Originally General practice attracted a fee for services and the doctor would treat people who couldn’t afford the the fee on a charitable basis as his contribution to the community.
I entered General Practice in 1979 and was in partnership with Dr Noel Thomas who was the fourth generation of a well established practice in a South Wales town called Maesteg. The population I cared for were miners, steelworkers as well as farmers and their families. They were hard working and there were many diseases which were particularly common in this part of Wales- miners contracted pneumoconiosis as a result mining coal alongside silicon rock and heart disease was rife. Also, back problems and other orthopaedic problems were common due to high number of men in heavy manual work. There was a high incidence of cystic fibrosis and spina bifida in children.
It was at this time that his son Dr Bell Thomas started to treat workers particularly miners and steelworkers in General practice. General practice covered workers under the Lloyd George’s National Insurance Act of 1911, but not their wives and families, whose proper demands were restricted by the need to pay fees for service.
At that time nearly about 35years ago it was found that a patient would have a better chance of survival staying at home rather than being admitted to hospital.
Medical diagnosis was often of academic rather than practical importance. Treatment was limited to insulin, thyroid extract, iron, liver extract for pernicious anaemia, digitalis, the new mercurial diuretics, barbiturates, simple analgesics, morphine derivatives and harmless mixtures.
In my experience medication such as Ipecac et Morph ( for coughs ) or Gentian ( tonic) Mist Pot Citrate ( known as cockles water) for cystitis Mist magnesium trisilicate ( ant- acid for indigestion) ,mandrax and barbiturates for sleeping and intravenous heroin for heart attacks , adrenaline for asthma were medicines I prescribed and administered regularly.
It was difficult to keep track of prescribing, all prescriptions were hand written often illegibly and I am sure compliance and abuse was not uncommon.
Records were in Lloyd George wallets and belonged to the Secretary of State and for written records this is still the case. Electronic records only started to evolve in 2001. Generally record keeping was poor and frequently doctors wrote inappropriate remarks on the notes such as PIN ( pain in the neck ie difficult patient) or a diagnosis of GOK ( God only knows) but this stopped when patients were allowed access to notes after 1990.
The NHS Act 1946 provided a family doctor to the entire population. The Bill emphasised health centres that were to be a main feature. At public cost, premises would be equipped and staffed for medical and dental services, health promotion, local health authority clinics and sometimes for specialist outpatient sessions. The programme was aborted before it even started.
Whereas Bevan had persuaded consultants into the service in part by merit awards, the GPs had been unwilling to join until virtually the last moment. The public, however, were encouraged to sign on with those doctors willing to enter the scheme, leaving others with the choice of joining as well or losing their practices. Within a month 90 per cent of the population had signed up with a GP. Twenty thousand GPs joined the scheme as they saw private practice disappear before their eyes.
The NHS Act made it illegal to sell ‘goodwill’; instead a fund was established that compensated GPs when they retired, but it was not inflation-linked. The GPs’ contracted for a 24-hour service, the nature of the complaints procedures and even the patients’ NHS cards were virtually unchanged (and still are). GPs, fearing that they might be no more than officials in a state service, argued successfully for a contract for services rather than a contract of service. As a result they remained independent practitioners, self-employed and organising their own professional lives. The Spens reports determined pay, which was entirely by capitation.
GPs’ income depended on the number of their patients; even their expenses were averaged and included in the payment-per-patient. Their independence thus assured, GPs were taxed as though they were self-employed, yet, unlike most people in small businesses, they could not set their fees. With a few exceptions, such as payment for a medical certificate for private purposes, no money could pass between patient and doctor. This system, combined with a shortage of doctors, provided no financial incentive to improve services, but neither was there any incentive to over-treat patients.
Now many doctors are salaried working for self employed doctors or in PCT(CCG) health centres.
In 1966 the Royal College of General Practitioners submitted evidence to the Royal Commission on Medical Education. This was to prove of decisive influence in shaping the recommendations of the Commission when they were published in 1968 (Todd Report). The Report made a powerful case for the recognition of general practice as a separate discipline within medicine, requiring its own form of postgraduate training organised by general practitioners. The fulfilment of the College’s work came in 1976 when parliament approved legislation making vocational training a requirement for any doctor seeking to become a principal in general practice and set up new national organisations to administer the act.
I was one of the first doctors to be selected to be part of a Vocational Training Scheme which took 3 years to complete and involved 6 months in 6 specialities. I worked as a junior doctor in General Medicine/ respiratory medicine, obstetrics & gynaecology, paediatrics, orthopaedics and trauma and ENT and General practise and at the end of this received the post graduate degree MRCGP following an external examination.
I decided to work for a further year in paediatrics before becoming a Partner in a practise in Maesteg,South Wales.
It makes sense to direct services where they are needed Southall needs more diabetic consultants and cardiologists than Reigate. Also to find out what we are doing well and what we are struggling to do effectively .
Based on results of this analysis and other audits it has become apparent how costly it is to use secondary(hospital) care if it can be done more or just as effectively and less costly in primary care.
However, it is paramount to knock down barriers of communication between hospital and primary care staff and I have seen great changes to improve this. Does a patient need to attend a hospital to hear everything is fine?
Blood tests can be carried out in general practise. Type 2 diabetes without complications does not need a specialist diabetic consultant and a mechanical back strain does not need an orthopaedic surgeon to treat. A few examples but there are many more and this has convinced both parties that a more rationale approach is needed to decide where a patient is best managed. Albeit, there are still health professionals out there who are vehemently hanging on to what they have always done but each year they are getting less and -at meetings those voices are disappearing.
The 2022 GP.
The 20th century model of healthcare – splitting up hospital and community-based care, as well as health and social care, is ‘outdated’, the report says.
‘We are moving instead towards a 21st century system of integrated care, where clinicians work closely together in flexible teams, formed around the needs of the patient and not driven by professional convenience or historic location.’
GPs will increasingly work in federations, leading multidisciplinary teams encompassing nursing and hospital staff, using electronic records to support co-ordination of care.
Contractual arrangements will be varied, with many GPs employed in salaried roles by federations, foundation trusts, and third or private sector providers, alongside independent contractors, the report suggests.
As the NHS celebrates its 65th birthday, it is entering what the RCGP identifies as a new era.
Over the next decade, patients will face ‘more complexity, morechoice and more uncertainty and will rely on the expertise, skill and compassion of their GP like never before’.
The college has called for 10,000 more GPs and a sharp rise in funding to help the profession absorb the pressure.
But to remain fit for purpose, it says, general practice must evolve, not simply expand.
So what is the RCGP’s vision for general practice in 2022 and how
realistic is it?
Adapted GP role
The RCGP is clear that as part of this shift, ‘the role of the GP will need to be adapted’. The report, co-authored by RCGP chairwoman Professor Clare Gerada, outlines a vision of the 2022 GP as an ‘expert generalist’.
This new breed of GP will be trained to manage increasingly complex patients with chronic conditions and polypharmacy, handling ‘urgent and routine needs’, and providing ‘first-contact care to the majority of children and those with mental health conditions’.
GPs can no longer stick to the 20th century model, in which they are considered ‘omnicompetent independent doctors’, the RCGP argues. Instead they will need to work ‘as part of a family of interconnected professionals’ that could include hospital specialists given additional generalist training.
Many Medical students now do 4 months in General Practise as part of their registration which now takes 2 years. until a few years ago it was 12 months and was 6 months general medicine and 6months general surgery. Two thirds of medical students will become GP ‘s.
During the past year we as GP’s are meeting with specialised consultants to discuss complex patients and consultants are visiting GP’s to discuss management of particular conditions and communicate which type of patient needs referring.
Meanwhile, GPs will train to take on extended roles in core areas that need ‘a generalist approach’ – perhaps care of those with dementia, homeless patients or those in nursing homes.
This month care of all nursing home patients in the defined Ealing CCG area has been taken over by a group of GP’s who will manage the care of residents and be accountable for the standard of care.
This model will be extended to other groups of patients if it is successful.
Practices will also need to reshape their services to meet the needs of more and more patients with complex chronic conditions.
Forming ‘micro-teams’ that bring together primary care, social care staff and clinicians from other specialties, such as paediatrics or mental health, could help provide continuity of care to named groups of patients in need of extra support.
This team-based approach may also provide the solution to rising rates of doctors working part time, the report suggests, through an ‘increased focus on team-based continuity’ and more ‘buddying up’ arrangements between doctors.
This has been attempted over many years with great resistance but the climate is changing and those not wanting to comply will be under great pressure from CQC inspectors.
The standard 10-minute appointment slot will become a thing of the past. GPs of the future will offer ‘flexible lengths of appointments, determined by need’ and will need to ‘adapt their working day to offer fewer but longer routine appointments for review of patients with complex needs’.
A generation of patients brought up with the internet will mean many ‘will expect to interact with their general practice team virtually’, with traditional face-to-face GP visits ‘no longer accepted as the default way to access care’.
We already use emailing as a a way of communicating with patients and ordering repeat prescriptions. Also more recently patients will check their own blood pressure in a pharmacist, supermarket or using there own machine and having face-to-face much less frequently. Pre-consultation questionnaire will be used to prioritise what needs to addressed in the consultation.
My only concern is that opportunistic screening and the doctor- patient relationship will be limited. However, with doctors working less hours and larger practises the norm and finances strained this will be seen as the only way forward.
Better planning across federated practices will improve co-ordination and continuity of out-of-hours care, although GPs will not be required to offer direct patient-to-doctor access out of hours.
The RCGP vision also sets out plans to train GPs to have a better ‘understanding of the needs of their practice population’. This could help shore up the profession’s role in commissioning, amid Labour pressure to hand more control to local authorities.
Professor Gerada and her co-authors acknowledge that without substantial investment to expand the GP workforce and premises, ‘the vision will be made much more difficult or will become impossible’.
Small practises will not be viable and CQC will have the power to lose a surgery that does meet the required standards. This will encourage mergers of small practises but in my opinion it is better to look around and plan this before someone else does. Working in these multidisciplinary groups at present is helping finding like minded GP’s that can work together. There are some delightful caring young GP’s in the area who I would have no problem working with and they need to be nurtured.
Step one is winning the battle of ideas – an action plan in the report highlights a need to ‘promote greater understanding of the value generalist care brings to the health service’.
RCGP council member and deputy GPC chairman Dr Richard Vautrey believes this battle will be won over time, simply because no alternative exists. ‘It is economically essential for the NHS to be built on a primary care base, it’s in politicians’ interest to value it as the way the NHS can survive and thrive long term,’ he says.
The RCGP vision is realistic, he says, because many of the innovations in the report are already being delivered by GPs in parts of the UK.
We have formed a network ( a smaller section of the ECCG consisting of all local practises and meet regularly 1-2 times each month with other health care professionals to discuss complex cases and we have found ways of sharing resources and experiences which have most beneficial in managing patients biopsychosocial needs aswell addressing our own learning needs.
But he adds: ‘One concern is that as practices struggle with workload, it is hard to develop in the way they want to, because they don’t have the resources. Resources are crucial.’
The ball is in the government’s court – it must invest and build on the innovation and modern working of GPs across the country, or miss out on what The 2022 GP calls ‘a historic opportunity to harness the power of general practice to transform the health service we will have in 2022’.