INTRODUCTION
On its landmark 70th anniversary, profound questions are being asked about the NHS. Can we afford it? Is it receiving enough funding? How can the recruitment crisis in general practice and other parts of the service be addressed? Are we really training doctors fit for 21st-century medical practice? One thing is certain, and that is the NHS will change, and it is possible that we will not recognise it as it is transformed over the coming decades. We interviewed four influential leaders in general practice, internal medicine, and health policy to learn their views on the challenges facing the NHS and what they see as possible solutions in the short and long term. Despite overwhelming pressures and a system under constant strain, reportedly on the brink of collapse, those leading the way are hopeful, maybe even truly optimistic. And it is good to know that their visions for an NHS fit for the future appear well aligned. With new challenges in a changing environment we have to develop novel and innovative ways of working, and perhaps revisit and redefine the public’s relationship with the NHS and health care in the future. Significant commitment to future spending on the NHS is fundamental to its survival and for that we wait with bated breath: it is possible that an announcement will be have been made by the time you read this article. Public support for the service remains as strong as ever, and, with such enthusiastic and committed professional leaders, we hope that it is not tempting fate to say that the future looks relatively bright.
DR JODIE BLACKADDER-WEINSTEIN
The Royal College of General Practitioners (RCGP) First5 Committee represents and supports over 10 000 GPs in their first 5 years after qualification. It is led by Dr Jodie Blackadder-Weinstein, an RAF doctor who also works in the NHS and as a medical educator, as well as doing a research Master’s degree and working on a study of exhaled nitric oxide monitoring in asthma. Just before our interview she had gone to collect her number for the London Marathon, which she was running in preparation for an Ironman Triathlon to support the forces charity SSAFA — you begin to get the picture?
Among this new generation of GPs things are not felt to be quite as awful as currently portrayed in the media. There is, Jodie says, more energy and joie de vivre than you might imagine, more determination to improve things, more hope. Many of her colleagues are now ‘muting’ the more stridently negative social media groups. So much, she believes, depends on how well new GPs are prepared for practice, on their exposure during training to the realities of general practice, and on their willingness and ability to become part of a practice team. Inadequate preparation during training for things like practice management, finances, indemnity, and conflict resolution could be addressed in an extended, 4-year training programme, which would need to be flexible, community-based, and responsive to trainees’ needs, including opportunities for deeper study of special clinical interests. The GP fellowships becoming available in topics such as care of the elderly and leadership are a welcome step in this direction.
First5 is working with the College and Associates in Training to provide appraisal and transition and pre-CCT workshops, and events to welcome new GPs to general practice. The Bawa-Garba case still reverberates across the profession, creating concerns about written reflection in appraisal, and fear of failure. Jodie thinks that lessons learned from her aviation background about the importance of looking at whole-system as well as individual failures could usefully be incorporated into the GP curriculum.
She draws an interesting parallel between the erosion of hospital firms and the creation of a shift system, with the decline of the partnership model in general practice. Although she realises that one model does not work for everyone, she strongly believes that the partnership model is not dead, and teamwork, joint planning, and joint responsibility remain of critical importance. We discussed how non-engagement and the lack of a sense of agency approximate to one of the dimensions of burnout.
Jodie admits to a having bee in her bonnet about the failure of communication across the primary–secondary care interface and the lack of interoperability in medical records and data transfer. She sees the RCGP Bright Ideas portal as an important way of sharing ideas, recognising and communicating failure as well as celebrating success, particularly in the adoption of new information communications technologies. She is less concerned about the confidentiality of digital communication, and more about the quality of patient contact. She makes a strong argument for much better information (such as improving practice websites) and education being made available for patients about what members of the practice team can offer and can be expected to provide. She thinks that the ‘3 before GP’ initiative (patients are asked to adopt a new 3-step ‘mantra’ to help relieve pressures on GP services: use self-care, NHS Choices or similar reputable websites/resources, and/or seek advice/treatment via a pharmacist) was a good start, and that nudge techniques — using behavioural insights in our practices to improve patient outcomes — are worth thinking about.
We managed to avoid Brexit, but on the other big question, the funding and politicisation of the NHS, First5 strongly supports treatment being free at the point of care but recognises that everything needs to be on the table when discussing funding mechanisms to achieve this. There is also a need for much longer-term financial planning and, probably, some kind of cross-party consensus on management.
The best things about her job, she says, are its variety and the patient contact. She values the social as well as professional interactions of working in a group practice and this view is, thankfully, shared by many of her peers, who do not want to see more of the hospital shift culture in general practice. RCGP First5 is the future of the profession. They have a thoughtful, effective, and clear-sighted leader who can very definitely see the difference between the baby and the bathwater.
DR RICHARD VAUTREY
Richard Vautrey chairs the GPC, the General Practitioners’ Committee of the British Medical Association (BMA), is an elected member of BMA Council and assistant secretary of Leeds LMC. He is an important voice for general practice, and has vital things to say to the profession and to government.
Richard is a GP partner in Leeds, and has worked in the same 10-partner, 14 000-patient practice since 1994. The practice encourages the development of a variety of interests among the partners and, externally, has excellent inter-practice collaboration. The practice manager is a partner. He strongly believes working in a stable but forward-thinking practice base has supported and enabled him to pursue a career in medical politics.
The diversity of the job is what attracted Richard to making a positive decision to go into general practice and he has no regrets. He thrives on the variety of work that he now does, and strongly believes that a well-functioning partnership, embedded in the community with all partners having responsibility for decision making, can be an excellent, fulfilling, and sustainable model of general practice. He strongly rejects the exaggerated claims of the death of the partnership model, while recognising that inter-practice collaboration, with the sharing of expertise, economies of scale, and shared infrastructure, is needed to support it.
Several topics, all connected, dominate the GPC agenda. These are underfunding of general practice, which has led to our current level of workforce, the recruitment, and retention crisis, which, in turn, along with changing demographics, has led to an increase in GP workload to unsustainable levels. This has inevitably caused problems for many practices, which have had to close or have been forced to merge to survive. Major difficulties relating to premises, property, and indemnity are all additional threats, and he points to the imaginative solutions being developed in the new GP contract in Scotland to deal with these issues.
To take these ideas forward, the Department of Health and Social Care has agreed that there should be a review of partnerships to which the BMA and the RCGP will be contributing, and a further review on GP premises is currently being set up. He agrees that GPs need to be better prepared during vocational training to take on the responsibilities of partnership working, but also thinks some of the myths about the difficulties of running a practice are overstated and that many can be dispelled by having strong practice management and effectively learning on the job. Working at scale in the future is likely to be increasingly important and this can range from sharing and networking between good practice managers, through more formalised networks, with shared back-office functions such as HR and accountancy, on to the superpractice model, which appears to be working well in some parts of the country. However, contact with the community is, he believes, essential — ‘the business owner needs to be on the shop floor day to day’, and management must not become remote from the patient population.
He strongly believes that the NHS should continue to be funded through taxation, preferably general taxation rather than an hypothecated health tax, which he thinks is a bit of a red herring. We need to bring our spending on health up to that of other European countries. A cross-party consensus is attractive, but will be very difficult to achieve in our adversarial political system. He and the BMA do not support proposals for co-payments for primary care services. We asked whether Brexit brings any silver linings, and he thinks that these have yet to emerge. The financial uncertainty over Brexit has led to considerable stasis in planning the financial future of the NHS, and is already having adverse effects on recruitment and retention of people from the EU currently working in, or thinking about moving to, the UK.
General practice still has work to do to regain its attraction as a career destination and to reinvigorate the GP workforce with pride and optimism. Richard Vautrey, it seems, is steering us firmly in the right direction to achieve this.
PROFESSOR DAME PARVEEN KUMAR
Parveen Kumar is a Professor of Medicine and Education at Barts and The London School of Medicine and Dentistry, Queen Mary University of London. Chair of the BMA’s Board of Science, President of the Medical Women’s Federation (MWF), and President of the Royal Medical Benevolent Fund. She is also a past President of the BMA and the Royal Society of Medicine. She still regularly sees patients. She is also the well known co-author and editor of Kumar and Clark Clinical Medicine, now in its 9th edition, and remains heavily involved in both undergraduate and postgraduate teaching internationally.
Parveen’s latest book Essentials of Global Health, co-edited with Babulal Sethia, was written in collaboration with medical students from all over the world, and perhaps best frames her view of the current challenges that the medical profession faces. We discussed the problems of an underfunded, understaffed, and inefficient service, and the effect that this was having not only on patient safety but also on the profession as a whole.
Parveen’s real areas of interest were in the progression of disease, the ageing population, and the preparedness of the NHS to deal with this. Her answer? To ‘think globally’. We need to train doctors for the world and the UK is a ‘sterile environment’ in which to do this. The loss of permit-free training has meant fewer doctors can come to work in the UK and we are losing out on the experience and education they can bring to the NHS. We need to send our doctors abroad to learn and bring back ideas and working practices learnt there. Another major factor for disease and health is what the effects of climate change will bring.
Parveen is a strong advocate for electives abroad for medical students. When travelling abroad to teach or examine, she aims to do a ward round with medical students in the local hospital, to learn about different diseases, cultures, and teaching practices. She is a supporter of problem-based learning, which she believes is key to promoting confidence and team working, and integrating clinical time with learning the biomedical sciences. Crucially she believes more clinical time spent in GP practices is needed, which, along with the expansion of academic general practice units, will go some way to improve training and better inform the career choices of our future doctors.
She is passionate about public education and ways to promote public health. Obesity is now an epidemic. Interventions need to start early and, as Chair of the BMA’s Board of Science, Parveen supports tackling the widespread social, economic, and cultural factors that contribute to obesity. The BMA, along with the Royal College of Physicians, the RCGP, and others, is doing this through the Obesity Health Alliance, which has made progress in limiting the sugar content of foods, and junk food marketing to children.
Antimicrobial resistance is taking us back to Victorian times and will have extremely serious consequences. There has been a lack of new antibiotics over the last 30 years or so and new ways of tackling over-prescription have to be developed. In general practice Parveen suggests that the focus should be on diagnostics and the development of point-of-care testing, including in-practice PCR to detect viruses and bacteria from finger-prick testing; this would help to reduce the prescription of antibiotics. Measures also need to be taken in farming and veterinary practices.
Parveen argues that the barriers between integrated primary and secondary care working stemmed from divided budgets with the purchaser–provider split. Is it possible to return to one well-managed but integrated budget centred on the needs of individual patients? It may be difficult, but it needs to be done. She sees the appeal of an NHS separate from party politics, run by a clinically-led board, but worries that the power to demand change will still lie with parliament.
As President, Parveen led the MWF through its centenary last year and has raised its profile, particularly promoting women in leadership and management. Parveen used to disapprove of gender-specific ‘clubs’ but came to realise through her professional work that ‘for all those who succeed, there are hundreds who do not’. There are few women in senior clinical academic roles and women are under-represented in medical politics. The reasons for this are varied but, while some may prioritise family life, Parveen argues that there are many training-grade doctors who are unaccounted for at the consultant level. Overall, there is still a pay gap between men and women in medicine even when doctors who work less than full time are taken into account. There is more work to be done, but having someone so passionate about women in medicine is key to pushing these issues forward.
Parveen describes herself as an optimist but worries about the NHS. However, her enthusiasm is catching and, despite her concerns, she believes that the future lies with new technologies such as improved, faster diagnostics and artificial intelligence. Seeing the keenness of young medical students and doctors, she is confident the medical profession will flourish in their hands, as long as politicians and the public allow them to care for their patients with appropriate help. Medicine remains a fantastic profession!
PROFESSOR CHRIS HAM
Professor Chris Ham CBE is the Chief Executive of the King’s Fund — the health think tank and charity working to improve health and care in England. He has degrees in politics, was professor of health policy and management at the University of Birmingham, and was seconded to the Department of Health as Director of the Strategy Unit until 2004. He has directed the King’s Fund since 2010. He probably knows more about the NHS than almost anyone, and is an extremely articulate guide to its problems and possibilities.
The NHS, he says, is at a crossroads. This is recognised at the highest levels in politics and a significant announcement on the future level of spending that will be committed to the NHS is expected at the time of its 70th birthday. There is a need for a long-term, year-on-year commitment of an extra £4 billion for the health service, along with plugging an annual £2 billion funding gap for social care. A funding commitment for the next 10 years is also required. This should not be impossible given the improving state of public finances, despite the financial uncertainties generated by the Brexit negotiations. There is, he recognises, a public appetite for a health tax of some kind, but he is firmly against the introduction of co-payments for medical services.
Indeed, Chris Ham is an optimist about the future of the NHS and takes a good deal of encouragement from his observations of innovation following the publication of the Five Year Forward View. There are good examples of the success of both the Primary and Acute Care and Multispecialty Community Provider models of working across the primary–secondary care interface. In Greater Manchester new resources did not simply vanish into the black holes of trust deficits, but were used more widely and more creatively in community services. Salford and Central Manchester trusts are pooling resources to support the struggling Pennine Acute Trust, for example. Wolverhampton GPs facing recruitment and workload difficulties approached their acute trust for help and support, finding that their problems could be greatly eased by the trust employing GPs as consultants. Innovation, heterogeneity, and locally effective solutions are critical, but crucially they require an earmarking of funds, set aside to resource new care models.
Ham firmly believes that general practice has to be at the heart of these new models of care, but not necessarily as we at present understand it. The practice–partnership, the list system, and continuity of patient care remain central, but we will see increasing inter-practice collaboration, from three or four practices working together, for example, to provide a rota for same-day appointments, to involvement in more formal networks or federations of practices with economies of scale, clinical cover, and unified back-office functions. He agrees that the partnership model, or at least a form of it, is important to provide professional variety and a rewarding career structure to aid GP retention. New professional roles and ways of working will also be important, and the King’s Fund will be reporting on this topic soon.
Perhaps most important of all, and another major agenda item for the Fund, is the relationship between the public and the NHS. Chris Ham believes that, at least in part, the future of the health service depends on identifying and redefining the compact that will exist between the NHS and the public in the years ahead.
- © British Journal of General Practice 2018
