David Colin-Thome. 23rd April 2024

At the January 2024 COIN meeting - https://youtu.be/MkVLbhPxn3Y - I presented my vision for future general practice. Here is a summary.

I became a GP because I like people. It seemed to me that general practice allowed me to appreciate what it is to be a Human Being better than other medical roles. GPs like Geoffrey Marsh and Julian Tudor-Hart inspired me with their vision for Community-Oriented Primary Care that builds healthy communities by combining personal care and public health. 

I soon realised that GPs have unusual privilege to experience the enormous complexity of life. Also, that medical science (almost the entirety of my training) sees only a fraction of this enormity Yet, the limitation of medical science and the potential of general practice still is rarely recognised by society, politicians, and even my own medical profession. The privilege was furthered by becoming a local councillor with its specific accountabilities.

The population responsibility of general practice combines deep insights into the complexity of life with the power to make a difference. Semi-independence allows ‘bottom up’ innovation, and sensible modification of Top-Down Contracts, Diktats, Targets and Protocols. Some call it ‘Bending the rules’; I call it ‘Applying the Rules in the Spirit that they were made as relationships are paramount:”. We lose this independence, creativity, and population responsibility at our peril.

For ten years I served as National Clinical Director for Primary Care under Labour and Coalition governments.  This helped me to realise that few in power understand the potential of general practice to be part of an Anchor Network that empowers local people to collaborate for health and care; and few practitioners and academics understand generalism and its importance. So, discussions about healthcare naturally revolve around hospitals and treatment of diseases. Society expects GPs to simply administer medical (laboratory) science – a terrible mistake. Most GPs go along with this – a terrible mistake.

I fear that the potential of general practice to be a force for a healthy society is about to be lost.  Many politicians want to do away with small units. Many academics dismiss bottom-up innovation. Many GPs want to distance themselves from life’s complexities. These reflect tensions between the mindsets of control and empowerment, Engineering and Organic images of the world. General practice can refine its potential to build healthy communities by reminding people that both control and empowerment are useful and we do know how to integrate them – how to integrate Small & Big, Bottom-Up & Top-Down, Health & Disease. But we don’t do it; and we don’t teach people how to do it.

The imminent potential collapse of UK healthcare could force politicians of both Right and Left to confront this question of how to develop BOTH-AND mindsets – what policies will empower people to build communities for health AND get people to do as they are told? Re-vitalised general practice could play an important role in shaping good ways forward.

I suggest:  

Apply traditional general practice values throughout healthcare.

• Whole person, whole family, personal care value of general practice has had very high patient satisfaction rates. This can be applied throughout healthcare. Patients can see health and care practitioners as equal partners - human beings who they know and trust to care for their well-being and that of their networks of relationships. ‘Conversations not clinical consultations.’

• Good general practice sees medical treatments as just one aspect of healthcare; it uses multi-disciplinary teams to provide holistic care. GP can be trained to do more than administer medical science, routinely developing multidisciplinary, extended primary care teams and networks of local people to care and create health.

Adapt the GP Partnership model to build local communities for health.

• The semi-independence of GP Partnerships gives elbow room to plan and innovate in locally relevant ways; this potential is inhibited by too much micro-management. GP Partnerships can develop community-embedded, innovative generalist health and social care.  Instead of monitoring discrete actions, routinely gathered data across geographic areas can demonstrate the effect of collaboration. 

• General practice partnerships list individuals that a practice is responsible for. Individuals and families on a GP list could be expected to contribute as partners to evaluation and development of local healthcare and society more generally. 

Teach the science of generalism, health and care.

• GPs often feel trapped in a system that expects them to be everything for everybody all of the time. Training at all stages of medical development should help all to appreciate how to collaborate to make health and care achievable. 

• The belief that the world is a simple machine that obeys simple commands inhibits good development. Learning about generalism and health-creation needs to happen throughout life, including carers, parents and school children. We must remind people that focused interventions are snap-shots of longer-term journeys.

Primary Care Networks should facilitate the development of local communities for health.

• PCNs are well placed to lead a next stage of healthcare development. They should: 1) Develop primary, community, social and voluntary care as Anchor Networks for local development, 2) Reshape Hospitals, Universities and Public Health to enable combined horizontal and vertical integration in geographic areas, 3) Train health professionals and the wider community in the theory and practice of community-oriented integrated practice.

• The language surrounding health and care – words like ‘disease’ - is overly combative and compartmentalised. We must remind people that multiple factors contribute to dis-ease. Flourishing spaces where people can learn to help themselves are more likely to help overall than instant fixes.