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Five into seven doesn’t fit, or does it?
Thinking back to the time before the 2004 contract, working as a GP, times were hard. We were all on call and responsible for our patients 24 hours a day, seven days a week. Or were we?
In my part of the world we were working as co-operatives, covering ‘urgent care’. Remember them? We organised ourselves in local networks to make life more bearable and the workload more manageable. Some GPs ‘contracted out’ to colleagues whilst others contracted out the day job to take over out of hours services. It worked for most of us but to is important to remember that some colleagues hated it.
That said it is true to say that what did work was providing comprehensive 24 hour out of hospital emergency care for our patients and the local communities we served. There was variation but as GPs we felt more in control and understood the need to escalate the service when demand for out of hours care rose, which as we can see is fairly predictable. We had never heard of the term ‘winter pressures’ but we sure knew that acuity rose in the dark early months of the year.
Speaking to colleagues from other parts of the country at the time I know there was a general feeling that whilst we saw lots of non-urgent cases, and others did abuse the service, the overwhelming majority of patients didn’t. It worked as professionals, GPs, nurses, paramedics worked with managers to make the system work. There was a collegiate approach and measures of performance with feedback when things went wrong was common.
Last week Sir Bruce Keogh laid out his ideas for a seven day consultant led acute service. It was universally well received, by practitioners, the public, patients and the press. But, what is primary care’s response – all of primary care – not just general practice?
We have an out of hours service but is it fit for purpose everywhere? Could we better co-ordinate care and be more proactive with the frail elderly and other groups who need more care and support?
Regardless, it is clear that general practice is under pressure and we need to change: doing nothing is not an option.
As the demand for appointments and routine surgeries increase, is now the time to see the challenge fund for general practice as an opportunity to start down the path of 12 hour days 7 days a week? Or is that unimaginable and unaffordable?
I am clear that prescribing a top-down, one-size-fits all solution will not work. What we must do is allow innovators to take the lead. Let’s legislate for innovation not for restrictive rules. Often the best changes are those most simply implemented, reducing barriers. I visited the ‘urgent care’ centre in Corby yesterday. Innovative practice running a hybrid A&E/Primary Care centre seeing up to 250 patients a day open 8 until midnight. Patients love it, the doctors are happy and the workload containable. Apart from the spin offs reducing secondary care admissions, it is incredibly effective. For this type of situation it is the future and supports Sir Bruce’s review.
Foremost in our thinking and design must be the needs of our patients and we must let the ‘thousand flowers bloom’, encourage different pilot schemes across the country that address the needs and demands of their communities.
This will challenge the current paradigm and in the long term improve care for patients and found a system that is sustainable for practitioners.
We must make the most of informatics and the most up-to-date technology, and promote self-care, but these will take time to embed. We must also win the ‘hearts and minds’ of those who we require to support and lead new services.
Seven day services is not the same as seven day working. It may not be attractive to everyone but with a changing workforce and shifting expectation, it is the future.
Those who lead and innovate will find workable solutions and no profession can lead this alone or without support. NHS England must find that support to enable system change.
All clinicians must play their part. Patients need and deserve consistent access to healthcare, and Primary Care must play its part.
The fundamental point here is I think designing the system around the needs of patients. We know that good access during core hours is important and takes pressure off out of hours. We also know that (according to GPs) something like 20% of demand is clinically urgent, ie “should be dealt with today”. The question is how to design and measure a system which can respond to this appropriately and economically within primary care. Will be an interesting year ahead.