The 60th anniversary of the NHS is an opportunity to celebrate its many achievements—both in hospitals, in the treatment of life threatening and seriously disabling disorders, and in general practice, in the development of an effective and efficient primary care service. Together with many others we have contributed to the renaissance of general practice in the United Kingdom after the 1966 charter, through our involvement in the establishment of general practice as a research based discipline in universities with properly structured postgraduate training.
However, we wish to express a number of worries we have about potential harm to the care of patients and to medical education that, we think, is an unintended consequence of recent reforms. Our starting point is a statement of what we think needs to be safeguarded: the distinguishing feature of UK general practice before the 1990 contract was the long term relationship between a patient (and often a family) and an individually named doctor, whose clinical training was grounded in the diagnosis and treatment of illness but was expanded to include awareness of the importance of psychosocial factors that affect patients’ experience of illness and their ability to manage it. The fact that most care was initiated by patients meant that GPs had an implicit mandate to respond to their patients’ agendas and involve them in decision making. Importantly, this allowed patients to be cared for in the community to their personal advantage—and with economic benefit to the NHS—or to be referred for specialist care if needed.
Four matters now threaten this vision. The first is the population health agenda.Governments are bound to see health care as population based, whether in terms of preventing disease or in managing long term illness and disability. Population medicine is, however, not principally concerned with the agendas of individual patients consulting their doctors. Integrating the public health agenda into routine general practice means that the reasons for patients wishing to consult their GP are in danger of being relegated in favour of an agenda to which patients may not give priority. Thus the benefits of the traditional consultation with a known personal doctor are at risk of being lost.
The second matter is perverse incentives.Targets have their place, and incentives help achieve them. However, the quality and outcomes framework (QOF) seems a disproportionate response to the challenge to improve the quality of care. It also has known limitations: most of the measures are processes rather than outcomes; “ticking boxes” may distract doctors from dealing with important topics during consultations; and measures of what patients value and gain from personal care are poorly represented as individual QOF items or as a proportion of the whole QOF package. Previous work indicates that patients with non-incentivised health problems (in particular, in the context of QOF, psychosocial illness) are also likely to be disadvantaged.
The third is access. The extra work resulting from implementing the public health agenda and the pursuit of QOF points has made it increasingly difficult for patients to get timely access to care from their first choice of provider. Also, in many practices the move to improve GPs’ work-life balance has gone too far, resulting in few or no evening or weekend surgeries being offered and out of hours care being widely delegated to dedicated services. Already the consequences of the new culture of “team care” include the replacement of the “known doctor” by a practice nurse or by a pharmacist or other professional outside the practice. Provision of primary care in, for example, supermarkets and railway stations is a growing trend that cannot be expected to deliver the benefits to patients of a well constructed traditional general practice.
Our fourth concern is the effect of these changes on the learning opportunities of undergraduates and general practice registrars (if they do not see the different presentations of illness in evenings and out of hours) and on their chances of absorbing an ethos of personal and continuing care.
The most serious consequences of the current reforms arise from the tinkering with the model of patient led personal care given by a known GP in favour of episodic delivery of a top-down agenda by any of a variety of healthcare workers in a variety of sites. The best of the past is in danger of being lost without sufficient proved benefit in return. Our conversations with doctors in practice suggest that many share our concerns; so too do many patients.
Allowing these trends to continue unchallenged will result in the dismemberment of a primary care system that has been the envy of other countries. Patients will lose holistic care, doctors will lose job satisfaction, and the NHS will lose effectiveness and efficiency. As medicine changes, and the society it serves changes, evolution is inevitable and desirable. But in a complex organisation such as the NHS, simplistic and unpiloted measures are likely to have unintended consequences. We believe they are already happening and that GPs need to reclaim their traditional overall responsibility for the continuing care of patients in their own practices and to make their concerns about the new system more generally known.