There is an overwhelming consensus that PCC works to deliver high value healthcare, and it features strongly in the Five Year Forward View for the NHS. In this approach one size does not fit all. Some people will already be expert self-managers, whilst others will believe they really have no part to play in their healthcare at all. Up until now we have generally treated people in similar ways. In our practice we’ve traditionally had the ‘diabetes package’. Once a year patients get invited for a review. We collect disease focused data and bring everyone back to see the nurse for a 20 min chat. This leads to either a fairly pointless reassurance that everything is OK, or varying degrees of finger wagging about loosing weight, eating better, and moving more.

In my practice, we’ve started to experiment with pragmatic ways of embedding PCC. We are using the Patient Activation Measure (PAM) to assess people’s skills, knowledge and confidence to self-mange. PAM uses a well validated psychological construct to divide people into 4 groups from low activation (1) to high (4). We capture this through a short questionnaire (takes around 3 minutes), alongside traditional measures of disease control.

We then use these results to match patients to a range of management options. For people who are lower in activation we steer away from a medical model and adopt a ‘social prescribing’ approach that focuses more on the wider determinants of health. Latest strategies such as the Health Foundation’s ‘Healthier Lives’, draw attention to the limitations of a purely health-focused approach . So Health Trainers, or Age UK staff deliver a more holistic approach, with the understanding that they know how to access medical input when patients want it.

We are also identifying those patients who are well controlled and good self-managers (high activation). We are writing to them, sign posting self management resources and adopting a light touch approach. No need for a nurse review unless they really want one.

These days people rarely identify areas where we can do less in General Practice. “Can you just do this brief intervention”, “can you just signpost this”, “can you just check that”. So to identify people in whom we can justifiably do less, or involve others who can offer more appropriate support is refreshing.

This then leaves us more time to adopt a coaching approach for those patients with long-term conditions who really need it, and who are in a position to cope with a medical care plan.
So our clinicians can spend 30 minutes adopting a truly collaborative approach to care and support planning. This approach is strongly supported by RCGP, but it often needs this extra time to do it well.

It’s early days, but this approach feels right. Time to do things properly with the people most ready for us. It’s time for collaboration with a wider community team to bring in capacity to address the wider determinants of health.

This resonates well with a new value set that we are seeing coming out of really robust reports like “Realising the Value”, a collaboration between NHS, Nesta, The Health Foundation and others. This 2 year long investigation highlights that we should focus on what matters most to people, and adopt evidence based methods to develop the capabilities of people and their communities to contribute.

My hope is that a PCC approach to long-term conditions care will re-establish our core purpose in the NHS, and enable us to deliver high quality care in a satisfying, effective and sustainable way. Everyones a winner, especially our patients.

Dr Ollie Hart is a GP partner in Sheffield at the Sloan Medical centre. He also works for NHS Sheffield as a clinical commissioner, leading projects in person centred care and physical activity. He is an executive board member for the Move More project in Sheffield, a culture change program to make it easier to be active in Sheffield. He is a national champion for RCGP in their Collaborative Care and Support Planning program. He is a Director for Peak Health Coaching a company that specialises in health coaching training and organisational development for person centred care. If not at his standing desk, Ollie is most at home running or biking in the Peak District, or toiling on the family allotment with his 2 daughters and wife.


  • Tim williams
    Posted at 18:16h, 21 June Reply

    Exactly Ollie. The systems need to be set up to facilitate people to manage their own health care as far as they are able and give appropriate support to others. I’m sure we will get more sophisticated at tailoring our approach and move away from a one size fits all/most system…. the NHS needs this and so do patients.

  • John J Gessler
    Posted at 19:28h, 21 June Reply

    I heartily support Ollie’s views and sentiments and hope this approach is supported by the patients as well as the practice staff. One thing that would support this patient-centred approach would be for patients to have full access to all their records; including advanced notification of the results of blood tests so that they could prepare for the consultations and have useful, considered questions ready.
    It comes down to trust and access to records would be a clear demonstration that patients (and people) have a. clear role to play in their health and that the system wants to support them

  • Lynne Craven
    Posted at 08:31h, 22 June Reply

    Hi Ollie, you know I concur with all of this and more, however just one piece of feedback about language! We are not ‘your’ patients if it is true partnership, I too am guilty of using unhelpful phrases such as ‘my’ GP because it’s easier than saying the GP who supports me! Lynne

  • Ollie Hart
    Posted at 22:29h, 22 June Reply

    Thanks for the comments. Great to hear supporting views. Point well made about language Lynne.
    John I think that we should go further and get to the point where people hold their own notes (probably digitally) and we contribute to them.

    • John J Gessler
      Posted at 13:53h, 23 June Reply

      Just microchip us. Or failing that, I do have a usb stick…

  • Pete Moore
    Posted at 09:32h, 23 June Reply

    If the NHS / Social Care / Decision makers want to see a reduction in unplanned A&E visits and GP appointments in future years, we need to start teaching educational self-management in schools.

    Sadly, don’t think this will happen in my lifetime. Not enough Dr Ollie’s or Dr Tim’s who are switched on to self-management.

  • Andrew Rix
    Posted at 08:13h, 06 October Reply

    The biggest barrier to PCC is the belief that ‘we are already doing it’.

    You are NOT doing it unless you
    1 have a systematic and inclusive means for discovering individual needs and preferences
    2. can provide a range of treatment options to meet those needs
    3 work with patients to agree on an individual plan
    4 monitor plans in terms that are meaningful to the patient
    5 support the patient to have 1-4 above in all their dealings with the health and care system

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