Has general practice a role beyond medicine?

A wider role for general practice has always appealed to me having always wanted to be a GP, whereas many GP colleagues originally wished to be specialists.  I hankered after a generalist connect with people rather than a specialist partialist outlook, working within an area of social deprivation. The maldistribution of general practice persists, an example of the ‘inverse care law’ where areas of most need receive the lesser provision. I also believed that my role encompassed the bio, social and emotional. As I gained in experience and confidence, I perceived the practice’s role as being a community resource with the patient- doctor relationship a meeting of two experts thereby medical consultations becoming conversations. Now this might seem woke nonsense to some and indeed the source of a recent heated disagreement thankfully brief with former traditionalist minded GPs- one of the reasons I chose for it to be a blog subject.

As previously I strongly support the government’s 10Year Health Plan and their wider focus on neighbourhood health. Whilst recognising the priority to revivify the NHS, a group of former and current GPs are working towards a unifying coherence of neighbourhood policies. UK General Practice uniquely has a population responsibility – the registered list- and is physically, and for some of us more connected to our community. What is enlightening is a small yet burgeoning interest in shaping the Plan’s development to this end. PCC is already supporting COIN (Community Oriented Integrated Networks) of which I am a member whose underlying premise is the community in partnership with local services. Further I recently attended a House of Lords dinner led by Andrew Mawson the social entrepreneur who instigated the brilliant Bromley by bow health centre and beyond, combining integrated healthcare with community regeneration. The purpose of the meeting is to promulgate and hopefully spread similar initiatives under the auspice of the government many neighbourhood policies. I understand fully the need to have a laser focus on improving the NHS but in focusing for the many it’s important not to close off more visionary achievable approaches. There persists an incipient prevailing NHS culture of over focusing on a narrow range of specifics and deenergising the energised. In private I have a more robust expression to describe this tendency!  Two other personal involvements, speaking at a meeting organised by Radix a centre-left think tank on how the NHS involving primary care can help regenerate town/city centres which have become depressingly denuded and separately working in a small group attempting to free up GP innovators. The secretary of state for health in a recent letter to GPs promised a new GMS contract. A type of contract that historically after both helpful and unhelpful negotiation with the GPC -hosted by the BMA- delivered an adequate contract for the many, but stultifying for innovators.

Despite my support for the 10 Year Health Plan, I have concerns about its development which if NHS history is any guide, will be bureaucratic and often disabling.

1. The proposed development programme for NHS neighbourhood health service sites given John Oldham’s withdrawal as leader. Many of us indeed felt the collaborative methodology is too narrowly focused and non-participatory to be of long-term value. When I originated the Primary Care Home its subsequent development led by the NAPC with support from NHS then CEO Simon Stephens was more the enabling participatory approach required. Simon was impressed enough to create national primary care networks to continue energising primary care. Inevitably once part of NHS management, enthusiasm and energy faded with some honourable exceptions.
2. I know money is tight, but there were 80% of all neighbourhood practice sites volunteering to be chosen for the development programme and only 43 chosen, 98 disappointed. We can’t afford to lose the energy of the 98. It’s rare enough to accrue such energy so to dissipate it would be a huge folly.
3. We can’t afford to bureaucratise general medical practice. This may seem like special pleading, but the population based storied community provider must be preserved. Within a new culture, subsidiarity could be a game enhancer- the principle that decisions should be made at the most local level of authority. It will require a trust in localism and people through adaptive reflective active leadership not frozen by dichotomous thinking. For most of general practice the GMS contract would suffice, but the energetic innovators and social entrepreneurs would wish a more enabling contract. PMS is still available. The individual general practice must remain important as indeed local community pharmacy- the predominant contact point for the public. To be maximally effective and deliver on the 10 Year Health Plan services must remain local and yet concomitantly be part of a larger scale. It cannot be either/ or-the dichotomy- but both.

The apotheosis of general practice beckons and achievable wherever along the spectrum of ambition I have described. Hopefully joined by wider primary care and community services as in the Primary Care Home pilots. As for the larger purpose of community involvement and regeneration – my preference-should not be forced on the unwilling. The late Chief Rabbi Jonathan Sacks in his ‘The Politics of Hope’ ascertained that such leadership should be identified from a wider population of the willing- schools, religious organisations for instance. My experience exactly.

Professor David Colin-Thomé is chair of PCC, a not-for-profit social enterprise supporting primary care, the development of neighbourhoods and collaborative leadership, contact enquiries@pcc-cic.org.uk or visit www.pcc-cic.org.uk for more information.