In July we celebrated the 70th anniversary of the NHS and a number of us pointed out that within the NHS, Bevan had had to create very different models of care. Whilst nationalising a variety of different organisations to create a single system of NHS hospitals for secondary care, he developed a different organisational system for primary care.
To get GPs on board he agreed that they could develop an organisational structure based upon a small business model. GPs set up their own small private sector organisations, and these ‘practices’ competed for NHS patients. During the 1950s and 60s GPs improved their income by succeeding in that competition.
The small business model – GP owned practices – thrived as the model of primary care and became the main ‘jewel in the crown’ of the NHS. When we compared the NHS with other international health systems, this universal system of registering patients with these small practices, provided the primary care system that was one of the things that made the NHS special.
Over the next 70 years we came to think that this model of primary care was the only model of primary care. So any problem with this particular clinician-owned small business model version of primary care was seen a problem for primary care itself – rather than just one model.
This is not an unusual historical experience. After all this way of organising primary care is the only one that most of us have experienced. When I went to see my GP in the front room of his house in the 1950s it was the only experience of primary care that existed. When my Dad was ill in the 1980s a different GP came from the same house to see him.
Medicine has changed many times during the lifetime of the NHS and nowadays the norm is for many more diagnostic tests to be made for GPs to be able to carry out their work. But small GP practices find it difficult to possess all that equipment, so these days a major patient experience is of going from GP to hospital and back to GP before a diagnosis is made.
That’s three visits for the patient and two for the GP.
But the primary care model of small business owned by a GP mitigates against them owning all that diagnostic equipment. It’s the model that has problems, not primary care itself.
In addition, over the last ten years, this model of primary care came under increased pressure from the demand from sicker older people – we became worried that primary care would not survive. In reality the problem was once again for a particular model of primary care.
If, over a 2 year period, a small organisation of 3 or 4 people experiences a 20% increase in demand for their services, they will find it difficult to find the slack or to reorganise resources to meet that extra demand. Whereas an organisation with say 400 staff will have more flexibility to reorganise itself to meet demand.
So many GPs have grown up with this small business, clinician-owned, primary care model that they almost inevitably see it as the only one. The GP profession might feel that if this model were to go then primary care itself would be under threat.
But a recent survey of trainee GPs calls this view into question.
This summer the Kings Fund conducted a survey of GP trainees working intentions and found a fairly consistent rejection of the current model of care. Only 21.7% of GP trainees planned to work as a full time GP a year after they qualified, and this fell to 5.4% five years after qualifying. Only 37% planned to become GP partners. This is a pretty astonishing and fairly complete rejection of the current model of primary care.
As with many of their generation, young GPs want to work by developing a portfolio career. The idea that at 30 the only future for your medical skills is to become a part of a practice and, in owning that practice stay there for the next 30 years is a million miles from their expectations and desires. They mainly want to engage in a number of different medical activities including research and education. The current practice-owning model of primary care makes that harder and many reject that.
This lifestyle set of choices is not a rejection of primary care but it is another strong rejection of the current model.
And of course what makes change all the more likely is that across England some GPs are beginning to organise themselves very differently. A few have developed ‘super’ practices where, taking significant workload off GPs, they have employed some very significant additions to the primary care team. In others strong organisations have been formed which carry out the same function as the super practices – limiting the autonomy of the small unit – but without changing the ownership model.
Given that we are now seeing alternative models of primary care actually working in our midst, it’s getting harder to claim that the demise of a 70 year old model would signal the end of primary care.