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General practice at scale

An oft used phrase which has seemingly different meanings, thereby a common source of confusion and cross purposes. There are many such words and phrases in our NHS subject to interpretation, the description primary care itself being a case in point. To focus on general practice at scale, where meanings range from the GP ‘factory’ concept of the all-encompassing polyclinic, right through to the adaptive concept of general practice concomitantly working at several levels and adopting both a strategic and an operational role.

david colin thome
David Colin-Thome

My long experience of the NHS is of a dominant and prevailing culture that values large organisations. This ‘large is beautiful’ concept is usually associated with a technocratic focus while exuding a culture of utilitarian impersonal services, and the organisation emanating a distant power.  Not ‘of us’, more the ‘cathedral on the hill’. I contend it a culture that should not reflect NHS or the public sector values necessary for the modern world. A current culture that unfortunately abounds elsewhere, for instance in large call centres, our impersonal banks and when trying to contact large organisations. I shudder whenever there is a need to do so. Does the NHS and especially primary care need to keep following that self-same path? I strongly contend we do not if we desire to reverse the trend of increasing dissatisfaction. We need to bridge that gap between the patient as citizen and as a customer, the underpinning aim of all attempts at NHS reform.

At its best primary care has a rich local heritage – ‘soul of a proper, community orientated, health-preserving care system’ (Donald Berwick), ‘The well-known but underappreciated secret of the value of primary care is its person and population, rather than disease, focus’ (Barbara Starfield). Interestingly both these appreciative academics are USA citizens. More Starfield – ‘primary-care physicians do at least as well as specialists in caring for specific common diseases, and they do better overall when the measures of quality are generic’. And ‘first contact, accessibility, co-ordination, comprehensiveness, and continuity are the enduring strengths of primary health care’. I know the Covid pandemic has damaged services, but I fear the trend to impersonal care predates this modern plague.

So, what’s the alternative? To build from the local and subsidiarity is key – the principle that a central authority should have a subsidiary function, performing only those tasks which cannot be performed at a more local level. The very principles of list based primary care, the Primary Care Home (PCH) and potentially its administrative successor the primary care network. Larger organisations are to support not subsume that basic principle whether they be hubs, big GP partnerships, federations, and the large NHS organisations of the new NHS architecture. Human beings, whether citizens, patients, and staff value and prosper in relationships, yet we build bigger and distant.

The PCH attempted to develop those principles. It was originated by me in 2009 influenced by the Royal College of General Practitioners Primary Care Federations paper of 2008 and predicated on extending the vision and scope of the existing ‘GP home’ for its registered list of patients.  The Primary Care Home’s overarching aim being a population based (GP registered list) community provider possessing its own budget and ultimately providing an alternative to current NHS hospital centricity. A home not only for general medical practitioners and their teams but for all primary care independent contractors (pharmacists, dentists, optometrists) and their staff,, community health service and social care professionals. And potentially a home for many currently working in hospitals.

Importantly also a scope beyond healthcare, with a responsibility for broader health and wellbeing. A place where a bio-clinical focus and addressing the social determinants of health can be the responsibility of one provider organisation.

My paper which was based on the aspiration and achievements at Castlefields Heath Centre, Runcorn where I worked, did not specify a population size as it was about an aspirational way of working in primary care. The National Association of Primary Care developed the PCH concept in conjunction with the strategic requirements of former NHS chief executive Simon Stevens. An optimal population size of 30-50 thousand was recommended to operate on a small enough scale to make relationships work, an essential facet of the original PCH sites.

The focus on relationships is the kernel of my desire for the adaptive leadership and management essential for the future sustainability of primary care. Healthcare, as life in general, abounds with paradoxes and dichotomies which can best be managed in a relationship focused local. What appear to be conflicts will be assuaged by adaptive thinking for example the citizen as patient and customer, to have an individual patient and equally a population focus, a public health approach that focuses on disease prevention and treatment yet a contribution to a broader view of health. And most relevant to the topic of this blog, how to both be small and local, yet to be larger and strategic.

That’s what I perceive as working at scale, well beyond the fetters of big is beautiful. Being of service to local communities and concomitantly of service to the wider NHS. Primary Care Home sites and some so-called super practices have already shown the way. Let’s just do it.

Last Updated on 30 November 2022