Dr Phil Hammond, broadcaster and GP returner in Bristol

Primary care must remain the cornerstone of the NHS

There are few conference events I look forward to as much as the Lincolnshire Practice Managers. This year's meeting was the fourth I've hosted and despite the general gloom and confusion of the NHS reforms, the mood is always cheerful and challenging, and the speakers are generally entertaining and thought provoking. In 2009, GPs were largely apathetic about practice-based commissioning; this year they're largely apathetic about clinical commissioning, but their managers still struggle on trying to join the dots between what the centre demands and the frontline can deliver.

My favourite speaker this year was Dr Nitti Pall, whose passion for delivering top-quality primary care to disadvantaged communities is matched by her business acumen to make it happen. I'm not sure where she finds the energy to integrate and extend primary care in Sandwell,1 collect the evidence to show it delivers better outcomes, and then—in her spare time—start the rollout of primary care across five Indian cities. She is adamant that primary care must remain the cornerstone of the NHS, but to do that we need to prove the benefit of having registered lists, particularly in the way we use them to prevent disease and manage long-term conditions better than, say, a walk-in centre or a supermarket chain. As Dr Pall put it, 'Scratch a commissioner and you will find a provider underneath.' And to survive and see off the competition of large companies, GPs should focus on providing the best services on the ground that they possibly can.

The biggest service improvement challenge Dr Pall has faced is workforce development: 'What other job allows you to see 50–60 patients a day, every day, without any mentoring?' Small wonder many of us crawl back to our homes to drink. Dr Pall used the private company, Aetna, to collect and analyse her data and made some interesting discoveries. Patients with two or more long-term conditions account for 60% of hospital-bed days. Patients start presenting to their GP more frequently between the ages of 50 and 52 years, and admissions to hospital via accident and emergency peak when the GP surgery is open.

The last point seems counter intuitive until you understand that patients have a different understanding of the word 'urgent' compared with doctors. Dr Pall discovered that to prevent an unnecessary hospital admission you had to promise that you'd phone patients back within an hour, rather than later that day, and actually do it. Telephone outreach and the My Health Assessment page on EMIS have also helped manage demand; patients have access to their notes, medication information, investigations, and letters online. Finally, a long-term condition clinic—managing them all in one go—has really helped coordinate care and improve management. In summary, Dr Pall advocated, 'Care without walls, using good data and professional wisdom to stop patients falling in the cracks between services.'

The Lincolnshire practice managers were mightily impressed, but not all were able to name a GP in their patch with similar drive and vision. And those GPs who were getting involved in commissioning just seemed to spend an inordinate amount of time at very expensive meetings, leaving the surgery understaffed and patients complaining that they couldn't see 'their' doctor. Service improvement was very hard in the current climate, akin to 'rolling porridge up a hill', and there simply wasn't the money to upgrade premises and allow them to extend the range of services they provide.

We also heard from the accountable officers from the four new clinical commissioning groups and from the Chief Executive of the new Local Area Team who handed out his mobile number to everyone—something I've never seen before in the NHS. But with fewer managers around and Labour promising to reverse many of the reforms if they return to office, the general feeling was to concentrate on the day job and leave the reforms alone to sort themselves out. Not what Andrew Lansley had in mind, but it's how GPs have always coped with enforced, unevidence-based change. The next 2 years will see us doing even more for even less, and if the economy doesn't pick up all our salaries will suffer. But the Dr Palls of this world will continue to fight hard to make sure their patients don't.

  1. Smethwick Medical Centre website. www.smethwickmc.co.uk (accessed 8 October 2012). G

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