I’ve been re-reading Julian Pratt’s ‘Practitioners and Practices’, out of a niggling worry that the funding and policy focus on PC Networks will mean yet again that the developments needed in general practice will get neglected – as if the two are not interlinked. PCNs will only work if general practice is robust, adapting, and managing and reducing demand. Julian’s book is a lovely description of the work of general practice. PCNs need a purpose – i.e. to be clear what is the work that can only be done at that scale. They should only ‘suck up’ work that cant be delivered well at a local GP practice scale. In order to have that conversation participating practices need to be clear about the work that is best done in general practice at its best, otherwise the tendency will just be to shift the burden from general practice to the PCNs, rather than to consider the work of PCNs as unique and different from the work of general practice. For PCNs to be effective and useful, General Practice to be the best it can be.
The Work of the General Practitioner (which is not just the GP)
What we find in our work in general practices is that there isn’t a consensus on GP work (what a GP should do versus another practitioner) nor what work best resides at their practice population scale. In this diagram the blue line is the number of appointments where the GP thought that they were doing GP work.
Fig 1: London Primary Care Quality Academy one practice example of variations between GPs from 40% of my appts are appropriate to 90% are appropriate.
In the hurley burley of ‘doing’ appointments, the conversation within practices about what their work is and how they are doing it can get lost. General practice practitioners (all the professionals working in general practice) need a coherent view about the value and work of the consultation at an individual level, and the work that can be done at practice population scale, and only then can they decide what needs to be done at PCNetwork scale. It’s a messy dilemma which has the potential to predicate the biomedical work of primary care over the other domains. The biomedical work is easy to describe and to ascribe metrics too, so its easy to count and therefore becomes the dominant descriptor of the work.
So lets start with the individual work in the consultation. Back to Julian’s book – he describes the domains of the work as these:
Fig2: The practitioner as synthesiser of the four aspects in working with the body, mind, emotions and spirit of the whole person (Pratt 1995)
These domains require different relational skills that are poorly described by the words ‘diagnose’ and ‘treat’, and require the primary care clinician/ practitioner to be able to help the person understand and make sense of their experience (sometimes not described as a clinical condition) and their own role in how they both deal with this experience and make choices about it. The primary care practitioner brings caring and emotional support as much as biomedical treatment. I was struck by the value of bearing witness to the person’s struggle with their life and health, and to take this one step further, the value of the general practitioner as a healer helping the person find their inner strength and meaning. When the NHS talks about the work of primary care and individual consultation, the focus is on flow, on the right practitioner for the right work, on how to help people who struggle with life through social prescribing (as if this isn’t the work of the GP or PC practitioner).
Compartmentalising people’s lived experience further fragments their care. This seems to loose the integral importance of the healing, caring and biographical modes of being a general practitioner. This range of relational approaches, describes the craft of the general practice consultation. How this is provided varies by person and need, which is why practices need a whole range of access modes from e-consult to online appointment bookings; and consultation types and length from triaged 5 min calls to half hour regular reviews.
This model articulates the work at practice scale. PCNs will also be providing personalized bespoke multidimensional care to and with vulnerable people, but at this scale the work is described by the complexity of service that is needed. This is not ‘economies of scale’ the rationalisation of resources to drive efficiency, it is ‘working at scale. My colleague Nick Downham describes this as emerging from the support, service or innovation need that can only be achieved at a certain scale:
- To support the maintenance of a certain technical expertise.
- To provide depth and quality of collaboration network.
- To reflect natural sizes of communities.
- To support team based approaches (Team based approaches are not the same as broadening skill mix – which is generally a form of division of labour)
………in order to speed up the meeting of need.
Starting with need is critical followed by then describing what scale is best to meet that need.
Here is an example of how the system as it works now fails to meet need
Fig 3: One person’s touchpoints of hospital, community and Local authority services in 2 years.
This is how Intermountain Healthcare has worked on developing primary care teams out of need.
Fig 4: intermountain Healthcare Physical and Mental Health Integration
Starting with need and the whole relational approach to meeting needs, will help general practice determine what should reside at that level and what needs to be done at PCN level.
Working with Populations
So far I have been exploring individual need and care, but the consultation is not the only work of general practices. The work to support the health needs of the practice population as a whole is a further dimension of general practice work– often described in terms of how resources are allocated equitably, and fairly. With access organised in the way it traditionally has been the needs of the population is subverted by the needs of the individual – those that demand get more than those that might need but don’t ask. Often little time is spent in practices for instance on preventative or early needs of teenagers who rarely try and access services, and a lot on people who attend frequently.
Fig 5: London Primary Care Quality Academy – where General Practices in the Academy focus their efforts.
The work of general practice in working upstream of the presenting issues needs attention, if only to help manage the demand in later life, which means focusing on the health and wellbeing of the practice population alongside the individual.
The final strength of general practice is the love it has for its local people, and how much general practitioners know about them. This care for, and knowledge of the place, has the mostly untapped potential of collaborating with the assets in communities to bring local people’s equal concern for their neighbours and friends into the work. This happens at the scale of meaningful communities, which is described by history, geography and identity, which may or may not reside at PCN scale. Some practices do amazing work collaborating with their community (Robin Lane, Leeds) as do some PCHomes (Fleetwood) at a larger scale. The starting point is the identity of the community not the population size.
Developing PCNs starts with understanding the work of general practice and developing practices and teams to be the very best thay can be with their local population.
At the outset of the book Julian identifies the influences leading to an increased emphasis on primary care in the NHS (nearly 25 years ago now) as:
- Demographics changes and chronic illness
- Development of tech processes reducing need to stay in hospital but increasing he need for aftercare
- The need for generalist services as specialisms increase
- NHS transferring transport costs to families
- Users wanting community based services
- An increased role for primary care in commissioning giving the potential to shape overall delivery
In Memorium: Julian always gently reminded me to be human in my privileged work with people who are vulnerable.
Pratt, J. (1995) Practitioners and Practices. A conflict of values? Radcliffe Medical Press. Oxford.