Amanda Doyle caused a ruckus on social media.
She’s a doctor who gave up doctoring in Blackpool, to become the national director of primary and community services.
Tuff-gig, fixing the dreaded four Ps.
The Four Noble Truths of suffering, epitomised in Buddhism.
The four components of a classic ‘Intractable Problem’.
Doyle’s four Ps; people, patients, pounds, premises.
1. People… we don’t have enough GPs. If the Health Foundation are right, the shortfall is set to increase to around 8,800 GPs by 2030-31… one in four posts vacant.
A knackering job. Not seen as glamorous. Few young doctors want it.
Name the country and you’ll find there aren’t enough GPs… and there won’t be. For years
2. Patients… more with complex health conditions. Ageing and multi-morbidity. Over a quarter have two or more long-term conditions.
Often persuaded and bullied into seeing a physio or pharmacist or a Zumba class when we all know, they’ll end up seeing a GP.
3. Pounds… +90% of first contact for less than 12% of the budget…
… when we all know, a strong primary care is associated with reduced costs and improved outcomes.
4. Premisses… many stuck in the era of corner shops when grocers, bakers and butchers were in the high street.
Now, marooned.
Planning and building constraints make expansion impossible… anyway, there’s no capital… half unsiutable.
The model of family practice of the 1940’s… that I for one, look back upon, fondly.
Established not because it was ideal but because it was the only deal Bevan could get.
Doyle’s dilemma… industrialising primary care and keeping it personal.
Doyle told the Health Select Committee, in terms, the GP partnership model has to go.
Lord Darzi, said as much in 2008, and more recently in the £walled FT;
‘… the independent GP contractor model is ‘frozen in time’.
Doyle is dealing with a national emergency, a workforce catastrophe. She knows, more money and fine words won’t fix it.
The scale of the problem should be on the nation’s risk register. I doubt it is.
Most problems of organisational optimisation and control are easy to solve.
However, the four Ps give Doyle an ‘Intractable Problem’ more usually seen in conflict or computer theory.
The worse case; it gets worse and the problem size grows.
The best case; it gets worse and the problem size grows.
There are no exact solutions that can be employed with certainty and obvious solutions are disputed or contradictory;
- Expanding primary isn’t possible, it takes 15yrs to grow a GP…
- expansion isn’t feasible with estate and capital restrictions…
- consolidation threatens cherished independence.
The solution to Intractable Problems can sometimes be found by focussing on the values that are fundamentally important to all concerned.
Values like; localism, personal, independent, modern and interoperable.
Is there a way to keep the ‘family’ in practice and cope with demand?
This is a classic ‘Intractable Problem’.
We can’t bully our way through and we can’t buy a solution. Apart from supply issues, GPs will always struggle because they are trying to fill a widening gap between primary and secondary care.
That’s the missing piece.
First-step, look for when things were working better…
… when primary care was less complicated.
Maybe… GPs-unplugged.
A deliberate attempt to strip back primary care, de-industrialise it;
- A license to practice as a GP, a type of franchise, based on a tight operations manuals. Salaried?
- Peripatetic; based in supermarkets, high street shops, community centres, using web-based connectivity to records, testing results, etc, partnered by or perhaps a prescribing, practice nurse lead… dealing with all the basic requirements of mums, kids, the elderly, first-line for long-term conditions.
- All other contacts supplied by a new, national, NHS Digital First service.
- The missing piece, intermediate care, what we once called Darzi Centres. What Tesco call Tesco-Extra.
- Secondary care, vertically integrated, providing back-office services, diagnostic and testing, plus referrals for treatment.
Will it work… dunno.
Will it cause a row… yup.
Will what we are doing now endure… nope.
It’s pretty clear: more of the same is doomed.
The gap isn’t in primary care. The gap is between Primary and Secondary care that GPs can’t fill.
Call it intermediate care. Darzi had a fix but the idea was implemented badly and was killed off by McKinsey and the BMA.
Australia, France, Germany, Northern Ireland, Switzerland and Russia (!), have Darzi style centres… polyclinics.
This time around we know enough, to do it well.
Doctor, digital, Darzi… done.
Four Ds for the four Ps.
News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.
