Dr Katie Musgrave on the need to shift general practice away from MDTs and back towards GPs
It strikes me as hugely self-evident that GPs are fundamental to the effective running of the NHS. And when I say GPs: I don’t mean ‘the general practice team’ or ‘the different practitioners seeing patients’. I mean GPs. On the frontline, seeing undifferentiated presentations. From rashes, to weight loss, to chest infections…
Over the past decade we have seen an increasing shift towards the diversification of the general practice workforce. Most of us will have worked alongside excellent colleagues: including physiotherapists, pharmacists, paramedics, mental health workers, nurse practitioners, even perhaps (gasp) physician associates.
But is this shift a positive change for general practice as a whole? Will it make our service safer, higher quality, and more sustainable? On an individual level, we will all have built relationships with different members of MDTs, and many GPs will be loath to raise concerns for fear of causing offence. But our instinctive reluctance to criticise well-intentioned colleagues must not, and cannot, prevent us from advocating for the best model of UK general practice.
I worry that the steady introduction of other professional groups seeing undifferentiated presentations may steadily reduce the quality of medical care, reduce continuity, and risk allowing our service to become more protocol-driven and dependent on tests and referrals. I fear it may prove a distraction from the primary goal: to retain and attract more GPs to the NHS, and provide conditions under which it is possible to spend a career working full time.
If the Government truly believes that a mental health worker, paramedic or pharmacist can fulfil the role of a GP, they will be less concerned about our retention. They will design a ‘doctor-lite’ service which sees a complement of clinicians seeing patients, while a GP provides leadership, occasional clinical reviews, or deals with the most complex cases. But every case can be complex! And this model may actually prove counter-productive and reduce efficiency and effectiveness in the long run.
Interestingly, those practices I have worked at that have scaled up most enthusiastically, and brought in the widest range of different MDT members, have consistently had the lowest patient satisfaction scores. Anecdotally, the workload at these practices also felt more intense and overwhelming – the loss of continuity and the higher burden of complex cases coming to the GP takes its toll.
Not knowing the experience of other clinicians can increase stress, as it is difficult to be sure that important red flags or differentials might have been considered, and that a ‘convenient diagnosis’ has not been reached for. When patients consult with multiple different clinicians – increasingly probable when practices scale up or diversify with a broader MDT – histories can become confused, wires crossed, patients frustrated, tests repeated or missed. Medicine is complex and difficult – the undifferentiated presentations we see in GP surgeries particularly so.
General practice is at a crossroads. There are voices in the NHS urging us to move towards a universal ‘at scale’ or hub model, with a division of acute from chronic presentations. I wonder how long it has been since these voices (if ever) have worked in general practice? Have they experienced the wide variety in quality of care provided, and staff and patient satisfaction in these differing models? Or are they blindly following a neat solution for the UK GP crisis – which may make the situation worse?
In my view we should not capitulate and accept a second class model of general practice, because senior NHS leaders have undervalued GPs and failed to defend our working conditions. It seems inevitable that over time, a two-tier system will develop where the NHS uses this ‘doctor-lite’ (and increasingly remote) model, while those who can afford it will pay to see a GP in person privately. But is this the best, most equitable solution to the crisis we face?
Our hapless leaders at NHS England and in government continue to plough on with their ill-thought out solutions, and frankly it’s exhausting. Just when you think the NHS couldn’t get any worse, it seems to. As grassroots GPs, it is incumbent on us to defend the model of care we know works best. After all, if we don’t argue our case, who will?
Dr Katie Musgrave is a GP in Devon
Katie this is so true. Thank you for being brave enough to say it.
Well said Katie, I quite definitely agree (although have to state a conflict of interest, being both a qualified GP and a Patient too! )
GPs are not only trained to provide wholistic psycho-socio-physical care, but also to deal with a wide range of rare but significant events, diagnoses, and also to be alert to and pick up on those small signals that indicate a hidden condition or hidden agenda below the obvious surface appearances – and then to negotiate the system for the patient to obtain mutually-agreed best care in the patient’s circumstances. This is a very complex job, and can be very stressful – even just the sudden change every 15 minutes from dealing with emotional or physical abuse, to consoling and managing a cancer diagnosis, to playing brightly with a child to enable a proper examination. This is shown to contribute to burnout, and if these aspects are concentrated on a smaller and smaller number of doctors, this will get worse, even if a small proportion of the routine staff is dealt with by Noctors. It would be a mistake – and I think patients know and appreciate that deep-down : even if politicians and ‘managers’ at NHSE do not. That is why we should have REAL ‘clinical governance’ : Governance by Clinicians !
I fully support Dr Musgraves comments. I do think that the extended team do have their roles and can reduce some level of demand however this does not replace the fact that GP seeing patients managing all conditions and maintaining continuity of care. This has been the beauty of General Practice.
We shouldn’t be pushing for the two tier system – why isn’t anyone listening to anyone on the ground. Practice managers are hard to recruit and retain because the bureaucracy of making claims, managing HR issues, dealing with IT core system issues etc
There could definitely be a need for some background support with admin tasks etc. HR management could be streamlined. Why reduce our budgets and put them into PCNS when the money is often lost in the black whole. How can we employ people on contracts for a year at a time? How can we get good quality reception/ care navigators when we are barely paying over the minimum living wage? Which corporate company is given a project eg PCNs told to find clinical directors that actually are totally new to the concept and get them in place in 2-3 months and then start recruiting and setting up teams etc when we only have a few months until the next contract change?? Who does that? Where is the buy in? Where is the time to plan ? Where is the time to coordinate staff and key players? This is a basic concert project management! We have been set up to fail! Why are we not being exempted from paying NI hikes to our staff. Great words saying funding has increased etc – The government is giving lavishly in one hand to get votes the sneakily using cut throat tactics that are under the radar of Jo public. I am truly saddened by the lack of foresight and one solution suits all type of management any sticky plasters are applied by people who do not eat sleep and breathe the job. This is time for everyone to speak up ! It’s everyone’s problem!
Another excellent article Katie which fairly balances being respectful to professional colleagues with the disquiet most of us feel about the direction of general practice.
For the last couple of decades, at least, neoliberal economic theory has been forcing successive Govts into a strategy that deprofessionalises GPs by shifting our work from professional to non-professional (PAs being the latest tactic). Part of that process has also been proletarianisation by increasing our workload and deskilling GPs so as to introduce what theorists call the “new professionalism”. Other professions eg teachers, have suffered the same pressures.
The idea is to make primary care less reliable on GPs.
Imo, it will bring about a “factory farm” primary care model that is made for corporate takeover but, of course, of very poor quality, like the “doctor-lite, second class” model you describe.
The chronically unreactive BMA, blind to Govt strategy for decades, still doesn’t seem capable of organising GPs into action to save the NHS. Instead it balloted principals only, and then just for the narrow reason of the GP contract and pay – no wonder the public has no idea and the media is totally unsympathetic.
We need a “wartime” increase in GP funding that supports and retains independent contractors and allows their growth. And reform that supports GPs in practising their complex irreducible skills.
Will this Labour party fulfill its foundational mission?
It’s worth remembering why we have ended up with MDTS ….. for over a decade nobody wanted to work as a GP other than as a locum. For those of us working as partners who had to keep the doors open and the lights on this was the only way to keep the show on the road and it actually worked ok. If the doctors had turned up we would have employed them but they didn’t so we had to look for solutions elsewhere
Anony Mouse above is correct . This article is unrealistic . We have ended up at this point after many years of GPs taking advantage of market forces . Partners had to keep practices running with available staff . It’s not possible to turn round the tanker in a year and not affordable for the NHS unless GPs all take a pay cut which we do not want to do . During the junior doctors strikes , Emergency Depts ran very smoothly as consultant led units . However it’s unaffordable so they continue as MDTs and using training grades . The same applies to GP.
It’s also worth doing some simple maths. The BMA have said that the safe number of consultations in a day is 25. The average patient demand is 6 appointments per year (some studies suggest more) so if every GP did 4 days a week for 44 weeks a year (allowing for annual leave and bank holidays) then each GP could service a list of roughly 750 patients. The average list is currently 3 times this so my challenge to the author is how do you propose that we triple the GP workforce (and make them all full time) in the next few years? It’s clearly not going to happen and hence we have a team of other clinicians because that is the only practical solution.
Well the solution – Drs Anony Mosue and Peter Fink – is clearly to get rid of you guys. Given, as you point out, the absence of Drs is entirely down to the outrageous greed and sloth of all the folk who wouldn’t work for you. We all appreciate the marvellous work you’ve done not selling out to your greedy work shy peers, while you toiled valiantly on replacing everyone but yourselves. Alas it really is time for you to bugger off too. Its time to sign the keys over to the practice manager.
Big fan of dripping sarcasm and cutting satire to make a point. Excellent use @a.fairbarn. Thanks for that. Made me laugh out loud…😉
Having been a GP Partner for 10 years we very much wanted and tried to keep a GP lead model – in fact partner lead model for as long as possible. Effectively we were forced by ARRS to diversify the workforce with funding explicity witheld unless we did so. This alongside people no longer wanting to be partners have lead to significant changes, which in my view are for the worse. Clearly there are roles for some for a wider team but the rushed and forced system ARRS has created was never going to be effective and succesful. A two tier system is now developing with those who can just paying to see private GPs…