Form follows function, or fails the purpose

Dr Mike Bewick, Deputy Medical Director of NHS England, calls for primary care organisations covering 300,000 patients staffed by salaried GPs, as reported in Pulse.  He claims, “in 10 years’ time the term independent contractor will be anachronistic and probably it will be gone.”  Now Andy Burnham has joined in calling for predominantly salaried GPs working in large health and social care organisations, run by hospitals.

Why?  What is the evidence of better outcomes for such a complete change of form in UK general practice?  Primary care takes many shapes around the world, and no one claims to have the final answer for all time everywhere.  But form is bound to have an impact on function, and if function, or rather purpose, is not properly understood and measured then there is no way to judge forms.

The debate has little to do with the clinical work of GPs, and everything to do with how they are organised.  Let’s instead look at what works, from the point of view of the patient, the weight of evidence, and the motivation of doctors.

  • Local and accessible, a pram push from home
  • Led by GPs, trained as generalists to the highest level
  • Whole person, GPs giving definitive care in over 95% of consults
  • Long term committed, for continuity of care
  • Relational continuity, more than merely information and management.
  • “I can easily contact my own family doctor”.  If only everyone could say that!

Just a little of the evidence:  Relational continuity is linked with lower hospital admissions, BMJ, and the same is found in USA, smaller practices 33% lower admissions, AAFP.  While Chauhan showed the link between choice of doctor and lower referrals.  Around Europe, everyone wants to be more like the NHS in primary care.

The purpose of general practice is unchanged: safe, effective and efficient primary care. It is the bedrock of the NHS, judged the best health system in the world. The function can and should be improved, but it does not follow that “The current organisational structure of primary care is no longer sustainable or, increasingly, desirable.”

Dr Bewick goes on to say that partnership is unattractive, as salaried positions multiply. Most of those positions are within partnerships, so the form is unchanged.  True, partnership has become relatively less attractive for some versus salaried status.  It does not follow that this is beneficial for the system.  It is the effect of a relative decline in partner incomes over  five years, an issue of funding, not of structure.  It is not for me to address GP incomes, but we do have evidence that funding relative to patient demand (driven by deprivation and age) should have a greater slope.

We have evidence on the value of continuity both for patients and GPs from over 140,000 submissions at individual patient and consultation level.  We know that continuity matters in nearly half of consultations in the GP view, and a similar proportion in the patient’s view.  When patients have a realistic chance of choosing a doctor, this rises from 42% to 56% (see the presentation to EFPC on understanding demand).  Further, we know that larger practices find it more difficult to achieve continuity.  The maths is against it - there is less chance of matching a patient with the same doctor each time.  We have worked with a wide range of sizes and forms of practice, and we see the same effect consistently.

The independent contractor model of general practice is not broken.  Any attempt to change it must be based on evidence of benefit, of which there is none.  Larger forms will lead as night follows day to:

  • Lower relational continuity
  • Less long term commitment from GPs to one place
  • Worse clinical effectiveness, and therefore
  • Higher costs

I’m not clinging to the status quo.  I’m arguing for better, a pragmatic, evidence based, determined improvement in what we already have,  The rest of the world would give its right arm to start with our proven model of independent, innovative, proud and professional GPs.  Treasure them.


Dr Sara Cowell

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