In my last blog I talked about the need to remember Primary Care when it comes to Winter Planning (https://drjongriffiths.wordpress.com/2018/08/01/winter-planning). Since this was published I have seen Social Media posts about how we measure workload in Primary Care, including this blog from Samir Dawlatly https://blogs.bmj.com/bmj/2018/08/17/samir-dawlatly-we-need-better-ways-to-measure-gp-workload/. This is important for a number of reasons.
First and foremost, as described in Samir’s blog, are the issues of safety relating to ever increasing, unsustainable workload. Ask any GP and they will likely tell you the same thing in this regard – individual GPs are struggling, going off sick, retiring early, emigrating, leaving. Practices are struggling to recruit, struggling to balance the books, and in some cases going under. We really need to understand the numbers involved here to draw some lines and tackle the problem.
The second reason is what I want to talk about though. If we cannot quantify how much work is undertaken in Primary Care, how can we begin to quantify the value of Primary Care? Like it or not the NHS has an internal market. It is transactional. Money ‘follows the patient’ and hospitals are paid according to numbers of patients being seen. Additionally there are targets in place relating to hospital activity – 4 hour A&E target, 18 week Referral to Treatment target etc. All of this means that hospital activity is measured (there is a whole industry devoted to this), and if you are measuring it, you can show to everyone how well you are doing, and how hard you are working, how important you are and (crucially) how important it is to invest in your services. The risk with Primary Care is that we don’t count things in the same way. And if you don’t count it, you don’t seem to count.
How will we see increased investment into Primary Care if we cannot demonstrate its value? We are already fighting an uphill battle with popular opinion seeming to think that Specialists are more important than Generalists (see my TEDx Talk for what I think of this https://youtu.be/-BfcvI49GCw). If hospitals are already more important than Primary Care, and they are able to demonstrate how hard they are working, and with the majority of the country’s media reporting in a way that suggests that NHS equals Hospitals, is it any wonder that Hospital care continues to be resourced in a different and, I would argue, more favourable way than General Practice?
We have to do something about this. We have to start to count.
Of course, individual practices already do count, or have the ability to do so with a click of a mouse. Primary Care has excellent IT. My IT system can tell me how many people have been seen in the past year, how many phone calls, home visits and face to face appointments. I have just looked – it took me a few seconds to see that in 2017 our surgery of just over 10,000 registered patients saw 8,406 patients in a total of 47,819 booked appointments (I will digress to point out that we had 3,474 wasted appointments where people did not turn up – this is more that the entire number of appointments I personally had on offer to see me for the whole year as a part time GP. I’ll just leave that statistic hanging there…). The information is all there. We just don’t share it. GPs, in fact, may be reluctant to share it due to fear that it will be ‘used against them’. They may fear that we will immediately start comparing numbers between practices and ‘encouraging’ those who have seen fewer patients to work harder. This is not what we should be about though. We should be about demonstrating our value.
I fundamentally believe that General Practice is of incredible value to the NHS. Unfortunately, currently, that value appears to be immeasurable. Unless we can do something to show what we are doing, and how this is helping the system as a whole, we will struggle to attract much needed resources into Community and Primary Care. Everyone is trying to bring about the fabled ‘Left-Shift’ – moving resource from expensive secondary care to more cost-effective Primary Care, but so far this does not seem to be happening. It feels like enough is enough. Time to act. I would suggest we need to be brave, take what seems to be a risk, and put the money where we know it is needed, and where we know it will do good. The challenge back to me will surely be “Jonathan, how do you know it will do good? Can you tell exactly how it will help and what you will achieve?”, and I fear that I won’t be able to tell them. At least, not in terms of the numbers and figures they are looking for.
The problem is that General Practice just doesn’t work that way. Some have described the GP-patient interaction as occurring within a ‘black-box’ where you cannot see what is going on. We need to get over this and just do something.
If providing some numbers and counting some patient-contacts will help – let’s start there.
Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and is Chair of NHS Vale Royal Clinical Commissioning Group.
Got a question? Find Jonathan on Twitter @DrJonGriffiths