General practice is not working. Many of us feel overwhelmed by a job that has become undo-able. We are trapped on a treadmill trying to meet escalating demand while lacking time to reflect on how to provide and organise general practice for the future.
We are not helped by an organisational structure that is way past its sell-by date – the ‘corner-shop’ partnership model. Innovative ideas are often vetoed by burnt-out older partners too close to retirement to contemplate major changes. Burn-out increasingly feels like a grim inevitably to young GPs.
Medical students and young doctors planning their careers are deterred by the bad press surrounding general practice, and the clearly exhausted GPs they meet during their primary care attachments. They see no ‘Big Ideas’ to make things better, resulting in the current recruitment crisis.
Despite this, most of us still want to do the best for our patients and look back through rose-tinted spectacles at the ‘Dr Finlay Model’ of general practice. We feel guilty that we are no longer available to our patients ‘24/7’. We feel guilty when we make the decision to work part-time even though full-time general practice is unsustainable for most normal people.
All of these factors militate against a wholesale ‘re-imagining’ of general practice, which is surely what is needed?
Re-imagining general practice
We invite you, therefore, to consider our attempt to ‘re-imagine’ general practice – the Roundhouse model of primary care. We’d be interested in your feedback.
The Roundhouse model relies on a new skill-mix of healthcare professionals working within an innovative building. The first port of call for patients is no longer a doctor, but a physician associate (PA) or an advanced clinical practitioner (ACP).
There could also be community pharmacists, occupational therapists, physiotherapists, community psychiatric nurses, counsellors, paramedics, social workers, medical assistants and others within the team.
The team is closely supported by doctors with a new title: consultant primary care physicians (CPCPs).
Patients would establish a long-term relationship with their ‘usual’ PA or ACP who would provide the continuity-of-care that we know is so highly valued. However they may be triaged to other healthcare professionals for certain clinical problems as revealed to the nurse triage team supported by CPCPs.
The PA remains a relatively new healthcare professional within the UK, although 22 British universities have now established PA courses from which PAs are beginning to graduate. The DH, Royal College of Physicians and RCGP have produced a competence and curriculum framework for PAs that it defines as:
‘a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision.’
The Roundhouse building
The Roundhouse consulting suite comprises a circular arrangement of consulting rooms, each with two doors. Patients enter through the door on the larger circumference.
The inner doors give access to the ‘Roundroom’, the hub of the complex, which is occupied by a small team of consultant primary care physicians who, importantly, have no booked patients. They support a small team of triage nurses, also in the Roundroom, and are available to speak to patients immediately, if required.
The diagram shows eight consulting rooms that would probably be supported by two CPCPs in the Roundroom. Early pilots would explore the optimum ratio.
The consultant primary care physician
In the Roundhouse model doctors would occupy a very different position from that of the traditional GP - a role possibly more appropriate to the duration and complexity of modern primary care training. It would include:
- leadership of this complex team of healthcare professionals (HCPs).
- overarching clinical responsibility for the Roundhouse.
- immediate support for any of the clinicians requiring advice, entering consultation rooms on request through the inner doors.
- advice to the nurse triage team co-located in the Roundroom.
- complex telephone consultations.
- complex email consultations referred by PAs and ACPs.
- advising on more complicated laboratory results.
- advice to resident community pharmacists on complex therapeutic optimisation matters.
- advice to resident community psychiatric nurses and counsellors on medical management of their patients.
- advice to home-visiting PAs and paramedics via video-links and head-cams with images relayed onto large screens in the Roundroom.
- have protected time to explore latest evidence and management guidelines.
- run frequent multi-disciplinary team meetings to disseminate their knowledge and experience.
CPCPs would not:
- see patients with ‘undifferentiated illness’.
- type clinical notes.
- perform routine clinical measurements.
- review hundreds of laboratory results.
- complete endless statutory forms .
- write referral letters for simple problems.
We are proposing a radical new role for physicians in primary healthcare. The role will certainly not be to everyone’s taste. Unfortunately, the NHS can simply no longer afford for every patient who ‘believes themselves to be ill’ to be seen by such an expensive and highly-trained ‘asset’.
Could you see yourself in this job?
- Dr David Lewis is a GP and honorary senior lecturer at the University of Worcester and Jane Perry is head of allied health and applied social sciences at the University of Worcester