Viewpoint: Dr Tony Downes: Health and social care: The next generation

A generation ago, new Labour won a landslide general election victory when the NHS was struggling with escalating demands, inadequate resources and problems with GP recruitment and retention, writes Dr Tony Downes.

Dr Downes: 'Many GPs are still defined by the way they are paid and not by their expertise and qualification.'
Dr Downes: 'Many GPs are still defined by the way they are paid and not by their expertise and qualification.'

At that time, the GP non-principal movement emerged from a significant minority of GPs unhappy with restricted career opportunities outside of the GP partnership model, and who held a sense of injustice and disenfranchisement; locum GPs were excluded from the NHS pension scheme and felt unappreciated despite delivering a substantial proportion of NHS care. The change of mood for equity and opportunity for all GPs was harnessed by the NANP, a small group of GPs who worked in their own time to successfully lobby their professional bodies and government for reform.

Also at that time, the incoming government inherited the outgoing government’s Primary Care Act of 1997 that allowed for ‘NHS family’ members to deliver pilot schemes with the opportunity for GPs, dentists and nurses to work in new ways to meet identified patient needs and improve outcomes. The maxim at the time was ‘no third party in the consulting room’ and certainly, no private interests. However, private sector involvement in the NHS has grown, as has managerialism and intrusion into the doctor patient relationship.

Little value placed on GP expertise

Despite the opportunities promised by the PMS and new GMS contracts, health and social care remain separate and a gulf exists between primary and secondary care with blame directed at GPs for secondary care problems and failures such as the A&E crises. Many GPs are still defined by the way they are paid and not by their expertise and qualification. There seems little value placed on the GP expertise in the car production line NHS or in the private contractor supermarket. Escalating demands, inadequate resources and GP recruitment and retention are the main issues at the current general election; not much change there then.

The health service is a complex adaptive system, which means that it will always respond to demands irrespective of any re-organisation and any top down directives but at high price for those who continue to run the NHS with their caring and altruistic natures. The industrial mindset that values the intervention and profit above all has failed to grasp the most fundamental driver of health outcomes; the relationship. It is the problems of attachment, separation and loss identified by Bowlby that affect us all and drives demand in health and social care. Toxic human relationships induce maladaptive behaviours and damage our genes. This is true of our patients as well as professionals, managers and government. We are all in this together.

The 21st century model of healthcare needs to embrace the science of the relationship and its potential for good or harm as defined by Balint; the doctor as a drug or as a side effect, and this concept can be extended to all professionals and organisations. The complex adaptive NHS on the edge of chaos requires equivalence of corporate governance to post-Shipman clinical governance; where there is zero tolerance of psychological violence and fraud.  Organisations with shared values of both nurturing relationships and evidence-based healthcare should facilitate integration and self- organisation of health and social care systems. The values of general practice with personalised, continuous and evidence-based care is the necessary attractor of this new system in which a new generation of GP is much more than just a commodity and also much more than even dear Dr Finlay.

  • Dr Downes is a GP and GP with a special interest in psychological trauma.

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