Health and Social Care in the Digital World

Meeting the Challenge for Primary Care

Nigel Starey

• Publisher: CRC Press
• Year: 2020
• eBook ISBN: 9781000052480
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This provocative and timely book examines the current state of primary care practice and outlines a new vision for the delivery of primary care services, primarily in the UK but also internationally. Encouraging a social compact between citizens, governments and the providers of care, the book describes how this will necessitate a redesign of the welfare sector to ensure it is 'fit for purpose' in the digital world. It explores the respective roles of the inverse care law and the rule of halves, systems theory and learning organisations, mutuality and active citizenship, and how these can be applied to improve service delivery.

Key Features

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• Offers an alternative approach to thinking and a challenge to leaders within primary care and to those with administrative responsibility for the sector

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• Reflects the multiple challenges facing primary care, including the rise in frail elderly patients, increasing multi-morbidities, the impact of changing demography with migration and much more

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• Sets these challenges in a context of increasing workforce pressures, including changing attitudes to professionalism, burnout and recruitment difficulties

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• Outlines a road map for improvement, responding to current challenges around social care as well as digital/e-health

Aimed at, and written for, all those committed to improving the future of the primary care sector in the UK and internationally, this important book will be of interest to students, clinicians, managers, commissioners, policy makers and service users.

1

Introduction: The burning platform

Key messages

The book’s key messages are presented right at the start, but the development and thinking which have led to them take up the rest of the book. They are presented here to make it absolutely clear where we are heading.

The current design of the British primary healthcare sector is no longer “fit for purpose” – we have a 1940s model which is no longer fit for our twenty-first century “digital” age. It has offered a national service with a uniform, “one size fits all” approach which lacks the flexibility of provision to make it fit for the digital age where the context within which the service is delivered is very different. The recommended redesign or transformation is based on four key elements and the following analysis makes the case for

1.Active citizenship

2.Redefined professionalism

3.Mutuality

4.Organisational integration

This means bringing together the elements of the existing National Health Service (NHS) “Mark 1”, which have underpinned the success of the primary care sector for its first seventy years, together with the opportunities offered by the digital world we now live in.

These key messages and all that they imply form the material I consider in the rest of the book. I hope you will be energised by the analysis, engaged by the stories and examples, and inspired by the vision. While I recognise that we will all disagree about elements, or dimensions, of the design, I hope you find the book a positive force offering you and your family a glimpse of a more secure and healthier future.

“Burning platforms”

These are very powerful drivers of strategic change [2]. They are what happens when

●There is a real and immediate crisis.

●There is a limited number of difficult and challenging choices or alternatives.

●Each of the choices is irreversible.

●Each choice has a high risk of failure.

The phrase comes from a real incident dating back to July 6, 1988. On that date the Piper Alpha oil rig in the North Sea exploded – the result of a failure to check some simple systems that had worked faultlessly for the previous decade. The explosion in turn caused a massive fire and 167 men died – the largest number killed in an offshore accident.

The scale of the blast was immense: the flames from the blaze shot 90 m in the air and apparently could be seen 100 km away. At first the workers locked themselves in a room in part of the rig, hoping the fire would burn out or emergency systems would kick in.

Eventually three men, realising this wouldn’t work, made it to the edge of the platform, and stood staring into one of the world’s coldest and roughest oceans. They had two choices – to stay where they were and hope for possible rescue from the flames, or to jump into the freezing ocean and risk almost certain death from hypothermia. Two men chose to jump – and they lived, despite being terribly injured, thanks to a rescue operation mounted by sea. The man who chose to stay put, sadly, perished, as helicopters failed to make it in time.

That story contains some powerful learning about the need to respond positively and proactively to serious strategic challenges. It also offers a clue about how to communicate about such challenges.

First, there is the idea of the unacceptable option of staying the same. The man who stayed put on the rig in the case study died essentially because he waited for someone else to help him. Staying the same – not going through the change – and hoping things will get better is to risk probable failure.

Second is the message that sometimes radical, risky change is essential, if painful. Against the odds, the two who jumped survived, though they broke their legs in the process. It hurt, but the action they took gave them the very slight advantage they needed. Above all they took action.

So a burning platform is so serious that it requires action. A burning platform requires a response to an acknowledged crisis, choosing from a limited number of difficult and challenging options. These choices are irreversible and each choice has a high risk of failure.

If we accept that English general practice faces a burning platform situation – and I do – then this book is written to describe a route away from it towards safety. This is not an academic textbook to support research and practice in the sector as this is already well catered for [3]; rather this is a book to support evolution of the sector to ensure it remains fit for purpose as the world around it changes.

At the epicentre of this burning platform, which is the current state of the English primary care sector, are the problems facing current general practitioners and concerns about their future as GPs or family doctors. This book is primarily written for them, from my experience as a GP or family doctor, to offer one vision or description of the future of the primary care sector. That is, being able to put all the evidence together across the primary care sector, which includes changes in their role as GPs or family doctors: from being the omnipotent Dr Finlay type of model practitioner, one who provided all the care he can to his (and it was largely a male preserve) patients, provided the practice premises, employed the staff referred when appropriate to specialist colleagues, and often worked in partnership with one or more other GPs. The GP who worked alongside district nurses and midwives in the local area and other colleagues and clinicians such as mental health and palliative care nurses, pharmacists and counsellors, and social workers and school nurses. From this traditional model of the omnipotent GP at the centre of a network of healthcare providers in the community we are moving into a future which GPs and other clinicians can rely on and commit to. We are moving through from the current burning platform of

1.Workload pressures resulting from demographic and clinical practice changes and the increasing burden of complex multi-morbidity and frailty.

2.Workforce problems, with recruitment and retention of clinical staff being particularly problematic for doctors and nurses.

3.Falling practice profitability, where after a decade of austerity, the partners’ take-home pay has been in decline.

4.Increasing accountability, with falling popularity and respect from the population alongside a rigorous inspection programme from the Care Quality Commission (CQC), which shines lights into forgotten corners and asks awkward questions before rating each practice and enforcing “quality improvements” across the sector for the first time.

5.At the same time as the key features of general practice, such as the role of the GP as gatekeeper to the rest of the NHS, are being challenged by walk-in centres and hubs, NHS 111, and minor injury units along with new empowered independent practitioners such as advanced nurse practitioners (ANPs), paramedics, clinical pharmacists and physiotherapists – all providing some gatekeeping functions or referral to other parts of the service.

6.Registration, another key feature of general practice, which is becoming less relevant and central to the model, as access to online services such as digital provision are emerging as an alternative option for many.

7.Another key feature, continuity of care, is increasingly tricky when so many practitioners work part-time, and as a result many locums and salaried clinicians are employed to supplement the self-employed GP partner workforce. Knowledge of people’s past medical history is increasingly reliant on comprehensive, reliable, properly coded medical records, rather than on long-term, trust-based relationships between people with good memories. (My first receptionist when I became a GP was Pam or “Aunty Pam” as everyone called her. She knew everyone and all their biographies. She had been the practice receptionist for my predecessor for over twenty years. Without her I would have been lost, and reliable records, while nowhere near as comprehensive as Pam’s memory, are essential for continuity of care in a modern service.)

8.Professional partnership has been the dominant business model of general practice since the beginning of the NHS, but is now seen as less attractive to many trained GPs, who see a career as a locum or salaried doctor as meeting their own personal needs and career aspirations without the responsibilities and burdens that they see as requirements of the partnership option.

9.The registered GP has been the holder of the “lifelong” biographical medical record since registration was introduced, but access to the record has become more of an issue as new providers and clinicians (walk in centres and out-of-hours GP services, for example) have emerged requiring access to the information about the people who consult with them. While it remains a key feature of the NHS that the lifelong record is maintained, it does need to inform our care wherever we attend, and currently the somewhat discoordinated sector is not able to ensure that.

10.On the other side of the consultation is an increasingly elderly population with increasingly complex health problems, taking a range of medicines long term, and requiring a level of knowledge skills and experience well beyond that available to previous generations.

It is this multi-legged platform which the book traces the history of. It describes the forces driving the platform towards a future vision which can inspire future generations of clinicians. This is a sector which provides for an increasing proportion of the populations health needs, spanning aspects of social care as well healthcare – covering treatment and prevention of disease, providing cradle-to-grave personal, expert generalist care to the whole population through a system which has the confidence of all parties. The transition fr...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• 1. Introduction: The burning platform
• 2. Keystones
• 3. The sector’s heritage
• 4. The current situation in primary care: From analysis to interpretation
• 5. Synergy
• 6. Learning to support effective care
• 7. Systems thinking in primary care “system archetypes”
• 8. Mutuality
• 9. Thinking outside the box
• 10. New dawn: Welfare in NHS Mk 2 – A new social compact
• Glossary
• Abbreviations
• Index