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What are the alternatives? 

What are the alternatives?
What are the alternatives?

Steve Iliffe

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Primary care is in crisis. The behavioural and economic evidence is ubiquitous. Patients are voting with their feet and pocketbooks by going directly to emergency departments and specialists. After promoting primary care as the manager of access to specialty care, health maintenance organizations have backed off their gatekeeper strategy for such referrals … Incomes of primary care physicians have decreased, and insurance companies are stripping payment for some types of primary care services out of benefit packages. Primary care residencies fail to attract enough applicants, while teaching hospitals continue to withdraw much-needed support for their primary care clinics. Despite primary care's proud history and theoretical advantages, the field has failed to hold its own among medical specialties.

Gordon Moore & Jonathan Showstack, Annals of Internal Medicine (2003)1

This dismal story is not confined to the USA. Only a quarter of Canadian medical graduates are choosing family medicine as a career,2 and the Canadian healthcare system may not be functioning in its present form in another decade if the current difficulties in filling family medicine residencies continue.3 In Sweden recruitment to general practice needs 30% of medical students to choose this career, for the discipline just to stand still, but the current trend is for only 17% to opt into primary care.4 A debate on the future of general practice in the Medical Journal of Australia in 2004 began with a vignette about a fictitious, undervalued, disempowered GP, Dr Zen, working in the year 2020 in the fully industrialized world of Australian general practice. ‘Regulation had reduced Dr Zen's role to pushing buttons to answer questions in an evidence based computerised diagnostic pathway. Tired, she could spend only 5 minutes with a patient. Longer consultations were punished by pay reductions. She aspired to become a taxi driver, which would provide her with the opportunity to talk to customers’5

In Britain, and probably in Holland and New Zealand too, general practice is less beleaguered. Our gatekeeper role still stands, our engagement in chronic disease management has increased, our public health role is expanding, our incomes have risen, recruitment to the discipline is healthy, postgraduate education is rich and flourishing. The industrialization process, for all its vicissitudes, creates many opportunities for enthusiastic doctors to innovate and experiment. We can still worry, of course, but perhaps this is a necessary counterpoint to the easy and superficial optimism of health service reformers: ‘there is a real danger that we will create a flat plurality which irons out diversity: a featureless, visionless and unimaginative profession’.6

Uneven development

What I hope this book demonstrates is that the components of industrialization that were apparent in the incorporation of the engineering profession in the USA into industry at the beginning of the twentieth century are visible in the working experiences of British general practitioners (GPs) one hundred years later. General practice is being industrialized into primary care, but the different components are developing at different rates. Evidence-based medicine has entered the mainstream of medical thinking rapidly, perhaps because of its modification by the different interest groups that have found it useful to achieve their own objectives. Medical management remains a minority activity among GPs, although every practice is slowly being drawn into a soft bureaucracy that will shape its performance over the coming years. The specialization and skill transfers that are needed for forward integration are underway, albeit on a small scale, while mass production methods of working have been established in every practice, and seem likely to expand in their reach and impact.

All of these components are influenced and modified by professional responses. GPs are unlikely to become serfs. The risks of industrialization are evident and widely debated, perhaps more than the benefits, and the experience of the industrialization of general practice to date is full of examples of resistance to or modification of externally imposed changes. Fears that patients or professionals are being turned into things—the process of reification—are part of the pervasive anxiety of market societies,7 and fit alongside the public preoccupation with risk. We have no need to fear that either markets or ‘command and control’ hierarchies will obliterate the individuality of people as patients or of GPs, because there are always ways to subvert and resist overweening power. Rudolf Klein's aphorism describing the way the NHS works remains true: ‘The captain shouts his orders and the crew carries on as before’. The only qualification to this is the impact of financial incentives, which do change the way we organize ourselves and our practices, delegate work, and see patients. Gaming aside, the net benefit seems to be an improvement in the quality of clinical practice.

Chaos or coherence?

Although we may experience the changes occurring in general practice as chaotic, there is more coherence to them than appears at first sight, and there is also evidence of joined-up thinking in the National Health Service (NHS) leadership. The first phase of industrialization was a failure, but its lessons appear to have been learned, particularly about the inability of competition to preserve equity or promote efficiency, as well as the proliferation of low trust relationships.8 NHS managers now approach general practice with a variety of governance methods, the pace of change is adapted to local settings, practitioner expertise is drawn into management, and skill transfer is promoted. Clinical governance, evidence-based medicine, forward integration and mass production work methods do fit together into a huge policy jigsaw, even if we cannot see the picture (because we are in it). The pessimistic assessment of Alan Maynard9 that ‘… Governments swing from one unevaluated structure to another, ever reluctant to evaluate, learn and improve …’ looks completely wrong when the reform of general practice is seen through the lens of industrialization. It is difficult to see how or why this multifaceted process would be reversed, in the absence of an alternative approach to organizing primary care that is as complex as the current thinking about clinical governance.

There are three lessons that I think we need to consider when responding to invitations to participate more enthusiastically in practice-based commissioning. The first is that GPs as a whole are adaptable and are willing to trade-off managerial control against clinical autonomy, relinquishing some of the former to retain as much as possible of the latter. What is not clear is how far these trade-off's can go, and where the limits of the non-negotiable are in clinical autonomy. Dr Zen is a caricature, but her desire to retrain as a taxi driver tells us that a line has been crossed. At the moment my computer challenges me if I prescribe ciprofloxacin, and suggest an alternative within our local ‘top ten’ list of antibiotics, but I can over-ride this without difficulty, discomfort, or threat. How would I respond a call from the pharmaceutical advisor as acceptable to my sense of professional competence and autonomy, on each of the (rare) occasions when I prescribe outside the local formulary?

The second lesson is that the economic organization of general practice favours local adaptability but leads to conservative decision-making about investment, and this in turn encourages government to seek market solutions when seeking to accelerate the rate of change in the health service. It also means that the practice economy has more influence on the behaviour of practitioners than professional imperatives, with the result that we behave as a group more like Le Grand's knaves than his knights, systematizing the care of long-term conditions only when financial inducements are introduced. Professionalism functions here as a catalyst or test-bed for innovation by a few adventurous or academic practitioners, who develop and test ways of systematizing care or changing clinical practice that can be later deployed for the majority within a modified general practice contract. This conservatism is a problem for us, for when our ability to contain demand decreases, as it has done so dramatically in some specialities, we do not have to hand mechanisms for correcting this, and simply seek extra resources. The escape route from this situation that preserves some elements of managerial and clinical autonomy is probably through practice-based commissioning rather than through salaried status.

The third lesson is that our place in the public domain, which has grown so secure during the second phase of industrialization that we are as a discipline closer than ever to the public sector, means that we are instinctively antimarket (except for a few real entrepreneurs). While this is an antidote to the kind of reforms that put our North American and Australian colleagues into direct competition with specialists, it is a problem for us if we persist with an unmodified dependent contractor status. Challenges from external providers and incentives that count towards a growing proportion of practice budgets—Marquand's ‘market mimicry’—are likely to be effective in reshaping general practice into primary care, with our sometimes grateful acquiescence. ‘To hell with the market’ is therefore unlikely to rally much more than empathy, while ‘to hell with the type 2 market’ is too arcane to catch on as a battle cry, even though it is likely to be the principle that the majority of GPs follow in practice.

Four challenges

There are four big challenges to general practice that are emerging during industrialization.

The need to specialize, which is held back by the conservative nature of investment decision-making

To regain control of the gatekeeper function primary care needs to deploy specialist skills further forward than at present, not necessarily by performing as specialists but by employing or deploying specialist expertise in the community setting through the mechanism of practice-based commissioning. This will also be necessary if market competition increases, although the package of skills may be different. The appearance of a ‘general practice with a special interest’ in ENT medicine and dermatology is long overdue, and there is a need for rapid enhancement of GP skills in these domains; claims to be able to manage uncertainty are hollow when outpatient clinics are overfull with patients who could easily be managed in primary care. Imaging and possibly endoscopy need to move nearer to practices, and right into the larger ones, so that echocardiograms, ultrasound examinations and screening for gastrointestinal tract diseases can be carried out rapidly outside hospitals. Physiotherapy and podiatry on-site will improve the quality of personal care delivered to patients, with the potential for a positive feedback effect on GP knowledge and skills. Truly innovative practices will bring welfare benefits advice and social care assessment under the umbrella of general practice as well, just as they have already done with counselling.

The weakness of our arguments about having a psychosocial perspective on health and illness

The claim that GPs understand and respond to health and illness in biopsychosocial terms is repeated in recent statements10 about the future of general practice, but the evidence for it is thin. We are much more likely to be able to describe the consequences of cytokine release than those of youthful oppositional culture on future individual well-being or of transference on the doctor–patient relationship. We are lodged firmly within a medical model and so promote exercise as therapy well beyond the evidence of its effectiveness while not employing welfare benefits advisors despite the evidence of gain that they bring to ill and vulnerable patients. The lack of our grasp of the sociology of ‘high modern society’ is obvious from the responses to consumerism cited in Chapter 7, despite the huge but almost entirely segregated body of knowledge within medical sociology. Psychology is more of a problem, for there is no relevant, reliable, and predictive model of individual behaviour that applies to everyday clinical work.11 The best on offer are the Balint approach, a growing interest in ‘narrative’ and a handful of techniques beyond basic communications skills—modified cognitive-behavioural therapy, motivational interviewing—that some interested practitioners learn and try to employ. The Balint approach is no longer fashionable, perhaps because of its reliance on psychodynamic models of emotion and behaviour that fit uncomfortably alongside quantitative science. This may be our loss, for not only does it shed some light on interpersonal relationships but also (and unusually) talks about the pleasure of working in general practice, claiming as its essential nature:

to add to the pleasure, satisfaction and competence of doctors in their ordinary work. The aim is not to teach a specialty … but to leave these specialties to the specialists. The aim is to get to the heart of the matter with GPs whose burdens are great and whose satisfactions can sometimes be hidden because adequacy continues to be measured, both by GPs and patients, in terms formulated by specialists.12

One of the objectives of our professional body and of academic primary care might be to develop the theoretical basis and educational responses for a truly biopsychosocial model of general practice, but until that happens we should be cautious in our claims to ‘holism’.

We already have the beginnings of a theoretical basis for a truly generalist perspective, in a synthesis of epidemiology, sociology of health and illness, and in (an admittedly underdeveloped) social psychology of modern societies. We can understand why some become ill while others do not, and express this as in terms of the life course, as the Figure 8.1 shows.

              Fig. 8.1 The development of heterogeneity over a life
                course (modified from Hertzman et al 1994i)

Fig. 8.1
The development of heterogeneity over a life course (modified from Hertzman et al 1994i)

In this model health is seen as being determined by factors like socio-economic status, genetic predisposition and social environment and being modified by sources of heterogeneity, over a life course with discernable stages.13 The factors on the vertical and horizontal axes of the matrix interact throughout life, changing the health status of the person and creating individuals who become increasingly different from each other as they get older. The older population is heterogeneous in ways that the diverse population of children is not, because more interactions have accumulated over time. This model can be used for populations and for individuals, and can be applied to the consultation as well as to the commissioning plan.

The consumerist challenge and the relative weakness of general practice in engaging with the public need to be addressed. The strategy of public engagement that the NHS is using could be the beginnings of a serious attempt to correct the health service's ‘democratic deficit’, and to create a bulwark of participatory democracy against the rise of individualist medical consumerism. Much of current public engagement remains tokenistic, and there is a risk that it will stay that way, making primary care vulnerable to consumerist challenges. Wise GPs will think about the ways in which they can add different methods of public engagement to their routine work, without overloading themselves and their teams with yet another difficult, time-consuming task. This is another area of weakness within general practice where much work remains to be done, perhaps through the application of community development methods14 or COPC approaches.

The most evolved methodology for making public involvement central to service development appears to be community oriented primary care (COPC). COPC is a model of health service development which integrates public health and primary care in order to deliver targeted prioritized services to a defined population. It is an investment in the community that can reduce the ‘democratic deficit’ between public services and their users.15 COPC is a method of planning, implementing, and evaluating beneficial and wanted changes in local community health and social care using a dynamic and inclusive model16 (see the COPC cycle in Figure 8.2)

The COPC process

The tasks of each stage of the COPC cycle are:

  1. 1. Community diagnosis. Identifying the problem. Collect relevant demographic, economical, historical, political, and cultural data and locate human and other resources. Review the existing community/national databases, obtain the relevant demographic, social economic, mortality and morbidity data, conduct interviews, focus groups and carry out community surveys where appropriate. Unusual patterns of health or social problems in the target community should be highlighted in the analysis of the community's ‘health’ status. The community diagnostic process should ensure that the community's priorities are central to the next stages of the cycle.

  2. 2. Prioritization. A realistic, achievable number of problems to solve must be chosen by the ‘community’ for each turn of the cycle. This will involve debate leading to an explicit process of prioritization.

  3. 3. Detailed problem assessment. The short-list of problems needs to be ‘worked up’ in enough detail to make planning a realistic intervention possible. The academic expertise is essential to this step, both as a source of knowledge and of critical reflection.

  4. 4. Intervention planning. A plan for action to address the chosen problems needs to be agreed by the community.

  5. 5. Implementation. This entails involving the community in the implementation of the intervention and using existing community resources wherever possible. Training of community members in skills specific to the COPC intervention will be a feature at this stage. The intervention should include short-term and long-term measurable goals.

  6. 6. Evaluation and re-assessment. The monitoring, evaluation, and reassessment of the COPC programme are a continuous part of the process and will generally involve a mixture of qualitative and quantitative methods to obtain the fullest possible picture of community views.

The origins of the COPC approach have parallels with the service improvement and organizational change theories proposed in the social movements literature.17 Both involve collective action by individual volunteers with a common cause, often involving ‘radical’ approaches that may be in conflict with the accepted norms and ‘ways of doing’ things. The social movement literature proposes an alternative approach to traditional organizational change theory, incorporating the mobilization of people's own ‘internal’ energies, and so creating a bottom-up, locally led, ‘grass-roots’ movement for improvement and change.16 Furthermore, ensuring that aims and objectives are appropriately framed can ‘ignite collective action, mobilize people and inspire change’.18

The introduction of Primary Care Trusts has been likened to COPC,19 partly because the community orientation develops the capacity of professionals to combine a population perspective with personal care, supports and develops teamwork processes, and extends audit to explore the needs of the local population,20 all features of the industrialization of primary care. Furthermore, by placing the community at the centre of the development process, the issues of ‘voice’ and power discussed in Chapter 7 can be explicitly addressed, as they must be if communities are to able to exert any substantial influence on primary care organizations.21

COPC is not a panacea for consumerism, and may be too complex for busy practitioners, or even locality commissioning groups to take on. Nevertheless it is an option for small numbers of interested practices or commissioning groups, or even Primary Care Trusts themselves, which must not underestimate the difficulties in sustaining public involvement22 and of demonstrating its effectiveness.23 Exploratory work of this intensity will inevitably be done by enthusiasts in large organizations, but there are many processes for public engagement and all GPs can develop an interest in what is on the website, in the practice bulletin, or said in the patient survey.

The tendency to avoid engagement with current changes and revert to a romanticized idea about general practice

Reification—the anxiety that people are being converted into things—presumes that there was once a time when this did not happen, an invented past when Dr Findlay treated all his patients with attentive but sometimes naïve enthusiasm and Dr Cameron tempered his junior partner's modernity with a deeper and profoundly humane knowledge of human psychology.

There is a risk in British general practice that we will lapse into this kind of romanticism, perhaps by thinking that John Berger's ‘A Fortunate Man’ is a helpful description of a person-centred alternative to the routines of industrialized primary care. General practices can be described as being ‘at the heart of their communities’24 and GPs can be placed ‘at the heart of a vibrant multidisciplinary team’,10 but these are claims to status and position that are potentially misleading and somewhat optimistic.

General practices are accessible during office hours, but at evenings and weekends NHS Direct, local out-of-hours services and Accident and Emergency departments deal with the same patients. At the moment general practice occupies the central position because it contains the only medical record that is close to being comprehensive and offers some continuity of care when other services do not, but it no longer has a monopoly role as gatekeeper to specialist services. All that is needed to reduce the centrality of general practice (short of full privatization of the health service) is the transfer of the electronic medical record from the doctor's desktop PC to the patient's smart card. Then general practices would compete with other services, American-style, perhaps trading on their main remaining asset, continuity of care. A central role in multidisciplinary teams—the beating heart, which if it stops brings down all with it—is also a slightly odd idea in the new world of industrialized primary care. Practices are grouping together or merging to manage practice-based commissioning or to see off real or imagined competitors, and the large teams containing different disciplines with variable levels of skill that are emerging from this aggregation of practitioners will be lead by GP managers, the super-ordinate stratum cultivated during the second phase of industrialization. They may well be at the heart of these teams, but the jobbing GP will not, especially if she is a salaried employee.

The future

The industrialization of general practice into primary care need not follow one path. As we have seen, the industrialization process is being made up as its protagonists go along, with ample scope for failed experiments and policy jaunts down blind alleys. At each stage a number options appear and jostle for attention, always competing with the desire to go back to the old system of organizing general practice. The only thing we can be sure about is that the NHS will continue to change. There are plenty of opinions about how this might happen, and some of them give a special role to general practice and primary care. Alison While, professor of Community Nursing at King's College London, suggests that neither staff nor users are prepared to tolerate the current situation in the NHS and points towards the solution recommended by Reform, a mixed economy of providers and enhanced primary care.25 Another suggestion is to abandon the single payer system of the current NHS altogether and opt for competing funding bodies, so that citizens can choose to join one ‘health plan’ from a menu (but not choose not to join any). Competition between commissioners would focus the minds of providers, in general practice and in hospital, on cost and quality of care, and the conflict of interest in general practice commissioning (where GPs are both commissioners and providers) would be eliminated.26

In my view there are a number of future possibilities inherent in present trends. If maximal industrialization occurs in general practice without professional amelioration, but against a background of increasing resource constraint, we might see:

  • The growth of a professionally diversified primary care workforce, with increasing part-time working, and a target-driven, impersonal work style with limited responsiveness to individuals and evident rationing of services.

  • Large scale skill transfers, with nurse practitioners becoming alternatives to doctors and minimally trained staff (healthcare assistants) taking on simple nursing tasks.

  • The further growth of the private medical sector, which will claim to offer the personalized service that the public sector is losing. (This claim is likely to be spurious, as the growth of the private sector is also likely to result in industrialization processes occurring within it as insurance companies seek to contain costs).

  • The further growth of ‘alternative medicine’, which will be genuinely personal as long as it is based on individual transactions between patients and practitioners, but of limited effectiveness.

However, if general practice resists change powerfully (and is supported by other disciplines in doing so), there is likely to be:

  • Less emphasis on the standardization of primary care services, and continued acceptance of some degree of variation in the quality of practice.

  • A slower pace of change in general practice, and in the diffusion of knowledge and expertise.

  • Professional resistance to rationalization of services and cost containment.

  • Continuous conflict between professions and government over resource allocation.

  • Justifications in terms of patient-centredness.

This alternative to industrialization does nothing to address the issue of resources and demand, and may be little more than a route to conflict between professionals and politicians, with failure to change the performance and character of public health services. Given the tendency to find compromise solutions at micro-, meso-, and macro-levels within the healthcare system, such conflicts may appear and be resolved piecemeal (but perhaps only partially) over a long period of time. If this occurs privatization of primary care might appear to be an acceptable alternative to continuous conflict to both government and the profession.

Leading change

It should be obvious by now that my preferred option is different to both of these, and requires the full but critical engagement of GPs in the development of clinical governance and the industrialization of general practice into primary care. The pragmatic reasons for this are that it will preserve the working autonomy of practitioners, improve the quality of medical care in the community and help ward off market solutions to the problems of the public health service. The fundamental reason is that in ‘high modern society’ all the processes at work in the population that were described in Chapter 7 need to be moderated by a healthcare system that does not exploit patients as a source of profit (that is, as commodities), but instead treats them as citizens of equal worth. In my view this can be achieved better by the full-on application of psychology, sociology and medical science and technology than by the elaboration of principles of patient-centredness. The onus is on the professional organizations of primary care to take leading roles in the processes of change. The Royal College of General Practitioners has a track record of innovation that will be tested by industrialization, but will need to beware of its latent romanticism, while the negotiators within the British Medical Association will need to adopt a positive attitude to change and not seek to defend forms of economic organization that limit the rate and scope of change.

Family medicine is faced with the rise of market liberalism throughout the world, giving rise to new perspectives of economic prosperity, as well as widening gaps between the rich and affluent, and a growing number of unemployed, poor, and marginalized people. Poverty and long-term unemployment are becoming permanent problems even in the rich world. The challenge to family medicine is twofold. First, to develop a broader understanding of the associations between social risk factors on a population level, and their clinical expressions in individual patients in terms of illness, sick role behaviour and manifest disease, and potential for constructive coping. Second, to maintain a system of universally available primary healthcare, meeting the needs of those who are not in the best position to pay.27 We neednot end on a pessimistic note, because general practice and family medicine still have much to offer, and could even have decisive effects on the direction of social development, but only if they can continue to evolve. As one American family physician puts it: ‘In a world plagued with unforeseen discontinuities, general practice will need to maintain its core of “personal doctoring”. Meeting people at the primary care level provides unique opportunities of being sensitive and responsive to unexpected changes in society, and in some areas even making contributions to the directions of change’.27

‘Making contributions to the direction of change’ is one way of describing clinical work with patients in general practice, and it requires a long-term commitment and a continuous desire to acquire new knowledge and apply it. The same applies to influencing wider change, by making social reality legible to ourselves and our communities, and by challenging the routines and habits that make up that reality.


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