Brian McAvoy

Brian McAvoy is Executive Director, Researching and Practice Support, Royal Australian College of General Practitioners and an Adjunct Professor of General Practice at the Universities of Melbourne and Queensland.

(This article is based on a paper presented to the 2000 National Conference of the Doctors Reform Society in Melbourne, 21 October 2000.)

Introduction

"General practice stands at a professional crossroads. There are various forks in the road ahead, and the signposting isn’t terribly clear, but arguing to remain in the same spot and not move on, doesn’t seem a sensible option."

This quotation from a booklet published by the British Medical Association this year (Shaping Tomorrow: Issues facing general practice in the new millennium), indicates the ferment of change affecting general practise in the United Kingdom. This article provides a snapshot of current UK general practice, and offers an historical perspective to the health reforms in the UK and suggests some lessons and opportunities for Australian general practice.

Whilst it is relatively easy to marvel at the achievements of modern medicine at the start of the new millennium, it is salutary to place them in an historical perspective. As Henderson reminds us "somewhere between 1910 and 1912 in this country.... a random patient, with a random disease, consulting a doctor chosen at random, had for the first time in the history of mankind, a better than fifty-fifty chance of profiting from the encounter."

Although general practice has been a late developer in terms of academic medicine, over the past 10-15 years it has assumed a key role in NHS policy and practice, epitomised by the phrase "a primary care led NHS", which began to appear in Government publications in the mid-nineties.

Snapshot of the NHS Today

In the late nineties the NHS workforce comprised 35,000 general practitioners, 55,000 hospital doctors, 140,000 managers and administrators and 500,000 nurses - the backbone of the health service. Sixty-nine per cent of GP’s were male (compared to 83% in 1983), 79% UK born, 84% full time and 70% aged 30 to 49. Nearly one third worked in health centres, 13.5% were dispensing doctors (essentially in rural and remote areas) and 25% were clinical assistants, working part-time in hospital specialty services such as anaesthetics, dermatology and emergency medicine.

There are approximately 11,000 practices in the UK, with an average list size of 1,821 patients per GP (Compared to 2,011 in 1985). Only 10% of practices are single-handed, with 13% having 2 partners, 16% 3 partners, 18% 4 partners, 17% 5 partners and 26% having 6 or more partners.

In terms of workload the average GP spends:

• 39 hours/week on general medical services (GMS)

• 58 hours/week on non-GMS duties plus on call

On average he or she will have 152 consultations per week, 87% of these being at the surgery, leaving over 10% of consultations as home visits. The average consultation time is 8.4 minutes and the average home visit time (including travel) is 25.2 minutes.

Seventy-one per cent of consultations involve issuing a prescription, with the average number of items per person being 8.8 per year. Seventy-five percent of prescriptions are for repeats- the GP drug bill accounts for 10% of the total NHS budget. Thirteen per cent of patients are referred on to secondary care.

Historical Perspective to Health Reforms

The NHS has been in continuous evolution, but the pace of change has accelerated over the past 10 years. Key developments have been:

1948 NHS established

1966 GP Charter

1989 Thatcherite "reforms"

1996 "Primary Care led NHS"

1997 White Paper-The New NHS

2000 Modernisation Agenda

Harrison and van Zwanenberg have described four ages of NHS general practice, characterised as follows:

The Dark Ages (1948-1966)

• Single handed and on call at all times

• Home as surgery and wife as receptionist

• Income from capitation only

The Renaissance (1966-1986)

• Group practices and primary health care teams

• Better premises

• Academic Departments

The Reformation (1986-1990)

• New GP contract

• NHS reforms

Modern Times (1990-2000)

• Strategic shift to primary care

They also identified five strategic themes in the NHS in the 1990’s:

1. Value for Money
• Efficiency
• Equity
• More for less

2. Quality
• Clinical Audit
• Clinical Effectiveness
• Evidence-based medicine

3. Engaging with Patients
• Information for patients
• Patients’ involvement
• Patient’s’ rights and responsibilities

4. More influence for GP’s
• GP fund holding
• Locality commissioning
• GP involvement with health authorities

5. More community-based services
• Extension of primary-care
• Hospital at home
• Hospital outreach

The strategic shift to primary care involved:

1. Capital assets
• Through GP fundholding savings

2. Provision of care
• Wider range of services in the community

3. Commissioning of care
• GP Fundholding
• Locality Commissioning
• Total Purchasing
• Primary care groups (PCGsS)

4. Sitting at the top-table
• GP involvement in local health strategy
• GP’s in senior positions in health authorities

The Thatcherite "reforms" involved a funder-provider split and a market-driven, competitive model. A new GP contract was imposed unilaterally, despite overwhelming opposition from the profession, and the wild card of GP fundholding was introduced. This proved to be a powerful catalyst for change, altering significantly the balance of power between primary and secondary care. By the mid-nineties, the Conservative government began to realise that that the red-blooded Thatcherite competitive model was hindering collaboration and instituted a cultural shift by launching the "Primary care led NHS".

In an unprecedented consultative process called the "listening exercise", senior health ministers and civil servants travelled the length and breadth of the country, meeting with health professionals, health service managers and consumers. Innovation and alternative models of delivering primary health care were encouraged, involving extended roles for primary care providers (particularly nurses and community pharmacists) and new contractual arrangements for GP’s (including salaried posts).

When the new Labour government was elected in 1997, one of the first initiatives was to introduce a White Paper on the NHS, boldly entitled The New NHS: Modern, Dependable. Ten key features of this radical document were:

Primary Care Groups And Primary Care Trusts

Groups of GP’s, nurses and social care professionals who, together with patient and Health Authority representatives, take devolved responsibility for their community’s health care needs.

NHS Direct

24-hour telephone triage system and help-line operated by nurses to advise callers about the most appropriate form of care.

Commission for Health Improvement

Statutory body providing independent assessment of local action to improve quality. Will support and oversee the quality of clinical governance and clinical services.

National Patient and User Survey

To provide annual feedback on issues of importance to patients, carers and service users - ranging from quality of food to pain relief.

Clinical Governance

Framework through which organisations are accountable for continuously improving the quality of service and safeguarding high standards of care.

National Institute For Clinical Excellence

Statutory body to promote clinical and cost effectiveness by producing clinical guidelines for dissemination throughout the NHS.

National Service Frameworks

New tools to set national standards and define service models for a specific service or care group (eg. mental health, coronary heart disease, and older people).

Health Action zones

Multi agency approach to promote innovation in public health and community care initiatives specifically targeted at areas of high need.

Healthy Living Centres

Bringing together medical, social and community-based services and targeting the most disadvantaged sectors of the population.

Five Key UK Developments Relevant to Australia

Primary Care Groups

These cover populations ranging from 46,000 to 257,000 patients, involving on average 50 GP’s. Unlike fundholding, membership is mandatory for GP’s, and the primary care groups (PCG’s) also have community nursing, social service and consumer representatives. There are 4 levels of development and function for PCG’s:

Level 1 Act in support of the health authority in commissioning care for its population, acting in an advisory capacity.

Level 2 Take devolved responsibility for managing the budget for health care in their area, acting as part of the health authority.

Level 3 Become established as freestanding bodies accountable to the health authority for commissioning care.

Level 4 Become freestanding bodies accountable to the health authority for commissioning care, and with added responsibility for the provision of community health services for their populations.(Primary Care Trusts).

National Institute for Clinical Excellence

This statutory body was established in 1999 with 3 main functions:

• Appraising new technologies, including drugs, before they are introduced to the NHS.
• Issuing and approving guidelines
• Encouraging national audit

NHS Direct

This 24-hour telephone triage system and helpline is operated by specially trained nurses. It was piloted in three sites in 1998 and has now been extended nationwide. Initial evaluation suggests high levels of reassurance among callers but it is uncertain at present what effects it has had on demand for services.

Extended Nursing Roles

Practice nurses have been a mainstay of UK general practice for many years. However, additional training is producing a new cadre of nurse practitioners, who consult independently and are extending considerably the traditional nursing role.

The Secretary of State for Health has recently declared that he wishes to see a health service that "liberates nurses rather then limits them". He has issued a ten point challenge on nursing skills, calling on nurses to extend their role to ordering diagnostic tests, making referrals, admitting and discharging patients, prescribing, performing minor surgery and running their own clinics.

The fact that GP’s and nurses are not competing financially for patient services in the NHS has facilitated these changes.

Information Technology Advances

The NHS spent 1 billion pounds on IT in 1998-1999. There is now a NHS Information Authority, a National Information Strategy and a National Education, Training and Development Strategy.

Electronic patient records are being used widely as are decision support systems such as PRODIGY and clinical messaging. Plans for the universal introduction of the NHS net are well advanced.

The pace of change in the NHS has accelerated considerably over the past few years. In part this is because of the change in government but also because the public’s concerns about self-regulation of the medical profession have been raised by a several high-profile scandals - the Bristol children’s heart surgery inquiry, the Alder Hey Hospital inquiry over removing dead children’s organs and the trial of Dr Harold Shipman, the GP serial killer.

NHS Modernisation Agenda From 2000

The latest ingredient in the NHS’s recipe for change is the modernisation agenda, unexpectedly announced by the Prime Minister in March 2000. This involves five key challenges:

1. Partnership - making all parts of the health and social care system work better together and ensuring the right emphasis at each level of care.

2. Performance - improving both clinical performance and health service productivity.

3. Professions - increasing flexibility in training and working practices and removing demarcations, in the context of major expansion of the health care workforce.

4. Patient care - ensuring fast and convenient access to services, empowering and informing patients so that they can be more involved in their own care.

5. Prevention - tackling inequalities and focusing the health system on its contribution to dealing with the causes of avoidable ill-health.

Reassuringly, significant increases in resources have been promised to underpin this ambitious initiative - 19.4 billion pounds over the next four years. However, despite this being an average annual growth rate of 6.1%, the UK’s health service funding as a proportion of gross domestic product (GDP) will still remain below the European Union average of 8.61%

Finally, the key issues emerging from the NHS Modernisation Agenda, all of which are relevant to Australia, are:

• Changing professional practice and the need for health professionals to be more flexible and adaptable in their roles and activities.
• Increasing emphasis on evidence-based practice and policy.
• Growing consumerism and patient partnership/empowerment.
• Clinical governance and increasingly explicit links between resources and performance.
• Reforms in medical education and training to encourage a whole system approach to health.

Acknowledgement This article is based on a presentation given to the Doctors Reform Society in Melbourne on 21st October 2000, and an article published in the Medical Journal Of Australia (MJA 2000;173:91-94).

References are available from the author.

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