Transcript Will it work here? New thinking for primary care

Will it work here?
New thinking for primary care
Professor Mike Pringle
President-elect, RCGP
The givens
• Generalism is an essential part of a costeffective health service
• Britain has one of the most primary care
orientated health services
• ‘Primary care led’ has been the dogma for 20
years: CCGs are only the latest manifestation
The givens
• We have lost our 24/7 commitment but taken
on greater responsibilities
• In the 1980s GPs took over the role of the
general physician
• In the 1990s and 2000s GPs took over public
health
Benefits of generalism
“Primary health care offers the best way of
coping with the ills of life in the 21st Century:
the globalisation of unhealthy lifestyles, rapid
unplanned urbanisation and the ageing of
populations”
Margaret Chan, Director General, WHO, 2008
Benefits of generalism
“Those who work as generalists – and I am
hugely proud to be one of them – see the
positive results that generalism delivers for
patients, day in, day out”
Clare Gerada, Chair RCGP, 2012
CHALLENGES
The capacity of general practice
In the 20 years to 2008, the primary care
consultation rate increased by 75%
Over that period, consultations/pat/year rose from
3.9 to 5.5
The average GP consultation lasts 11.7 minutes
96% of patients say they want longer appointments
The capacity of general practice
In 2000 the RCGP called for a 30% increase in GP
2001-2011 the FTE number of GPs increased by 2%
per year
Between 2001 and 2011 District Nurses numbers fell
34%
FTE numbers of practice Nurses peaked in 2006
since when we have lost 7%
Ageing and multiple morbidity
Number of people aged over 80 will double
between 2010 and 2030
Average consultation rate with GP is 5.5/year
But for over 80s, consultation rate is 14/year
(2008)
Ageing and multiple morbidity
Number of people in England with a LTC:
2010: 15 million
2025: 18 million (DH projection)
People with LTCs:
29% of the population
50% of all GP appointments
64% of all OPD appointments
70% of in-patient bed days
70% of total health and social care spend
Effect of deprivation
Health inequalities are widening
The Inverse Care Law is alive and well
• In Scotland 11% more GPs in the most affluent
half of population than in the other half
• In England PCTs with highest provision had
twice the numbers of GPs per capita that those
PCTs with fewest GPs
• Consider English male life expectancy and GP
distribution
Effect of deprivation
Multi-morbidity (esp mix of physical and mental)
occurs on average 12 years earlier in most
deprived vs most affluent quintiles
“More multiple morbidity in deprived areas means
that the population die younger, are sicker for
longer before they die and they present more
complex problems to their GP”
RCGP, 2022 vision, 2012
Continuity of care
“Seeing a doctor who knows the patient and
remembers key events in the life of that patient
and the family, who will be there subsequently
when required and who takes a longer term
view of care and its outcomes is an important
feature of primary care”
Michael Balint, 1961
Continuity of care
Continuity of care, a key attribute of generalism,
gives:
• Earlier diagnosis
• Better health outcomes
• Patient centred care and higher satisfaction
• Cost control: less duplication, expensive
interventions better targeted, better prescribing
Fragmentation of care
Multiple contacts with different parts of the health
service = lack of coordination, duplication of
services, increased costs
In general practice, fragmentation = loss of
continuity of care
Shared decision making
This is not abdication but responsible sharing
At the centre is ‘care planning’, education and
support
Average person with diabetes spends 3 hours a
year face to face with a health professional; its
the choices in the other 8,757 hours that really
determines their outcome.
The financial climate
The NHS in England faces 4% ‘efficiency savings’
year on year - £20 billion over 5 years
A face-to-face consultation with a GP costs the
NHS about the same as a telephone
consultation with an NHS Direct nurse
OPPORTUNITIES
The RCGP Vision
“More GPs, with longer training,
spending more time with their
patients – A world where excellent
patient-centred care in general
practiced is at the heart of health
care”
The capacity of general practice
Use Commissioning in England to recognise and
fund primary care provision
Move care and services, and the funds, back to
general practice
Recruit more of the emerging doctors into general
practice
The capacity of general practice
Introduce Revalidation
Extend vocational training
Improve our skill mix, especially reverse decline in
practice nurses
Telephone triage and telephone/email consulting
Use GPs with special clinical interests
Use pharmacists better
Effect of deprivation
Renew incentives for GPs to work in deprived areas
Care planning for people with multi-morbidity, with
GPs retaining/regaining central role
Better IT and information sharing
Redesign pathways around the patient not the staff
– why three hospital appointments in one week?
Invest in primary care rather than secondary care
Continuity of care
We cannot return to the 24/7 commitment
But we can encourage a “named doctor” and doctordoctor-nurse-nurse pairing in big practices
Promote self care and shared decision making
Explore tele-health
Fragmentation of care
Identified lead clinician
Good team communication, including electronic
records
Shared decision making with the patient or carer
Different ways of ‘consulting’ (telephone, email)
Agreement of pathways and roles
Emphasis of community/OPD care were possible
The financial climate
We cannot magic up more money overall, but we
can argue for the value of general practice
Starfield showed that, internationally, primary care
orientation was associated with better Value for
Money, better outcomes and better patient
satisfaction
We must make the case to address NHS funding
through strengthening General Practice
Will it work here?
New thinking for primary care
Professor Mike Pringle
President-elect, RCGP