The best laid plans ‘o mice and men gang aft agley

I was at Roy Lilley’s Health Chat, King’s Fund last Monday evening, 100 very well informed primary care folk, very few of them sticking to Dry January, all having fun.

Airy predictions are doing the rounds of “a minimum 50,000 patients in primary care units” of the future.  It’s all new models, MSCPs and PACs.  It seems I’m the heretic for asking “Why?”, and “How will they work better?”

Three key numbers:

  • every day 12 times as many patients visit GPs as go to A&E
  • the cost of one A&E visit at £114 is greater than the annual cost of GP care per patient
  • over 95% of patient presentations to GPs are resolved within primary care.  That’s an astonishing achievement for medical generalism.

Excuse me for pointing out, as a taxpayer, that the obvious priority for investment is in primary care.

Clare Gerada entreated us to think not about structures but about the function of GPs, what they do, and at its heart GP-patient relational continuity.  Hear hear.

Everyone who cares about the NHS should read the evidence from Uni of Bristol studies, “Seeing the same GP at every visit will reduce emergency department attendance”

Let’s see how NHS England planning guidance 2015/16 incorporates the evidence.  You don’t have to stay awake through 27 pages, and I cheated by doing a word search, but the picture emerges:

  • 55 mentions of “patient”, good, 0 for “doctor” but 10 for “GP” and only 3 for “consultant” (like that)
  • 6 for “targets” and 14 for “standards”.  Now here’s the rub:
  • 0 for “relationships” and 0 for “continuity”

Are we measuring what matters?  And if we don’t, is it any surprise that we get surprises?  No one planned the A&E crisis, the headline grabbing target breaches, questions in parliament.

No one, as far as I know, has evidence on how the size of primary care unit affects outcomes, yet this is central to design.  Form follows function.  Continuity is more difficult in larger units, that’s a mathematical certainty.  Do other benefits offset?

It’s an urgent research question, and I put it to EFPC, the European Forum for Primay Care, of which we are members.  Do get in touch if you want to help us investigate.

Until we have better answers, we’ll have to agree with Burns (celebrating 256th tonight),  “The best laid plans o’ mice and men gang aft agley”


Dr Sara Cowell
Founder, Chief Executive
Dot Community Health Ltd

PS do watch the excellent new RCGP video attracting trainees to GP, all about continuity and relationships.

PPS several GP groups have been in touch with us since last week, applying as vanguard sites for New Models of Care.  With the deadline approaching on 2/2/15 it’s worth getting your EOI in pdq.

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