RCGP2019 - Wrong questions are underpinning attempts to improve general practice


  • UK Medical News
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By Rachel Pugh

Politicians attempting to solve the problems of general practice are basing their solutions on the wrong questions according to Professor of Health Systems Innovation at London South Bank University, Rebecca Malby.

Speaking immediately after Health Secretary Matt Hancock at the Royal College of GPs annual conference in Liverpool, Malby said: “The central message of politicians is to solve the problems of General Practice, but what you see determines what you do. The current government’s ideology gets in the way of what we are doing to solve the problems facing general practice.”

She denied that more money and employing 5,000 more GPs would solve the problems of General Practice as the Government says because she questioned the truth of the accepted assertions underlying the actions. These are that there is not enough capacity, that frequent attenders all have more than one chronic disease and that secondary care shifts the burden onto GPs.

“We don’t actually know what is going on in general practice,” said Malby. “And we are asking the wrong questions.”

Given that research at practice level shows that 40-90% of GP appointments are considered inappropriate, she urged for more research to go into defining exactly what does, or does not, fall into a family doctor’s remit.

Assumptions are made that frequent attenders are old, isolated, suffer from multiple comorbidities and from mental health problems. However, her analysis of ‘super attenders’ (who have at least three weekly appointments) in certain London practices paints a different picture of a very mixed group, but who might cost the organisation as much as £200,000 a year.

“Why is spending £200,000 on people who are persistently turning up, the right way of spending £200,000?” challenged Malby. “Why don’t you find out what is going on in your practice, who is turning up, why and what is the best design for the solution, rather than putting in that ten-minute appointment -because that ten minutes is not working. We have to do things differently.”

Examination of frequent attenders shows that 40% of frequent attenders are struggling with life as a result of poverty, domestic violence and lack of self-worth, and unemployment. No 10-minute appointment would be adequate to solve that.

She urged for primary and secondary care to be looked at as a system to counteract what she maintained was a myth that patients were being driven to A&E by GP access problems. in her view A&E patients are mostly very sick, but the staff are geared towards treating trauma.

Known contributions by primary known to reducing attendances at A&E include:

*  Active management of people with complex needs

*  Stopping patient’s condition from moving from stable to unstable disease

*   Care homes need to be associated with one practice per home - but many of them have five GP practices and very high hospital referrals. Why are you sweating the small stuff.

“Some things we know,” pointed out Malby. “Why don’t we just get on with it.”

Primary Care Networks (PCNs) can be the solution to helping ‘super attenders’ at GP practices, who often struggle with life because of serious problems of poverty, domestic violence and mental health. However, she rejected definitions of a PCN as simply performance management structures to make commissioning easier.

She insisted that PCNs have much greater potential value to alleviate GP pressures, generate income, and extend hours, but only by supporting struggling practices, proactively looking at frequent attenders bouncing through the system, enabling robust general practice and promoting an asset-based approach to health.

“The first conversation to improve GP should be about what we think the work of a GP should be? The danger is of turning it into just medical treatment, but sometimes you are the person to hold someone’s hand and help them to get their kids to school tomorrow - and then do the same the next week.” Said Malby.