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Professor Roger Jones, Chair of the RMBF, looks at how developments in the UK compare with general practice elsewhere in the developed world.
Q: In the early days of the NHS, GPs were often sole practitioners or family practices, operating from their home. Now group practices in medical centres are the norm, with the idea of new build polyclinics being hotly debated. How does this compare with provision elsewhere in the developed world?
A: Group practice is the norm in the UK but isn’t necessarily typical of general practice internationally.
Although group practices exist in northern Europe, southern Europe, Scandinavia and north America, solo practice is much more common in these countries. For instance, in the Netherlands, Germany and France, GPs more often than not practise solo, although there are health centres and arrangements between individual GPs to share facilities.
Medium-sized practices (four to six GPs) are more common in the UK than in any other developed country.
Q: Is there any evidence that size matters, for instance that the size of practice has any impact on the quality of clinical care, patient satisfaction or cost-effectiveness?
A: My observation, primarily from the UK, with some observation from the US and Europe, is that it is very difficult for a single-handed practitioner to provide the range of services patients now require in primary care, such as chronic disease management in nurse-led clinics, or the therapies that often find a natural place in the larger group of doctors.
Most importantly, it is difficult to provide alternatives for patients. Although continuity of patient care is usually seen as helpful, there may sometimes be problems about having to see the same doctor every time. From a professional point of view, it is difficult to see how a single-handed GP can be comfortable with all the material presented. We all spend a lot of our time asking our colleagues for advice and tips, either informally or formally, so I personally find single-handed practice wanting in a number of respects.
That isn’t to say that there aren’t some great single-handed doctors around. If you look at quality markers such as the QOF and at patient satisfaction surveys, there isn’t any real evidence that single-handed practices are doing less well – although patients tend to be satisfied with the treatment they’re receiving, perhaps because human contact with any GP compares favourably with the more impersonal treatment in many other organisations these days.
Q: Primary care and general practice are almost synonymous in the UK. Is this true of the rest of the developed world?
A: No, in many countries they’re not synonymous. For example, in areas such as eastern Europe, and to an extent north America, first-contact care is provided by specialists. The polyclinics in the former communist countries were the places where specialists gathered together to provide first-contact care.
The gatekeeper role of GPs is also particularly strong in the UK. It is almost impossible to see a specialist in the UK without going through your GP, whereas in countries like France it is normal for people to see a specialist as the clinician of first contact.
Some of this is to do with the robustness of training for general practice, the need to train as a ‘specialist’ in general practice – which is the case in the UK, Canada, the US and Scandinavia but isn’t the case in other European countries.
Q: One person I interviewed recently commented, “I used to know my GPs well and they knew me. These days I often end up seeing locums. The relationship isn’t the same as it was before.” Are you aware of any evidence that continuity of patient care has reduced in recent years and, if so, of any effects this may have had?
A: There is evidence of less continuity of patient care. This is partly due to changing patterns within the primary care workforce and to GPs having other interests, with a portfolio approach becoming more common, possibly developing a special interest or working part-time while bringing up children. These are all appropriate and understandable but inevitably lead to an element of discontinuity in patient care. It is less common to see GPs go into the surgery for seven sessions a week than it used to be.
Some patients are prepared to trade continuity for convenience. Walk-in centres attract a certain clientele who don’t need to see the same doctor. Indeed sometimes patients may prefer to see a doctor they don’t know about some issues, for instance relating to a marital problem, a substance problem or a sexual problem.
However, for many patients and doctors continuity of care is a good thing. It enables the doctor to understand much better the context in which new things are happening, including family and social and psychological factors, which seems to me essential if you’re to make sensible decisions about treatment, investigation and referral. An out-of-hours call by a doctor who knows the patient is likely to be much more helpful than a call by a doctor who doesn’t know the patient or their circumstances.
That’s not to say that after 20 years you might not become somewhat blind to new things, and sometimes the relationship can become too cosy. In two or three group practices I’ve taken over lists from retired doctors. Most of the notes indicated a good quality of care but it wasn’t difficult to pick up an element of ‘going through the motions’ and doing a minimum with some patients, keeping the lid on some problems that might have rocked the doctor-patient relationship. So people just came in and had their blood pressure taken whereas, in the background, there may have been other problems that weren’t addressed, because they didn’t quite surface within that comfortable relationship that had developed over 20-30 years.
So I can see the downside of seeing the same doctor all the time and getting into such a comfortable groove you can’t really talk about anything.
Q: How primary care is financed seems to vary from country to country. What are the main models and which countries best exemplify them?
A: The small business model we have in the UK, where you become a fully-fledged partner/shareholder in the practice and the property, is fairly unusual. The positive side of this is that there is an incentive to continue to improve patient care and to maximise income and the two things are often interrelated.
In many countries GPs are simply employed by the health authority or the state to work in premises they have no interest in and with staff they don’t control. The UK GP partnership model is pretty unique.
The capitation system for GPs was also quite unusual in that it rewarded numbers of patients in the lists, whereas in other countries GPs tended to be rewarded for doing more things for patients (which may not always be a good thing, as it can encourage unnecessary investigation and treatment).
There’s no billing system in the UK (whether paid by patients or insurance). So there’s less pressure from patients wanting their money’s worth. Where there are billing systems you often don’t see the doctor until further down the line, after nurse-led examinations and tests.
Q: Where there is a strong private sector involvement in primary care, what have the pros and cons of this approach tended to be, in practice?
A: I’m more familiar with the pros and cons in north America than Europe. When an HMO or private health organisation works well, it can work very well. Kaiser Permanente is often cited as an example. It is famous for valuing its employees, for breaking down primary/secondary care barriers and for providing a very good standard of care. However, this may be due in part to their serving relatively affluent and healthy populations. There are still 30 million Americans without health insurance.
One problem in the UK is ensuring decent premises for urban practices. Providing better facilities through private sector involvement may be no bad thing. My concern obviously is the extent to which the profit motive may dominate.
From an academic angle, a possible concern is that private new builds and polyclinics will exclude the role of the GP in undergraduate education and research, and these will be squeezed out by the need to make money for shareholders.
Pressure to maximise profits could also affect decisions in areas like prescribing and commissioning operations. I’ve heard it reported this may already be happening in the three Camden practices which were taken over by a private company who undercut everyone else’s bid (although NICE guidelines and other clinical practice guidelines should help GPs defend their basis for clinical management).
Conversely the need to attract and retain patients to achieve profits could encourage good practice and a more patient orientated approach.
Q: Where state provision is the norm, what have the advantages and disadvantages tended to be?
A: The ability to promote and guide professional change, which couldn’t be obstructed by claims of independence and clinical freedom, is a potential advantage. In the UK there has always been very uneven provision. There have been great GPs and there have been awful GPs. It has been notoriously difficult to address this. GPs have often been very unwilling to acknowledge there has been a problem and to do something about it. We have traded on our independent contractor status, probably to our disadvantage, over the last 20 years. Governments have the potential to set standards and bring about change more quickly than, say, the RCGP. A more uniform system would have some advantages in a sector currently made up of independent contractors.
However, really good practices were already there. When the QOF came in, for instance, there were many practices who didn’t have to do anything to score maximum points – they were already way beyond QOF.
And too much government intervention can undermine commitment. There used to be a real pride in the NHS among doctors, which led them to work much harder to get the job done. That is going. The understanding and appreciation of what the NHS is and the commitment to it are shrivelling. Among junior staff the move to shift work is another factor here and is an example of a further unintended consequence of de-professionalising doctors.
Q: The balance between primary and secondary care varies from country to country. Where does the UK sit within the overall spectrum?
A: It is difficult to generalise about this. In the US for instance, ready access to specialists has driven up the cost of care enormously and encouraged more defensive medicine, to reduce the risk of litigation. However, in France, unregulated access to specialists has produced no significant differences compared with the UK in terms of cost or health outcomes. This suggests that differences in the overall structure of care, in themselves, may not make a big difference. It seems to depend more on the context.
Here in the UK we shouldn’t be complacent, for instance in relation to cancer survival rates and the implications for earlier diagnosis and early recognition of serious diseases that GPs may not be as good at as they may think. In Australia, for example, primary care postgraduate exams are pretty tough and a higher premium is placed on clinical skills – the ability to make diagnosis, to look after the complex patients, and so on, possibly more like work in a polyclinic or a GPSI.
Communications skills and interpersonal skills are important but might we have overemphasised them? When I did the membership exams for the RCGP there was nothing clinical in it. I didn’t have to see a patient. I didn’t have to demonstrate that I had clinical acumen. It was all theoretical. I’m not sure what the situation is now but that is how it used to be.
Q: Is there any evidence that a strong primary care system, relative to a greater reliance on hospitals, has advantages, for instance in relation to access, cost or clinical outcomes?
A: Professor Barbara Starfield’s research some years ago suggested that a stronger primary care system produced the same health outcomes for a lower proportion of GDP. There is a consensus that there is that effect.
However, I’m not sure this is going to remain true. The effect is already reducing across Europe, as there isn’t much difference now between GDP expenditure on health. Across many countries in Europe the figure is 8-9% of GDP, suggesting that different systems cost pretty much the same in practice.
Q: In what ways have changes in primary care in recent years changed the role of GP principals and how positive (or not) have these changes been?
A: If you’re on your own, or in a small practice with not much support, it must feel uncomfortable to be expected to do a lot more chronic disease management and a lot more paperwork, which is difficult to delegate in a small practice. In a well-managed larger practice, some of this can be appropriately delegated to other members of the practice team, thereby sharing the problem.
The changing population we treat is also changing us, particularly in inner-city practices. Patients may come to us with very different perceptions of medical practice – for instance expecting the reassurance of seeing doctors in a white coat and not being sure how much confidence to have in someone more casually dressed; or seeing some symptoms as potentially more dangerous if they come, for instance, from countries where fever could indicate malaria, diarrhoea could indicate cholera, and so on.
I don’t think the core job has changed. What has changed are the bits around the core job and also how GPs organise their work depending on their outside interests and commitments.
Q: Some recently qualified GPs seem to be finding it hard to find posts in primary care. Why is this and how do you see the situation here developing?
A: Yes, this is a problem at the moment. I suspect this is cyclical. The star of general practice rises and wanes. If you were to go back ten or so years there was great difficulty attracting GPs to London.
At present, incomes are high, even for salaried GPs, and general practice is an attractive medical career option, whereas hospital medicine is looking less attractive to some people (for instance, in London, with peripheral hospitals being looked at very carefully and the possibility of ‘superhospital’ mergers).
You may need to think carefully about what you need to do to get a partnership and take a year or two or three to develop skills which GP partnerships are likely to find helpful, like very good IT skills, the ability to get useful data out of the system and certain clinical skills, perhaps endoscopy and dermatology. Teaching and research are also areas people can get involved in.
Q: The UK isn’t the only country in the developed world where changes in primary care have been taking place. What sort of factors are leading governments to review how primary care is provided?
A: Cost is a big factor – the inexorable rise in the cost of providing a medical service has led many governments to look at the role of GPs as gatekeepers. Improving public health is another significant motive.
Hong Kong, mainland China, Japan and a number of south American countries have all given priority to the development of primary care.
Q: To what extent, as far as you can see, are government proposals for change in primary care in the UK based on sound evidence (including evidence from comparable countries)?
They are not strongly evidence-based. A lot are pre-existing policy. For instance, there was a conference for architects on polyclinics long before the Darzi report came out. The concept of polyclinics has been in the mind of government for years.
I applaud the Darzi report for looking at inequalities in health provision and outcomes but it is naive to assume polyclinics will solve all our problems. In areas where provision is poor, a nice building with good management could help, but where group practices are working well, as in North Lambeth, why go for polyclinics?
Putting patients closer to investigation doesn’t necessarily help diagnosis. It may just flag up abnormalities which have nothing to do with the problem the patient is complaining of.
Q: From your research and experience over the years, if the government could do three things to improve primary care in the UK what would you recommend they do?
First, give CCGs more powers to support and develop group practices of five to eight doctors, so that there is a critical, clinical mass of GPs and other primary care professions. Try to avoid tiny practices. This could save money and improve services.
Second, try to re-establish respectful and creative relations between primary and secondary care, so that we could go back to some of the good old days when GPs and consultants looked together at the health needs of the patient and planned together. Payment by results for hospitals and practice-based commissioning arrangements in primary care are hindering this.
Third, provide incentives for groups of GPs to participate more in out-of-hours work, at least in the first 10-20 years of work as a GP, to develop and maintain critical acumen. This isn’t learnt to the same extent between 9 and 5, dealing with patients who tend to be less seriously ill. In terms of relations with the public and professional colleagues, we made a big mistake by shrinking back into 9-5 workers.
Professor Roger Jones is Chair of the RMBF, Editor of the British Journal of General Practice, Emeritus Professor of General Practice at King’s College London and Provost of the South London Faculty of the RCGP.