. Primary Care

Following the Lost Decade of Austerity the NHS is undertaking a process of readjustment and reconfiguration to prevent the service falling over. In primary care the most prominent outward signs are “new models of care” and “Digital First”.

The new models of care vary depending on locations but at their core is an attempt to divert what might be classed as routine and less serious illnesses from general practitioners so that they can concentrate on more serious specialist work. The focus shifts from the individual GP to a multi-disciplinary teams in its broadest, an often disconnected, sense. The GP is not longer the obvious and uncontested access point to the NHS.

In the first instance patients are encouraged to take greater responsibility for their own health and its management rather than “bothering” the NHS. This has always gone on but now there are the additional opportunities and pathways for on-line advice and guidance.

If that fails then consideration should be give to using alternative non-medical practitioners such as “blue light services if deemed an emergency, specialist nurses, physician’s assistants, pharmacists, self-referral physiotherapy, opticians, health visitors etc. And while use is made of these alternative practitioners by very many, a substantial number of patients who feel unwell vote with their feet and take themselves to an already over-pressed Accident & Emergency service.

For those who cross this initial threshold, access to general practice is increasingly via a triage / “Digital First” portal. From here, it is claimed, patients access the advice, support and treatment they need using telephone, digital and online tools. In practical terms, this means patients should use these tools to access all primary care services, such as receiving advice, getting repeat prescriptions, booking and cancelling appointments, having a consultation with a healthcare professional, receiving a referral and obtaining a prescription. And any patient who wishes to consult their GP must digitally provide an initial description of their problem to a third party and will then wait for electronic triage via a phone or video call. It is only at this stage a face to face consultation may be offered if felt appropriate.

Much of this has commendable elements if it was part of a strategy where primary care was evolving to meet to meet ever growing and complex needs. Many patients will find the use of “digital consultations” both convenient, time saving and satisfactory. Indeed there is some evidence to suggest that patients may be more satisfied with a digital consultation than the clinician.

However overwhelmingly that transition to “digital first” is being hastily introduced as a dominant new paradigm of care and as a pressure valve for a service that is already in serious danger of imploding. Most of these changes have been introduced with bullish optimism and little consultation or debate with either patients or the professions involved. The speed of this uncritical implementation has been greatly accelerated by the Covid pandemic – for understandable reasons.

An increasingly obvious outcome of these changes is a public perception that general practice is no longer a accessible first port of call for either new problems or the management of chronic long-term conditions. And fanned by some Tory politicians and elements in the right-wing press, general practitioners are having to shoulder the blame for this state of affairs in an increasingly hostile atmosphere.

Some GPs have been dragged into a confrontation with patients on these issues in a way that seeks to minimise legitimate public concern. Such a response may be understandable but it is ill conceived. Both they and their patients must seek to make common cause to address the real underlying problems they jointly face.

At the core of this problem has been the failure to expand medical capacity in primary care. In contrast to many other primary care professionals or their hospital colleagues, the numbers of GPs in general practice has been static for decades. This failure to increase numbers, linked to the changes in contract preferences of new GPs, has meant that more and more service is being expected from fewer and fewer practitioners. This is not sustainable.

Jeremy Hunt MP, a former Tory Health Minister ( 2012-1218), has stated that his efforts to increase GP numbers failed, not because extra GPs were not trained but because more experienced GPs were retiring or going part time faster than new trainees arrived. This is a crucial lesson for the current Health Minister Sajid Javid MP.

Javid’s recent proposals to provide an additional £250m to improve GP access provides some long over-due remediation for years of under-investment. But very worrying there are a range of conditions attached to the payments which most GPs will see as toxic strings. This could drive even more GPs out of the service when the need for them is greater than ever.

Collectively all of these changes pose a risk to the essence of British general practice. As a gateway to the NHS, general practice had a key role in sorting undifferentiated presenting problems and to make decisions accordingly. GPs become a crucial signpost and the patient’s advocate in an every complex care service.

The consultation has also been where opportunist preventive and anticipatory care took beyond the presenting problem. And this was the basis for the building of a continuing personal relationship between the patient and their practitioner. Time was of the essence in building this relationship – but time is one thing the present system does not have.

Instead much of primary care provision is being fragmented into disconnected episodic incidents where continuity and personalisation is sacrificed for a transactional, call centre style of medicine. In this model patients move through the system as quickly as possible with a focus of narrowing  care down to just “today’s problem”.

This approach will inevitably undermine the personal, generalist and holistic nature of general practice. The initial contact with primary care becomes the lottery of the taxi rank. Remote access will deprive the clinician of many important non-verbal cues and time pressures will mitigate against pursuing broader concerns that are not immediately relevant — though they may have longer term implications for patients’ health and well-being. Instead of being a holistic generalist , the GP is at risk of becoming a “specaloid in episodic care”.

As the rivets pop throughout health and social care, rising such issues of quality may seem to be an indulgence. To some with immediate and pressing medical problems these concerns could look like worrying about the icing on a cake when there is no bread on the table. But these issues are fundamental way that British general underpins the whole of NHS. If we discard them, particularly in a trivial or cavalier way, the very fabric of the service will be placed at risk.