If you had been in Manchester in December 1908 you would have witnessed an unusual sight, a convoy of almost 300 sick patients being carried out of the dilapidated Infirmary on Piccadilly to the new hospital on Oxford Road. They were being transported in what historian Stuart Hylton describes as “a motley collection of horse drawn-ambulances, taxis, flat wagons and a horse bus”. Apparently, one person was so sick that they were left behind – perhaps an early example of personalised care, given the old infirmary was not demolished until two years later.
How do I know this? I know because the social history books are littered with stories about hospitals. Public health always gets a good look-in too, particularly the Chief Medical Officers, who tend to make heroic cameo appearances during cholera epidemics.
But look for references to the growth in and evolution of the role of family doctors, and you will be hard pressed. The bedrock of our National Health Service – general practice – has, it seems, always been taken somewhat for granted, flying under the radar of the sweep of history.
Perhaps this is part of the reason we have allowed general practice to fall into gradual decline. At a time when demand for primary care is rising, the proportion of our NHS budget we spend on general practice has been slowly falling. As the pressures on primary care grow so the numbers of GPs to deal with this is increasingly inadequate. And, while many GPs still love their job, others are demotivated and, frankly, lots are exhausted.
What can we do to change this? We know that here in Greater Manchester, the birthplace of the NHS, our superb medical school, (like many other top schools), struggles to persuade its students to choose a career in general practice it? What messages and opportunities are those students receiving that are influencing their choices? What could be done differently to convince those young men and women that a vocation in medicine can be fulfilled in general practice as much as in secondary care? That being a good GP is not only clinically fulfilling but actually goes much further? That it also places you at the heart of your local community, touching and influencing and connecting with the day to day lives of those people with whom you live and work.
Under our health and care devolution arrangements in Greater Manchester this is where we start from. We believe that general practice must be restored to its rightful place in our National Health Service, that the relationship between GP and patient is the pivot point of our whole plan to improve population health. We want to resource and release GPs to provide proactive continuity of care for their registered patients.
And we think we might know how to do it.
In October last year we published our primary care strategy which flowed from the excellent, national GP Five Year Forward View. It made a commitment both to wrap support services around our GPs but also to facilitate their work in wider neighbourhood clusters so as to liberate them to provide more targeted personal care for those patients who need it most. This week, we start to put some substance behind how we achieve this vision, backed by an investment of £41m from our Transformation Fund to help secure the changes.
Our first investment is to enhance access. This may seem counter-intuitive when we have talked about GPs being under such pressure, but we are convinced that there is an investable model that both improves patient access and makes better use of GP resources. The way we square the circle is by giving GPs, operating in their neighbourhood clusters, some freedom as to how they deploy the extra appointment time, particularly at weekends. This may enable them to focus on particular cohorts that make sense for their geography – students, homeless, carers etc. We also see this as a whole workforce endeavour, and so are also investing in additional clinical pharmacists and wider services.
Our second intervention is to make sense of our out-of-hours provision across Greater Manchester. We will align it much more sensibly with both routine access and the wider urgent care system, again using the neighbourhood clusters at 30-50,000 population level as key ‘cells’ in our network of local provision. Over time, we will support this coordinated offer with more integrated IT, enhanced access to diagnostic services and step-up beds. In return we will ask for a consistent approach to key primary care interventions, such as support to care homes.
If this sounds close to the US ‘medical home’ model, we don’t actually like that term in Greater Manchester. We want a model of primary care that relates to the whole person and has a social as well as a clinical mind-set. The plan is to use our emerging Local Care Organisations to give GPs ready access to wider social support for their patients, making use of wider public services and the local voluntary and community sector. Some call this ‘social prescribing’; if we get it right, it will just be ‘prescribing’ and will become part and parcel of our wider commitment to asset based community development with GP surgeries as a crucial anchor.
There are several other elements to our package but the final one I will pick out is support and resilience. It is really tough being a GP right now and they deserve better. We are therefore going to establish a support hub and network for our GPs, with peer support at its heart, not least from our CQC ‘outstanding’ practices, so that we can both spread best practice but also provide intensive help where practices are struggling. We will also help practices who want to change their status, to merge, to move into new neighbourhood hubs or just develop in new and exciting ways.
We can’t turn around decades of neglect overnight. But we believe in our GPs, they are the front-line leaders of our NHS, and we are going to back them as best we can to be the best that they can be. They hold the future of our NHS in their hands and we will strengthen that grip. In a century’s time, who knows, perhaps the history books will celebrate a different journey.