This article was first published in Practical Commissioning on 12 December 2011, and shows the origins of some of the ideas cited in my blog about managing expectations (1 March 2013).
What makes doctors choose general practice? When I made that choice, I was attracted by the idea of holistic whole person care, and of developing long term relationships with patients, their families and even their communities. There was also the appeal of ‘divergent thinking’, rather than the reductive mechanical approach that was followed in hospitals. But there was something stronger too, a pull towards the community as much as a push away from hospitals, something about self determination and control; doctors in general, and GPs in particular, are individualists who don’t think corporately. Is this down to nature or nurture?
As far as nature is concerned, medical schools select bright students with scientific backgrounds, and enough ‘open’ thinking to allow them to develop good clinical judgment. On the nurturing side, the emphasis throughout medical training and postgraduate development is on autonomy and the importance of personal accountability to back the primacy of the doctor/patient relationship, based as it is almost entirely on individuals.
We take this approach because society values the ‘sanctity’ of the consultation, and the fact that what happens between doctor and patient remains entirely between them. This mutual trust depends on this axis of confidentiality, and so anything that threatens the primacy of this relationship would be extremely hard to sell to GPs.
These thoughts came to mind when I was at the NHS Alliance conference recently, talking about the future of the NHS. I was thinking about what it takes to persuade the autonomous, self-determining, (generally) self-employed individuals who are GPs to change at all, never mind acting in a corporate fashion and taking on a externally imposed agenda, with a budget deficit and bureaucratic rules that would make even a seasoned civil servant blanche…
There isn’t a simple answer, but generally, if you want people to take on a new and risky role in a meaningful manner, you need to follow the dictum of ‘sell it, don’t tell it’. Those taking on the role need to believe in its value, see some benefit from doing it, and be exposed to as few surprises in its implementation as is possible.
Does this work if we consider the moves towards genuine clinical commissioning? Although the jury is still out about its effectiveness, most GPs like the notion of having more control over what happens to their patients in the secondary care arena. They are however highly suspicious and extremely cynical about the motives of the Government in setting out this agenda, many believing that any benefits will be in terms of money saved for the Government, rather than for improving services for patients or (dare one say it) benefitting GPs themselves.
Increasing the bureaucracy of the system (as already seems to be happening), making the approach ever more parental, and limiting the scope for innovation and diversity would all be excellent ways of smothering the changes before they even start; just look at what happened to practice-based commissioning, which ground to a halt even before it was fully established.
Moreover, in the words of the aphorism, ‘an expectation raised and dashed is worse than no expectation at all’, and over the past 20 years, GPs have had their expectations raised and dashed many times; whether we are talking about fundholding, ‘a primary care led NHS’, PCGs, PCTs, or PBC. In each instance, much effort was put into persuading the GP community that this was their breakthrough moment, only for each initiative to become diluted and eventually scrapped. For the evangelical GP, each step along this Via Dolorosa may be seen as inevitable on the path to salvation, but for the jobbing GP, perhaps vaguely interested but certainly not prepared to subsume her mortgage payments for the sake of eventual paradise, each dashed hope merely increases their sense of disengagement and cynicism.
If the current round of reforms isn’t fully implemented (and the current tussle between the centralising clusters and the nascent CCGs doesn’t look promising), Dr Average may well take his or her ball away for a very long time, and simply get on with the day job; and given that the day job includes indirect control of most of the resources of the NHS (wisely or otherwise), this scenario may be one that the Government wishes to avoid..