The Chinese word for “crisis” is often thought to comprise two characters signifying “danger” and “opportunity”. General practice is certainly in crisis. This has been building throughout the austerity decade, with a sustained funding squeeze provoking GPs to take early retirement, reduce their hours to counter burnout, or to seek other careers entirely. It has been accentuated by Covid and its care backlog.
In many areas there are too few doctors to meet escalated demand. This results in frenzied phone fights for appointments first thing in the morning, and patients being bounced between the NHS 111 helpline, walk-in centres, A&E, and ambulance and out-of-hours services. Little wonder there is such frustration. And danger, too. Patients are coming to grief through an inability to get timely care from the appropriate part of a dysfunctional system.
The right-wing think tank Policy Exchange has interpreted this crisis as an “opportunity”. In “At Your Service”, its paper published in March, which was heavily influenced by commercial health technology companies, it argued for nationwide reform. The proposal, endorsed in a foreword written by the former health secretary, Sajid Javid, would transform the entire English NHS into an app-fronted enterprise in which AI would allegedly determine patients’ onward journeys. Cui bono? One has to ask.
Dr Claire Fuller appears to have a better understanding of Chinese etymology: she says the second character in the word for crisis actually translates to “change point”. Tasked by NHS England with creating a plan to integrate primary care (not only GP but pharmacy, dentistry, community nursing and so on) Fuller – a GP of 25 years with a background in system leadership – set about a “stocktake”. Whereas Policy Exchange talked primarily to the tech industry, Fuller consulted widely with front-line practitioners and arrived at very different conclusions.
A stocktake conjures visions of Fuller surveying the shelves and store cupboards. She certainly found a lack of general practitioners, and she strongly emphasises the need for government to focus on recruitment, retention, and stabilising practices. What she also discovered was the vibrant talent throughout the system: innumerable examples of locally led, innovative solutions not only to access issues, but also to promoting and enhancing health, as a result of partnerships between health, local authority and third-sector organisations.
Fuller urges an end to top-down, nationally imposed “solutions”. Instead, policy must enable and support local system leaders in designing their own responses to their populations’ needs. Her conclusions have been countersigned by the CEOs of all 42 Integrated Care Systems – the latest incarnations of regional health management. My only substantive issue is her view of continuity of care between patients and their GP. Fuller has been seduced by the idea that continuity is relevant only to a subset of patients with complex long-term conditions. She would see separate urgent care hubs dealing with demand for on-the-day attention. In fact, continuity is vital in all groups. It’s what enables GPs to reduce so much cost and hospital activity. Repeated contact with a lead GP creates the conditions to limit antibiotic usage and increase self-management of illness. It enables the detection of post-natal depression, health anxiety, child protection issues, or domestic abuse. Complex patients with acute exacerbations in their long-term conditions invariably present urgently, and can often be managed without hospital admission by doctors familiar with their case. And relationships are made that will yield dividends when serious ill health strikes.
Crisis: yes. Opportunity: no. Change point: certainly. But let us get back to what GP teams have done for decades: meeting both the routine and the acute needs of all their patients. For that we need bold, decisive investment by government. And a willingness to cede centralised control.
[See also: The NHS is under strain from Covid-19 once again]
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This article appears in the 20 Jul 2022 issue of the New Statesman, The Broken Party