It’s a truism of progressive thinking that brave new worlds are a whole lot easier to envisage than to implement. This has certainly been the case in the healthcare sector; over the whole life of the NHS, the consistent milieu has been one of an organisation struggling to create an ideal version of itself while coping with a continuous crisis of funding, work pressures, and a public attitude shaped at least in part by an unfortunate media habit of treating bad news as a much sexier subject than good.
Against this background, this week’s publication of the General Practice Forward View, a collaboration between NHS England, the Department of Health, and a number of major players in the healthcare sector, is a cause for cautious optimism. The document sets out a new strategy for general practice, one that starts from the sensible standpoint of recognising that primary care represents close to 90% of public interaction with the NHS, and proposes a raft of changes – in funding, staffing, technology, and allocation of roles, among other things – that will see the traditional role of the GP practice enhanced towards that of a primary care hub.
This is the biggest package of support for GPs since 1966, and the New Deal for GPs. But it’s not simply a matter of throwing a bit more money at hard-pressed doctors and telling them they never had it so good. There is no new money involved; instead, existing funding is being reconfigured to allow front-line primary care services to handle the burden of care they carry in a more sensibly structured way. While this aspect of funding may mean short-term difficulty, in theory the long-term picture is that the savings enabled by a more efficient primary care sector will flow back to other sectors of the NHS, as well as reducing pressure on A&E and acute care providers. Moreover, if the savings proposed by the Carter Report can be achieved, much of the short-term pain could be alleviated, or avoided altogether.
The document proposes widening the range and number of healthcare professionals in GP practices: more pharmacists working in practice; a greater role for practice nurses; more physician associates; enhanced access to mental health, physiotherapy, and self-care support. Technology’s role – in making access to advice and care support easier; in streamlining the way we use primary care, from making appointments to planning and controlling our own care packages; in simplifying and improving communications between health professionals, and between those professionals and the user base – will expand. In sum, this is a broad, and in some respects radical, reshaping of the local health economy.
Implicit in the proposals is a more difficult shift, one that will perhaps influence the success or failure of this initiative more than any amount of money could do. To make the Forward View work in practice, a number of culture changes need to happen, and they need to happen in a timely way; otherwise, existing cultures and in-built resistances risk slowing, or even de-railing, the changes and improvements envisaged.
First, and foremost, that culture change needs to happen among GPs themselves. The traditional view of the GP (we all share this to some extent) is that of the main provider of primary care; the competent, knowledgeable all-rounder who receives, assesses, and treats the patient at the point of first contact. In this view, the GP is the person we all want to see when we feel unwell; anyone else is a poor substitute. GPs will need to relax their hold on the reins of primary care to allow other professionals, and patients themselves, to take up some of the burden of care. They will need to start seeing themselves as much as enablers of care as simply providers (and perhaps for some exclusive providers) of it. They will need to increase their willingness to delegate aspects of patient care to others; and we as patients will need to do the same.
We, the potential patients, also need to undergo a profound culture change. First, when we do have health problems, we need to see the primary care practice, and not the individual GP, as our partner in health. We have to be willing to accept care from the range of highly skilled and experienced people who will inhabit the new local health economy; if we resist, and insist on seeing the doctor and no one else, the opportunity for positive change will be limited and compromised; and the pressure on GPs will stay as it is, with all the unpleasant ramifications that situation suggests.
More broadly, both doctors and patients need to understand the new system as one which works on the principle of health care rather than sickness care. Health self-management (a term used far more often than it is understood) and personal responsibility for health and well-being will be the true drivers of a more diverse, personally tailored, flexible approach to healthcare. This will not happen overnight, and will not be easy to achieve, and this is where another implication of the Forward View comes to prominence.
Although the document does not dwell on the subject, it is clear from the proposals that the role of public health professionals will be vital in making the new primary care model work. First, the principles and practice envisaged need to be communicated to the public; this needs to happen soon, and needs to hit its target. The required messaging is on two broad fronts. First, the basic information – how the GP practice is changing, and the new opportunities for enhanced healthcare, and personally managed self-care – need broadcasting on a national and local level; national, because this affects us all, and local, because the flexibility inherent in the proposals means that the local health economy will look different in some details from one location to another.
Second, and this is both a subtler and infinitely more difficult and engaging task, public health is the obvious driver of the culture changes necessary for the long-term success of the new model. The messaging required – the practice not the individual, personal responsibility and management, understanding and using the potential that technology represents – could and probably should be embedded into all public-facing communications, and all communications aimed at health professionals. One could imagine a new vocabulary of health coming into being, created and initially communicated from public health sources, spreading to the media (there’s another cultural barrier to overcome), and eventually seeding itself into the common vocabulary of health.
We’re currently celebrating the 400th anniversary of William Shakespeare, one of whose greatest achievements as a writer is seeding our common language with his rich and wonderful arsenal of phrase and metaphor. Wouldn’t it be amazing if, in a few years’ time, we were celebrating a similar achievement on the part of our public health communicators?