Can you visualise primary care as an ecosystem? Gerald Durrell once described great ecosystems as:
‘… complex tapestries — a million complicated threads, interwoven, making up the big picture’.1
This is certainly what I see when I picture primary care as a system of diverse but interacting general practices, all connected through common goals. But this is an ecosystem in danger, whose foundations have been battered by underfunding, a recruitment and retention crisis, and a pandemic that has changed the nature of access and how we work with our patients.
In the depleted landscape of primary care, what needs cultivating and what should be left alone? How do ecosystems find their shape and natural form? In his book Feral, George Monbiot argues that nature responds when we stop trying to control it and proposes steps we can take to rewild ecosystems, an analogy Iona Heath discussed here in the BJGP in a previous editorial about rewilding general practice.2,3 In health care, what fences can we tear down? What can we cull back, and what should we introduce back into the ecosystem of primary care?
Rewilding is about letting nature take care of itself, but it is not just about doing ‘as much nothing as possible’ as per the House of God’s thirteenth law.4 It is a process of recovery. NHS England has recently published a delivery plan for recovering access to primary care, which is an attempt to better manage primary care systems through improved triage, digital solutions, self-referral, and capacity building. In this issue, Mark Ashworth and colleagues describe primary care as a national asset, and they are right. However, the value of primary care is too often undersold, and investment in the system has not matched what is needed to keep it afloat. The primary care ecosystem is nothing without the beating heart of its workforce, and what general practice now needs is substantial investment through the promised NHS workforce recovery plan.
Ecosystems can be managed, and mismanaged. This issue of the BJGP looks at systems within primary care through a variety of lenses, including the impact of general practice closures, patient online access to records, skill mix and the multidisciplinary team, continuity of care, and pathways for diagnosis. With its millions of complicated threads, primary care is a rich and diverse tapestry, and can be a thriving system. What is needed now is a period of active recovery and a plan for how to sustain the essential ecosystem of this cornerstone of the NHS.
This month, the focus is on primary care systems. General practice closures are concerning, and Hutchinson et al look at the consequences of closing practices on neighbouring practices and patients. It seems that plans for patients to get prospective online access to their records are going full steam ahead, and Davidge et al describe the cultural shift that clinicians are going to have to make as the purpose and function of the primary care record is transformed. Faecal immunochemical testing has increased dramatically in the past few years, and the Clinical Practice section covers its use among symptomatic patients and how to deal with negative test results. |
- © British Journal of General Practice 2023