Scotland’s independent think tank
Scotland’s independent think tank

Scottish General Practice: The Right Way Forward – Dr Alastair Noble

The House of Commons’ Health Committee in its latest report has said clearly that we must return to personal lists for GPs.

The committee called for a return of personal lists, so each patient is assigned an individual GP, alongside an expansion of GP training places.

By 2027, 80% of GP practices should be using personal lists, it said, and 100% by 2030.

Why is this important? Simply that a unique consistent relationship is the fundamental building block for continuity of care. All the evidence supports how much better clinical care flows from that essential relationship.

In response to how that can work with so many part-time partners, I think one option is to look at job sharing so that you might have 2 job sharing GPs as your list GP. This means the responsibility lies with them to provide real continuity of care. This worked well for me in practice although it was not a formal job share. One of our excellent assistants (who had previously been a principal) covered my management and political time. The patients loved it and all the practice highly prized continuity of care and the patient’s own individual GPs way of practicing, whilst still remaining very clear about getting it as near right as we could for the individual patient.

The practice is still doing our own Out-Of-Hours work with the community hospital nurses answering the phone and dealing with a lot of the patients. This again provides real continuity of care.

In a recent BMJ paper about learning lessons from Covid, in the paragraph about infrastructure for vaccine delivery, they emphasised again the importance of continuity.  The NHS has used a range of sites to deliver vaccines, including locations run by hospitals, GPs and community pharmacies. The NHS needs to decide how covid-19 vaccines will be delivered in the longer term.

A GP-led programme, supported by pharmacies and hospital sites, offers many potential benefits, including easier access for patients to GP and pharmacy sites than hospitals and, importantly higher vaccination rates. This is as a result of the ongoing relationship that primary care teams have with their patients. Greater frequency of contact between primary care staff and patients also provides the opportunity for health promotion activities, including co-administration of other vaccines such as influenza. 

The Italian Government is recommending 400 New Community Hospitals by 2026 following its response to Covid.

What about Scotland?

It appears to be to do away with General Practice and rely on Consultant Care only. The big problem with this strategy is that it clearly is not working.

Most patients have common conditions, most have more than one complaint and the overwhelming majority of patients are frail elderly who above all cherish their own GP’s care and continuity of care is vital for them.

Those Scottish mainly rural communities where they continued to provide real Scottish General Practice are seen as beacons of good practice. We must build on that model of integrated health and social care teams delivering continuity of care in their own unique locality. That allows the essential clinical decision making between Consultant and General Practice to take place, firstly who will benefit from Consultant Care and even more importantly who no longer needs it or will not benefit from Consultant Care.

The clinical accountability for Community Care then rests with the General Practitioner and their integrated locality team.

If we accept that the Clinical Decision is the Purchasing Decision, then we need accurate Clinical and Financial data. This will only work if we have a Fair Share Integrated Health and Social Care Budget for each locality, built on the Integrated Resource Framework. I am firmly convinced that the fairest way of paying for health and social care is by taxation, though I accept that this means to have to be able to show value for money for the taxpayer. (As clearly set out in Credit Crunch Health Care by Cam Donaldson)

This puts Clinical and Financial accountability on the Clinical Teams. Whatever is best for the individual patient in terms of current best practice will drive this model and resources, equalling mainly staff will follow.

The Centralist Specialist Model has failed. For example, in Covid; Medical admissions including Geriatrics (1800 Occupied Bed Days of Delayed Discharges;, A&E with 4 hour target not being met; and repeatedly in Maternity (numerous recent reports and Marjorie Tew Safer Childbirth).

It also means that those patients who will benefit from Consultant specialist care are stuck on long waiting times and lists awaiting essential treatment. This is clearly not best current model of care.

We have all the necessary data and the Perth & Kinross Fair Share work is an excellent starting point. This can clearly be rolled out throughout Scotland.

We have excellent models for the right premises to house these integrated Community Teams like Nairn. We also have examples of community beds in nursing homes (Ullapool) and combined nursing homes and community hospitals on the same site (Stonehaven). Italy may well provide some interesting models going forward.

Co-location is key and must include health and social care teams. In the cities it may well mean community beds under the GP as separate wards in big teaching hospitals.

We also must ensure that all professions are taught in this sort of Community Care premises as well as big Teaching Hospitals. NES must ensure this happens. This will also ensure we train and employ more generalists in all professions and the right number of specialists. All students must have equal access to all the diverse ways of caring and understanding that medicine is not all about the latest machine in the Big Teaching Hospital!

Repeated reports highlight our consistent underspend on capital and the poor condition of our properties, this gives us a massive opportunity to prioritise integrated care properties combing all the community teams and right size our big hospitals to meet the work they will be doing in the future. It is just crazy to have our most expensive beds full of patients who should not be there!

We have a massive opportunity to get this right now in Scotland. The Status Quo is indefensible, and we can restore a happy, healthy work force who enjoy their job and benefit the Community in which they live and work.

The Greeks worked out the ‘Healthy Body Healthy Mind’ relationship 4000 years ago.

Covid has again shown how important a healthy thriving Community is to us all.

Linking Health and Social Care into Local Place Planning will allow us to target those localities most in need and to support those localities who are doing the right thing by making them even better, greener and more sustainable.

Scotland is well placed to deliver on this place-based way forward. We have the clinical and financial data available to really integrate health and social care.

It also means we can deliver within existing budgets and improve patient care throughout Scotland. We already have excellent examples and all of Scotland’s patients will benefit from continuity of care, have confidence in the quality of their individual care package and delivered by a happy confident workforce.

Sir Alex Fergusson would never expect an unhappy demoralised team who had never played together to win. It is essential that politicians, management and finance all play their essential part in supporting the individual patients and their communities to get optimal care. This means good housing, good jobs, good education and above all a healthy green sustainable environment. This will produce better health outcomes for all.

It is already being done in many parts of our Country, we must make sure it is delivered everywhere.

Dr Alastair Noble worked as a GP in Nairn