Dr Michael Dixon, Chair of The College of Medicine and Co-Chair of the National Social Prescribing Network, delivered the following speech in his opening address at the Westminster Health Forum on March 9th 2022…
‘General practice is on the edge of a precipice. The family doctor, providing personal care and continuity, is fast disappearing. According to IPSOS MORI less than 50% of patients can now name their family doctor. Why? Because promises of extra GPs have been broken. When I started in general practice there were three times as many GPs as hospital consultants – today there are more hospital doctors than GPs.
Because general practice receives proportionately less of NHS resources year on year – down from almost 10% in 2005 to 7.1% two years ago – and when those resources do come, they come with absurd conditions. Because the bureaucracy is stifling and the working day now quite frankly unworkable. And all the Centre can do, in guidance published just eight days ago, is impose further rules and micro management, extra work and show a complete lack of understanding the real needs of beleaguered GPs and our equally beleaguered patients.
General practice – once the jewel in the crown of the NHS, envied by the outside world and dealing with 90% of problems with much less than 10% of the budget – has been betrayed. Particularly its young GPs and patients. That is the context in which I want to spend the next eight minutes talking about personalised care and multidisciplinary working with the community. I have just five points to make. First – the need for personalised care in our disordered and disconnected world has never been greater.
We know that having a personal GP leads to more satisfied patients and GPs, 30% less acute admissions to hospital and use of out of hours and you are 25% less likely to die. New discoveries around the genome and the biome are pushing our treatment and our science in a much more personal direction and away from that blunt instrument of simply applying population-based evidence to every individual.
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After all, we are self-organising beings with varying levels of self-healing abilities and resilience – personalised medicine recognises that our beliefs, our hopes, our history and our culture are all relevant to the process of healing. My second point is that Covid has quite obviously made these personal connections much more difficult whether it be the necessity of virtual consultations or wearing masks in the face-to-face consultation. Our medicine has become more transactional, more episodic and developing relationships has become more difficult whether it be between GP and patient or between social prescribing link worker and patient.
That has limited our ability to have the sort of complex and indepth consultations that really change things. So, my third point is that we must now restore those relationships and personalised care in spite of the enormous pressures now facing general practice. Each practice and patient will find different ways of doing this.
For some, given that so many of us work part-time, it may be a question of forming small teams within larger practices so that patients can contact a recognisable member of the team on any one day. The increasing number of non-clinical social prescribing link workers will enable them to relate to those in most need and often with complex problems and give time and provide a level of personalised care that has become so difficult for us GPs in recent years.
Fourthly, a crucial part of this reconnection will be the rebuilding of multidisciplinary teams in every general practice. Where have they gone? I used to meet our health visitor and district nurse every week but now they have disappeared into Community Trusts. Ten years ago, in my own practice, we had three attached psychiatric nurses for child and adolescents, adults and the confused elderly. Today they are in outer space in Mental Health or Partnership Trusts. We are left to cope on our own. So we need to rebuild the multidisciplinary team in general practice and extend it, as many are, with pharmacists, physiotherapists, paramedics nurse practitioners and social prescribing link workers.
Only then can we meet the almost infinite demands on general practice and GP practices and Primary Care Networks must be given much greater autonomy on how they go about this. Especially when it comes to mental health and children and young people in particular. How else can we possibly help the one quarter of 14-16 year old girls that are self-harming, children with autism and ADHD, who have to wait forever or those three quarters of children that we refer to child and adolescent mental health services, where our referrals are turned down?
When we have re-created an effective multidisciplinary team in every general practice with strong mental health input, we can then proceed to my final point. We must then connect GP practices and Primary Care Networks with the local authority and local voluntary sector if we are to revolutionise our potential for improving local health. Future general practice must work with schools, local planning, local business and every health-related aspect of the local scene.
There is no other way that we will ever be able to tackle those pressing issues such as the 40% of 11 year old London school children, who are obese or overweight, the 70% of people dying from heart disease that might have been prevented by a better lifestyle or the dreadful inequalities around us that are getting ever worse. Social prescribing can be a catalyst for this. Not only sweating local resources – both social and environmental to help those in most need – but also building up those resources as a result of needs that have been identified.
“Our medicine has become more transactional and developing relationships has become more difficult whether it be between GP and patient or between social prescribing link worker and patient…”Dr Michael Dixon
A crucial part of this, and which the NHS is ideally placed to offer, will be to create a huge local volunteer force that can supplement the work of us professionals. We have seen it already with volunteers in our Covid clinics but there are also some dramatic examples such as Ilfracombe, here in Devon, where there is a volunteer coordinator on every street connecting those in the street to any volunteer or voluntary services that they might require.
Nearby, in Frome in Somerset, there are almost two thousand community connectors – taxi drivers, hairdressers, shop assistants and students – again connecting people to local services that are available. Creating these local connections, de-professionalising and giving a greater role to volunteers and the voluntary sector is the only road to sustainability for our health service or, indeed, any other. In short, future general practice should become the activation arm of local public health. Now some of you will say that we have got enough to do already.
Of course we have but we will forever be trying to mop up the consequences of our unhealthy communities unless we begin to play an active role in making them healthier and happier in the first place. It will require more people and more resources but we already know from WHO and other extensive research that extra funds put in to primary care lead to less deaths, better health and financial savings for the health service.
I spoke at the beginning about betrayal but there is now an opportunity for salvation – the family doctor restored but also supported to play a major role in the health of the community and the ability of his or her patients to care for themselves. It is an opportunity, in the depth of crisis, that we must not miss.
A natural extension of our traditional role and model of family medicine that has historically served so well but is now the focus of central plans for reforming general practice. Plans – if I may end as I began – that must recognise that general practice has not failed but that it has been failed and that we must now urgently enable it to rise like the phoenix from the ashes of neglect.’