From General Practice to Primary Care: The Industrialisation of Family Medicine
Steve Iliffe
Oxford University Press
2008
233
£24.95
978-0199214501
Every morning our practice waiting room is filled with patients attending for blood tests. Doctors and nurses draw the blood, receptionists prepare and check the forms, and a courier transports the specimens to the laboratory. The results reach our computer system within 24 hours, slotting automatically into the data fields on the patients' Quality and Outcomes Framework encounter screens. The system in turn is interrogated by the Exeter unit, our QOF points are recalculated, and the practice's financial position is fractionally adjusted. Most of the blood tests are done in accordance with centrally determined protocols, and to satisfy an agenda that has more to do with public health statistics than individual wellbeing. The patients will have only the vaguest idea of why they are being done. The doctors will wonder whether they need to be done at all.
This is a brief caricature of the process of the industrialisation of general practice, and of some of the conflicts inherent in it, that Steve Iliffe explores in this provocative book. For those of us who have been GPs since 1990 or earlier, the changes we have seen have felt like a speeded-up movie sequence where storm clouds gather, race across the landscape, spill rain, and thunder and lightning and pass by to leave a moment of tranquillity before the next storm gathers: threatening and unpredictable.
Iliffe's use of the concept of industrialisation sheds some light and offers a helpful analytical framework. He identifies five features essential to the process. First, the growth of management at all levels; second, the ‘forward integration’ of suppliers and distributors of goods and services; third, the adoption of ‘large-batch, continuous-process’ technology; fourth, the application of production-line methods, buttressed by standardised protocols, cost-efficient skill-mix, and incentive payments; and fifth, the incorporation of science into the process, through evidence-based medicine and clinical governance.
Throughout, the author displays a degree of ambivalence towards the processes that he is describing, which must be shared by many GPs. We know that huge discrepancies between practices in their quality of care needed to be addressed, but we are suspicious of the central control and uniformity that is being imposed. We respect the power of randomised controlled trials and evidence-based medicine to consolidate efficacious treatments, but we are hesitant about applying their probabilistic conclusions to the individual. We know that the public health and the public purse must inform our use of resources, but we are wary of acting as government agents. We claim commitment to continuity of care, yet we absolve ourselves of out-of-hours work. We pay lip service to patient-centredness, but are suspicious of patients bearing internet printouts. And so on — all issues, among many, that Iliffe addresses with a wealth of cited research and his own analysis.
Not surprisingly, given all this ambivalence, his conclusions are hardly unequivocal. If industrialisation is ‘maximised’ we risk a demotivated, target-driven workforce and alienation of patients; if doctors resist the forces of change too strongly we risk permanent conflict with government and a temptation for both parties to move towards privatisation of primary care. Instead, Iliffe urges ‘the full but critical engagement of GPs in the development of clinical governance and the industrialisation of general practice into primary care’. I am not sure that he himself is critical enough — for example, I think he underplays the dangers of medicalisation of asymptomatic risk factors and the degree of coercion of patients (let alone doctors) exercised through the QOF — but I hope his book will encourage the engagement that he urges on us. This is a hard-headed book, and an antidote to the ‘latent romanticism’ of the Royal College of General Practitioners against which he cautions. Romantics will hate it.
- © British Journal of General Practice, 2009.
