This week we launched our report Primary care today and tomorrow: Adapting to survive, which provides an update on our understanding of the developments and challenges in primary care since our first report in 2012 ( Improving general practice by working differently). Since 2012, primary care providers have encountered an increasingly turbulent political and financial landscape, with a range of new pressures emerging. Workforce shortages have combined with rising patient demand, inadequate facilities and on-going under-funding.
Over the past eight months I've been privileged to be part of the research team on this new report and this week's blog provides my own take on the challenges that I have seen during my research and from my personal perspective as a doctor and a patient.
Throughout our research and particularly in the many discussions I had with stakeholders from a variety of backgrounds, I found that despite the technological developments and organisational reforms, it is people that remain the key to achieving a sustainable health systems. Indeed, as the crisis consuming primary care escalates, staff are experiencing the full brunt of the relentless and overwhelming pressures in trying to maintain services in the face of increasing demand, regulatory scrutiny and patient expectations.
One of the many people I met was Ruth, a GP, who recently decided to give up her partnership in a GP practice as a result of stress and burn-out. I met Ruth at a conference on the DNA of Care which was based around a series of digital stories about working in healthcare.i Ruth's story 'Forgotten to remember' explained how as a GP she listened to and carried the concerns of thousands of patients but also her own concerns and how her vocation, dedication and career was crushed between the pressures she faced on a daily basis. One statement that Ruth made resonated strongly with me "Now I find that I am at a crossroads of my life, one of grief and loss for my beloved general practice, because I can no longer be the GP that I know that I want to be."ii In response to a question from the audience, about what she would do if she had a magic wand, she replied without hesitation, "increase the length of consultations".
As a doctor, I empathised with Ruth's feelings of being overwhelmed by workload pressures that result from increases in annual numbers of consultations, rising complexity of care, and attempts to shift more and more activities into primary care, in the face of inadequate funding and capacity. From my own clinical work, I vividly remember the constant inner conflict caused by competing interests: wanting to provide each patient with high-quality and compassionate care, satisfying organisational demands, and almost never having enough time, to give adequate time and attention to either my patients or my own needs.
Our research found that it was not only the workforce feeling increasingly overwhelmed. Indeed the growing mismatch between demand for consultations and availability of appointments is having a negative impact on both staff and patient satisfaction and, in the words of a number of interviewees, 'starting to negatively affect clinical outcomes'. With primary care buckling under the strain and a workforce and facilities that are overburdened and increasingly unable to support the growing weight of demands, patients are failing to get what is ultimately the principle aim of the NHS: access to the right care, with the right person, at the right time, within a sustainable cost envelope.
Our interviewees also recognised and indeed supported the idea that reform of primary care is a pivotal first step, in addressing the significant financial pressures and supply shortages across the health system. They agreed that such reform needed to be supported by strengthening the sense of ownership among all stakeholders. Especially as any transformation will require some unpopular decisions on what we are prepared to trade-off and prioritise. Moreover, they also stressed that the process of reform should involve a high level of transparency and engagement, not only with healthcare professionals involved in delivering primary care, but also with patients, informal carers and the voluntary and private sectors.
This request for transparency was particularly heartfelt when it came to discussing the new Sustainability and Transformation Plans (STPs), the 44 geographical footprints that all NHS organisations have been allocated to; in the expectation that they will work with relevant local authorities and other stakeholders to implement radical changes in how services are planned and delivered, and at the same time identify how to balance their finances. Our research identified that the scale of the STP process is large and ambitious and that, in many regions, the organisations coming together in these new partnerships have not, traditionally, worked well together. Furthermore, that the governance of and accountabilities for the STP are obscure. To succeed, the STPs need to obtain buy-in from clinicians and other staff who will be implementing these new models and the support of patients, who will be the end-users of the transformed services. To date, however, there is a lack of evidence of adequate consultation and engagement.
The plans for transforming primary care include an expectation that new models of care will be implemented based on collaboration and integration and that innovation and technology will be adopted at scale. However to date, the progress is relatively limited. In our report we point to best practice examples that serve as an illustration of highly engaged and motivated teams. They demonstrate innovative ways of collaboration and leadership and make use of a variety of solutions.
Over the past few months engaging with many of the people working to deliver these new models of care has been inspirational and has demonstrated clearly the importance of sharing their experiences to date; so that others might learn and hopefully copy these examples and proactively improve patient care rather than re-inventing the wheel or worse, doing nothing.
Transformation of primary care is ongoing and the outcomes of the current reforms remain uncertain. We believe that primary care will become even more important in the future. And that GPs and staff in general practice will be the central co-ordinators, coaches and providers of first line treatments while championing prevention and supporting their local populations. To realise this vision, the GP Forward View will need to be implemented as intended, resources allocated as promised and emerging solutions adopted at scale.
By sharing the insights in our report and especially the good practice examples, we hope that health and social care stakeholders across the UK will be able to alleviate the immediate pressures facing individual staff and patients and enhance the future sustainability of care.
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