If you can’t say it at Christmas, when can you?

Having been a GP for longer than I’d probably care to admit to, at least not until imbibing a couple of glasses of festive fizz, it’s fair to say that General Practice is generally in a state of crisis. However it is perhaps probable, that the current parlous state of our profession would make even the most cock eyed optimist reach for some citalopram washed down (perhaps inadvisably) with a large glass of the amber nectar.

The current situation doesn’t really need outlining, but just in case you’ve been on a sabbatical in the Galapagos Islands or inhabiting the Wi-Fi desert that is a Virgin train for the last year or so, I’ll canter through some of the current travails. Firstly recruitment, or rather the lack of it and secondly income or, to coin a phrase, rather the lack of it! With regrettably all those much trumpeted 2004 gains clawed back, but with of course the chronic disease management remaining. That takes us on to  workload, with a perfect storm of increasing consultation rates and complexity carefully mixed with burgeoning bureaucracy to create a truly toxic cocktail.

So in this somewhat worrying situation, what is being offered as the solution in England. The GP 5 Year Forward View has had many proponents, but is the level of investment (one does suspect a degree of double counting m’Lud)  combined with it’s bewildering complexity, really  radical enough to solve the myriad of problems, re-energise our profession and stop the jewel in the NHS firmament permanently losing it’s luster?

Perhaps we need to go back to the future, with or without a DeLorean. What is it that GPs really do best and is so vital for the NHS system? I would suggest it is dealing with undifferentiated problems, complexity (those elderly patients with multiple co-morbidities) and of course urgent problems. Our patients would probably also value timely access as well.

So how do we make this much needed time travel possible, without the help of the brilliant Dr Emmett Brown. To preserve our sanity we patently need much longer appointments, finally a line has to be drawn under this frenetic farrago of the ten minute treadmill. We need to broaden substantially the primary care base. Of course we GPs can do everything really well, but other professionals can do much of what we do, so we need (and it won’t be easy for some of us and you know who you are) to let go a bit. But where do we find the time to make these radical changes, we hear you politely (of course) but firmly point out?

Well perhaps we need to lose the majority of the Chronic Disease Management that the hospitals have cleverly handed over and we have accumulated since 2004. This would necessitate finding a new way to provide QOF and Enhanced Services and involve redesigning the current model of outpatient services, that are frankly often not really providing what is required.

Perhaps we could even resuscitate that much maligned concept of an MCP contract (relax LMC secretaries across the land! While of course keeping all our funding, but repurposing it and retaining our beloved GMC contract) and creating a new structure. This would be one that contained QOF, enhanced services, shared care and an Extensivist team to look after those complex patients at the apex of the ‘care triangle.’

Undoubtedly this would involve massive changes in the way both General Practice and Hospital services work. However most sensible people would say that the current situation, with the funding that is on offer just can’t continue, as it is now very far from ideal for our patients and those struggling valiantly to provide said services. General Practice would of course have to change. For a number of reasons working at scale, seems like a pretty sensible idea and we really need to get on with it. Tariff would have to end (at least in part) for secondary care and Consultants will need to learn to work (as we do day in day out)  under a capitated contract. We might, as mentioned, even have to consider judicious use of the MCP Contract or something like it.

So radical solutions for a troubled times, but as someone said, more eloquently than me, if you can’t say it at Christmas, when can you! So have a great break over the festive period and I hope you find my thoughts a little more digestible than those legendary brussels you will no doubt soon be facing.

by Dr Gavin Ralston 

Gavin went to Birmingham Medical School and has lived in Birmingham since 1979. He has been a partner at Lordswood surgery in Harborne for 24 years where he helped redevelop the surgery and merge the practice with three other local surgeries to form the Lordswood Medical Group.

He developed an interest in commissioning after sitting on the South Birmingham Primary Care Trust professional executive committee for three years and together with a small number of colleagues helped to form Birmingham CrossCity CCG.

He believes in the value and benefits of using doctors and healthcare professional to help shape healthcare for the city and aims to ensure that services for all patients are more flexible, joined up and effective – the kind you would be pleased for your family and friends to use.

  • Sarah Longland
    Posted at 09:10h, 23 December Reply

    Fantastic blog! A joy to read although I admit reaching for the dictionary on a couple of occasions but we all know that every day is a school day in general practice!

  • Mark Newbold
    Posted at 12:57h, 23 December Reply

    Agree Sarah – there is a lot to think about here, and some really interesting ideas about how we best utilise general practitioners to best effect. I suspect the chronic disease management ideas will spark a fair bit of debate?

    • Sarah Longland
      Posted at 13:36h, 23 December Reply

      Community hubs will probably provide much of the solution I would think.

  • Dr Julie Barker
    Posted at 16:32h, 23 December Reply

    Local patient consultation on GP5yfv is in favour of GP specialists, more services in the community and a greater emphasis on help to self manage.
    These are all sensible and laudable but need resourcing with increased clinicians with suitable skills.

  • Ian Livingstone
    Posted at 17:18h, 23 December Reply

    “Hardest job in the world to do well and easiest to do badl” I believe
    Any other job…..ant the union might suggest more radical action?

  • john sharvill
    Posted at 20:08h, 01 January Reply

    Why are we sticking to 10 minutes? Who decides-it is us,the Gp. In the very old days moving form 6 minutes to 10 was prophesied to lead to disaster but it did not. There are practices that have done this and are smiling.
    Dont duplicate your work with triage before face to face, if you want to triage get others to do it and only phone those that can be sorted by phone
    If the community hubs take GP out of their practices there is a real risk of making things worse not better
    Employ the staff to do the work that you don’t need to be a Gp. (repeats, most docman, , audits for drug safety monitoring,chasing hospitals etc. We dropped sorting transport many years ago ‘ so let go’ of some things and look at what sucks the time and energy out of you and ask why is it coming our way-often not ”medical at all’ but we have accepted it- childhood behaviour problems a good example maybe health visitors take total responsibility of this as an example

  • Peter Maddock
    Posted at 13:23h, 08 January Reply

    An excellent blog Gavin. I do think the biggest challenge for the NHS is the manpower shortage, exacerbated by the lack of money to pump prime. The solutions at least short term lie in creativity and doing things differently. I do see a lot of potential in using the extended Primary care team more effectively. I also do realise from experience, not everyone in Primary Care is open to such an approach. Lastly Pbr in my view has had its day and is now an obstruction to progress.

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