Abstract
As Chairman of the RCGP, I'm often asked about ‘the future of general practice.’ Is privatization inevitable? What do we need to do to safeguard our future as expert generalists? How do we ensure our patients receive the high quality care they deserve?
Looking back over the 22 years that I've been a GP – and indeed the 60 years the NHS has been in existence – I'm heartened that we've seen so many advances, improvements and innovation offered by the UK health service.
General practice never stands still and as a profession we've learnt to be flexible and resilient. However, we are not immune to the problems and challenges that change can bring and large-scale, externally imposed policies can be unsettling.
The expectations of patients and politicians and the increasing complexity of healthcare delivery have resulted in a climate of continual change, yet throughout the history of the NHS, GP practices have been its most enduring feature.
General practice is the workhorse of the NHS – over 90% of healthcare problems are dealt with in primary care, with over a million consultations taking place on an average working day.
Further, it is widely acknowledged by healthcare professionals both at home and abroad as being the best in the world – we were ranked top overall in the survey of six major countries undertaken by the Commonwealth Fund in 2006.
The level of users' satisfaction is also very high. In the recent Health Care Commission survey of general practice, 75% of patients were completely satisfied that the main reason for visiting their local surgery had been dealt with, and only 3% were unsatisfied.
This begs the question of why there are repeated attempts by politicians to derail the service by constantly interfering with it and reorganizing it – the latest, of course, being the ‘Our NHS, Our Future’ review in England.
I'm not for one minute saying that improvements are not needed, but let's look at the facts: we have a health service that is free at the point of contact; is becoming increasingly patient-centred; and is available to all. So why do successive governments keep on trying to import system change from the US where they have a multitude of systems, spiralling costs and tens of millions of people who are without healthcare? My friends and colleagues in the US cannot understand why we keep sending aircraft-loads of NHS managers over the Atlantic to look at the various health systems in America when they look at general practice in the UK with envy.
We need to build on the strengths of high-quality general practice to meet the challenges ahead. These include the growing demand for primary care services arising from the aging population and people with increasingly complex comorbidities living longer and thus needing more care and support in the community. Even the newer epidemic of obesity will place increasing demands on the service.
To begin with, NHS policy makers must recognize that UK general practice and the wider primary care provision is something deserving of value and respect.
General practice is getting better all the time. The remit of the RCGP is ‘to encourage and maintain the highest standards of general medical practice and act as the voice of GPs on education, training, research and clinical standards’ and we've worked tirelessly to achieve this.
We see education and training – and continuing professional development – as the key to improving patient care and ensuring that general practice is fit for purpose in the 21st century.
High-quality generalism means high-quality patient care. As Chair of RCGP Council, and in my previous roles as author of the GP curriculum – the first ever for general practice – and Chair of the RCGP Postgraduate Development Board, my aim has always been to ensure we have appropriate education and training for GPs. To produce good doctors we need good programmes of education; delivery of the GP curriculum by our educators across the UK will produce GPs equipped with the appropriate knowledge, skills and behaviours to deliver the highest quality care for their patients.
The College has proved that it has a pivotal role in securing the future of the NHS. Thanks to its efforts there is now a single entrance route to general practice, and revalidation procedures are emerging. It seems unbelievable that it wasn't until 1982 that there was any formal training for GPs – something brought about by lobbying from the RCGP.
Improved training and revalidation will be lasting legacies, an epoch-making step for general practice which will lead to a united discipline. That we are united as a profession is of vital importance, because we are entering what is undeniably the most turbulent period in the history of family medicine.
The actions of Harold Shipman damaged the public's perception of the GP as the most trusted and respected professional. We cannot tolerate poor quality practice and must urgently address the variations in the quality of care that is provided in some areas of this country.
The paternalistic GP is yesterday's GP. The doctor-patient dynamic has changed and patient-centred care is of paramount importance. This is how it should be and we must welcome opportunities to improve and maintain the quality of care we offer. The acceptance of the new contract and the widespread achievement of practices in achieving the highest results in the Quality Outcomes Framework (QoF) demonstrate that GPs have accepted responsibility for the healthcare of their registered populations as well as responding to the needs of individual patients for the diagnosis and treatment of their illnesses.
The Health and Social Care White Paper on the regulation of the profession will produce a ground-breaking change for GPs. I believe that we need to answer the serious challenges that result from this government-led regulatory change by responding with strong professional leadership and solutions.
I am working hard to lead the RCGP in developing and piloting strategies for continuing professional development, for revalidation and for provider accreditation. I have created cross-profession stakeholder groups and am consulting widely on our proposals – it's far better to have professionally led solutions than imposed regulation and micromanagement.
Where GPs are practising patient-centred general practice – and the vast majority are – they won't have any trouble with revalidation because while judgements will inevitably have to be made, it is intended that it will be a supportive, formative process that will give both doctors and patients' reassurance that the best care possible is being provided. Revalidation and provider accreditation, although unsettling, are not threats to general practice: both will be professionally led and will undeniably improve the service for our patients.
So what will the future of general practice look like? Despite the ideological confusion that is prevalent in England, I believe that general practice will remain at the core of the health services in the four countries of the UK. The key to the future success of the health services will be how high-quality general practice is delivered as part of the wider more integrated primary care services.
If change in our healthcare system is to be successful, it must be clinician-led. In primary care it's the GP that is the lynch pin. Strong GP leadership is needed at all levels but most importantly at the local level, to drive local change. That local change must include practices and other primary care services working together in federations which will integrate more and more with secondary care services.
Our vision for the development of general practice was heralded before Lord Darzi's review was announced in October 2007 in the RCGP's publication ‘The Future Direction of General Practice – a Roadmap’. It also has the backing of the UK's major primary care organizations. Since the Roadmap was published I have been able to test out ideas around the country and in debate with politicians and civil servants. I am convinced that to provide the best 21st century integrated care for our patients, the role of the generalist will be key.
In the future, the focus will be on the patient and on pathways of care. This will provide a much better form of personalized care for patients, empowering them to become partners in their care, ensuring better levels of quality and safety.
GP practices will work together in their ‘federations’ to deliver a wide range of services such as X rays, scans, mental health services and even minor surgery in a community setting, meaning that patients would be referred to hospital only when absolutely necessary and that GPs and specialists would work more closely to deliver seamless care and aftercare.
GPs will develop their skills as expert generalists who manage hugely complex clinical problems whilst having better access to diagnostic facilities and opinions. They will work with physicians' assistants, nurses, physiotherapists, pharmacists and other professionals and carers across what are currently two rather separate services, health and social care, to provide a more integrated local service for the patients and the local population.
Partnership working will ensure that hospitals are reserved for serious acute illness and accidents, specialized investigations and major surgery. This blurring of the boundaries between primary and secondary care means that both clinicians and resources can be used wisely, saving time and money.
One of the great levers for change will be the development of commissioning responsibilities by the federations. Commissioning is an important tool to deliver improvements in health and community care, and innovative commissioning by GPs with specialist and most importantly patient involvement will produce more effective and efficient care focused on the needs of local people.
A focus on the health of the population will produce better health promotion and prevention strategies in conjunction with local authorities, schools and local employers. Despite improvements in overall health status and life expectancy, inequalities still remain. We must aim to promote health living, help keep people healthy, keep people at work and identify potential illnesses at an early stage so that they can be treated appropriately.
GPs are committed to ensuring that the UK has a thriving national health service that is fit for purpose in the 21st Century. To do this we must be allowed the freedom to meet the needs of our patients – and to make sure that all patients receive equally high standards of care.
Footnotes
DECLARATIONS
Footnotes
Acknowledgements
None