Practitioners and Practices

A Conflict of Values?

Julian Pratt, Martin Rowland

• Publisher: CRC Press
• Year: 2018
• eBook ISBN:
  9781315349039
• Topic: Medicine
• Subtopic: Health Care Delivery

General practice is the cornerstone of primary care in the UK. However, this traditional model has been challenged by new visions of its role, particularly a responsibility for improving health as well as for the care of illness, and a responsibility for populations as well as for individuals. This book focuses on the development of general practice as a framework within which community nurses and other professionals can build their contibution to the future of primary care. In so doing it shows how the care of general practice can be maintained and strengthened. This work is intended for all primary care staff, including doctors, nurses and managers, and for anyone interested in the future of primary care in the changing NHS.

1 Introduction

This chapter introduces the main themes that will be explored in the book and provides an outline summary of its conclusions.

There are many influences that are leading to an increased emphasis on primary care in the NHS.

• Demographic changes have increased the importance of the management of chronic illness in relation to treating acute episodes of illness.
• The development of less invasive and more effective technical procedures reduces the time patients need to stay in hospital but may increase the time during which they need care at home.
• As specialization in secondary care increases and ‘general physicians’ and ‘general surgeons’ are replaced by ‘consultants with an interest in …’, the need for a generalist primary care service increases.
• The NHS may reduce its expenditure by externalizing ‘hotel’ and transport costs, transferring them to patients and their families.
• Users of the NHS are expressing a preference for community-based services delivering an appropriate local service.
• Perhaps most importantly, the influence of primary care on the commissioning of secondary care has increased the power of primary care to shape the overall delivery of health care.

Primary care providers have the opportunity to play a pivotal role in the development of the NHS as a primary health care led service. This arises centrally from the change from rationing of services (allocation of resources) on the basis of the historical claims of providers (particularly in secondary care) to rationing on the basis of local health need, and the involvement of primary care providers (through the fundholding mechanism or non-fundholding consortia) in this process.

In order to play this role, general practice and other primary care providers will need to be different from how they have been in the past. If this change takes place without a genuine appreciation of the nature of general practice, there is a danger that some of its essential qualities may be damaged or lost.

The King’s Fund London Commission proposed increasing resources for primary health care in order to:

• strengthen core general practice
• extend primary health care
• reshape the primary/secondary care boundary.

As part of its commitment to taking forward the work of the Commission, the King’s Fund Primary Care Group organized a series of ‘Capital Conferences’ around each of these three themes. This book, on the theme of identifying and strengthening core general practice, is derived from the presentations, formal discussions and informal conversations that occurred at the conferences. The focus of the conferences on the values and role rather than the tasks of general practice is reflected in this book, the purpose of which is to contribute to an improved understanding of general practice, both by those who work in it and by those who commission and use its services.

The conferences chose to focus on the values of general practice, rather than more narrowly on the values of GPs or more widely on the values of primary health care. In particular, community health trusts and their community nurses have thus not been directly considered, in spite of their importance as providers of primary health care and their close working relationships with general practice. It seems likely that the core values of community nursing have much in common with those of general practice. This book may provide a framework for exploring the values of others providing primary health care – both as individuals and in organizations.

General practice is a cornerstone of primary care in this country. The traditional model has been challenged by new visions of its role, particularly a responsibility for improving health as well as for the care of illness, and a responsibility for populations as well as for individuals. The past independence of general practitioners has allowed innovation and good practice to flourish but has also resulted in some unacceptably poor practice². The failure of the medical profession to address this problem has resulted in this challenge being taken up by NHS management, through the Family Health Services Authorities (FHSAs) and health commissions.

There is low morale among many general practitioners, and the most commonly expressed reasons given for dissatisfaction are practical ones, such as the amount of paperwork, the clinical work-load (especially out of hours) and interaction with administrators³. There is also a debate within general practice about the ‘task of the new general practitioner’⁴. It seems likely that the low morale is in part related to the uncertainty about the changing tasks and, even more fundamentally, the changing underlying values and role of general practice. There is a feeling among many GPs that their core values are being eroded and that the good general practitioner now survives in spite of, rather than because of, the organizational context.

A core value of general practice is a very broad, high-level characteristic or quality, which is both wanted by those who use the service and needed in the judgement of those who provide it. It is a characteristic that is prized and without which the service is lacking something of importance. It is derived from past experience and transmitted to the future, much as the essence of an organism is transmitted by its genetic material.

The aim of the Capital Conferences was, therefore, to:

• examine the way in which current developments may be altering the core values and content of general practice
• clarify the nature of this core
• nourish the core without colluding with the avoidance of change.

There has been an historical development from the practitioner as a doctor working alone or with a small group of colleagues, to the practice as an organization. The values identified as being at the core of general practice appeared to fall into two broad groups.

• The first group, described here as practitioner values, are those appropriate to the one-to-one relationship with a patient. These are the values of doctors, nurses and counsellors. They reflect the central importance of the individual patient and the need for the practitioner to give the highest priority to that individual.
• The second group, described here as practice values, are those appropriate to improving the health of a population. These are the values of practice managers, some doctors and nurses, and colleagues outside the practice, from health commissions to ministers of state. They reflect the central importance of maximizing health gain for a population within the available resources.

Traditionally, a general practice used to share the values of its practitioners, that is to say the focus on the individual patient. What I have called practice values were held not within the general practice but by health authorities and the NHS management structure. Since the 1960s, many general practices, with the encouragement of the Royal College of General Practitioners, have taken on practice values. Since the 1990 contract, these values, particularly those related to the allocation of resources, have had an impact on all general practices.

Just as doctors in general practice have experienced uncertainty about their core values, similar dilemmas have arisen for others working in primary care, in particular practice nurses. Many have been recruited primarily to meet the needs of the practice (eg to achieve population targets and run well-person clinics). They thus need to subscribe to the core values of the practice, yet from their past experience of one-to-one patient care, nurses will also have brought a set of core values that are referred to here as the values of the practitioner rather than of the practice.

These two sets of values in some ways support each other but in other ways are in conflict. Many general practices have found ways of accommodating both sets of values without making them explicit, but this accommodation has consumed much energy and probably represents a truce rather than an equilibrium, with the potential for breaking down under the sort of pressure that would arise if general practice were expected to increase its work-load still further without the provision of the resources to enable it to do so.

This book seeks to name the core values of practitioners and the core values of practices, in the belief that each is appropriate in its appropriate context. Understanding and honouring both sets of values should help all who work in general practice to make sense of and resolve the confusion, conflicts and unease currently experienced. Practitioner and practice values must also be understood and valued by NHS managers if general practice is to play its part in the ‘strategic shift’ to a primary health care led NHS.

Summary of values

In describing core general practice, we can distinguish between practitioners, who work in one-to-one relationships with patients responding to their concerns, and the practice, an organization with wider concerns, particularly for improving the health of its registered population of patients with the available resources. Once this distinction has been made, it is clear that there are important differences in underlying core values. Practitioner and practice values are summarized in Table 1.1 and are explored in the body of this report.

Table 1.1 A summary of practitioner and practice values

Conflicts of values

The values described here by the term practitioner are broadly those of the family doctor, whereas the values described by the term practice are broadly those of the new public health. In many situations, the two sets of values support each other in constructive tension. However, the wants of individuals are not compatible invariably with their needs as assessed by another or with the needs of a population. In these situations, the two sets of values are in conflict.

This may be apparent whenever services are rationed. If a practitioner spends time working to improve the population health, that time is not available for individual patients. The conflict is apparent most obviously if a practitioner (whose value system requires her to represent the interest of her individual patient) is involved with the practice task of the allocation of funds f...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Series introduction
• Foreword
• Acknowledgements
• Terminology
• Abbreviations
• 1 Introduction
• 2 The core general practitioner: the doctor, the patient and the illness
• 3 Core general practice: the practice, its population and their health
• 4 Some possible futures
• References
• Index