Too big to sail? – A new perspective on General Practice at Scale
There is an Aesop fable called the ‘North Wind and the Sun’ in which the two title characters have a competition to see who is the strongest. The challenge they set each other is to make a passing traveller remove his cloak. But however hard the North Wind blew, the traveller only wrapped his cloak tighter to keep warm, but when the Sun shines, the traveller was overcome with warmth and took his cloak off.
I have been involved in ‘primary care at scale’ for the last decade, but only recently I am enlightened as to exactly what that means, and why we as a system are repeatedly getting it so very wrong up and down the country.
And just like the North Wind, any attempts to force General Practice into the type of structural integration being offered, is being met with General Practice tightening its cloak, more closed, and creating an attitude of just trying to get on with the day job of delivering care. Which inevitably helps nobody.
Unfortunately, it seems that the people who are behind ‘vanguarding’ these changes haven’t understood the subtle difference between size and scale. They often conflate the two and this means that they quickly move to discussions about structures, governance and contracts.
For those of you unsure as to the difference between ‘at size’ and ‘at scale’, let me use the crude (sorry) analogy of an oil tanker. Oil tankers are impressive beasts. Companies understand that an oil tanker can move up to 550,000 tonnes of oil across the ocean at a time. This allows a large amount of crude oil to be transported at any one time.
However, look closer and you will see that an oil tanker is typically made up of between 10-12 smaller tanks, each holding 40-50,000 tonnes of oil. This is to stop a large volume of oil sloshing around the hull of the vessel, causing it to lose balance and capsize. It is to allow fires, breaches and leaks to be contained on a smaller level so that the whole boat doesn’t go under.
The size of the individual tanks allows the tanker to achieve the scale of oil transport.
Why are smaller areas (tanks) essential for Primary Care to thrive?
Diversity – Most clinical commissioning groups will have large demographic variation in the geography they serve. They will have rich areas, poor areas, areas with a high elderly population, areas with particularly ethnic groups and some areas which are completely unique. A one size fits all approach to General Practice won’t give the personalised care the NHS so craves. As a wise colleague told me ‘GPs are like Welsh sheep farmers, we know our sheep’
Relationships – The main reason that practices or groups of practices manage to share staff, resources, data and patients is that they know each other. They trust each other. There is a named person with whom they can contact. Each task is someone’s (not a departments) responsibility. And the best thing is, that these relationships don’t need to artificially develop, they are there already in the most part. We already have an environment where we can embrace the whole primary care family of pharmacists, dentists, opticians and embrace social care through our local council ward.
Being Self Employed – Anyone who has run their own business will know the difference between that and being employed. Running your own business (even if that vehicle is a partnership) means that you get more than a clinical hourly commitment. You get commitment to the whole venture. If we think, the GP workforce crisis is bad now, just see what happens when the GP’s can work to rule. Which poor bugger is going to turn off the burglar alarm when it goes off on a Sunday morning.
I am not saying that GPs and the GP contract don’t need urgent reform. I am definitely not saying that I agree with the pointless attempts of the GP unions and colleges to blindly preserve aspects of the family doctor speciality that I, and many other GPs believe need urgent reform.
Heaven forbid, I am not even suggesting that all GPs are altruistic, hard working and committed to their patients (believe me I have met a lot who aren’t).
But there are enough of us who are.
Enough of us who want to work within our own oil tank not necessarily on our own but with our neighbouring practices in which we have geographical and philosophical alignment. Most GPs want to create an environment that is not only good for patients, but a great place to work. A place that means that they can be part of a larger tanker (which has a shared vision and purpose) but where they are allowed the structural autonomy to thrive and develop within their own community.
Just look at the work of Dr Jonathan Cope in Beacon Medical Group or Dr Steve Kell in Larwood to see the art of the possible. They have put the joy back in General Practice, improved healthcare without taking it back to the 70’s. There is something there that although can’t be replicated, the ethos can be distilled and spread.
So please. If you are an NHS Trust, NHS England or any organisation / person that is frantically trying to create an oil tanker for your region (and I know the pressure is on you from the very top), then instead of buying into the North Wind tactics being deployed currently (Estates funding, Indemnity costs, Workforce problems, GP Forward View), why not try to create an environment where the sun shines.
Help General Practice take its cloak off.
It thrives in the sunlight.