It’s impossible to begin this Briefing without reflecting on the present state of the NHS. Against a background of the closure of hospital beds and of emergency departments, the shift of clinical responsibility from secondary to primary care, and the increased emphasis on care in the community, first contact care in the UK is now in disarray. The primary care-led NHS may have worked, and could have saved money, if general practice had continued to work well, and if the social and community resources to support the frail elderly and the long-term sick had remained adequate, but neither is the case. For complex reasons general practice is creaking under the strain: the social fabric has unravelled, rather than strengthened, creating a paradoxically increased reliance on hospital-based services. Ill-advised schemes such as NHS Direct and NHS 111, along with other, well-rehearsed changes to the contractual and professional obligations of GPs and in many areas major demographic changes, are creating a perfect storm of escalating demand and a diminishing capacity to cope. These problems are well-exemplified by the care of patients with serious mental health problems, described clearly in one of this month’s editorials by Ben Green and Bill Gowans.
It’s also very difficult not to think that this may be a defining moment for the NHS. Although there is unanimous political support for the publicly-funded system, the elephant growing in the corner of the room is affordability. The realistic alternative to political parties committing unaffordable billions to shore up the service is the need for some form of co-payment or health-specific taxation to bring genuinely new money into the system. The chances of making savings within the health service, discussed very recently as a way of improving matters, now seem remote in the extreme. Co-payment works well in other countries with effective health systems offering full population coverage, and does not per se undermine the social good of the system or open the door to ‘privatisation’. However, it is almost unimaginable that this crucial discussion will take place in the run up to the general election, for obvious reasons.
Some of the articles in the BJGP this month touch on important aspects of the current problem. Both the editorial by Ben Riley and Amanda Howe on extending the period of training for general practice and my Editor’s Choice letter by Rosie Isaac emphasise the need for today’s GPs to be better equipped than ever to meet their clinical responsibilities. Green and Gowans make the same point in relation to the care of psychiatric problems. We have probably been a little complacent about the content of our 3-year programmes, concentrating instead on problems of assessment and competencies. The Research on respiratory symptoms in children and antimicrobial testing in respiratory disease both emphasise the need for an excellent grounding in paediatrics and child care for all GPs. Many urgent medical problems present in-hours, as well as out of hours, and the only way to learn how to look after these patients effectively is to obtain out-of-hours experience in doing so during the training period. There is good evidence, for example, that when well-trained GPs work in front-line positions in accident and emergency departments, they admit fewer patients, order fewer investigations, and write fewer prescriptions. Well-trained GPs, comfortable with acute and urgent presentations of illness and with minor surgical problems, could have a major impact on demand and attendance at minor illness and accident centres. We need to be sure that our postgraduate training is up to the task.
We aren’t alone in grappling with the demands of first contact medical care. Last month the BJGP started a series of International primary care snapshots, brief reports on primary care around the world, written by members of the BJGP’s International Advisory Board. This month we are in Nigeria and Poland, where things are far from straightforward. There is plenty more in Out of Hours to divert you for a few moments away from these weighty matters, and whatever you do, don’t miss reading about Miss Havisham and the ultimate generalist.
- © British Journal of General Practice 2015
