Updated: Nov 1, 2018
Written by Professor Clare Gerada - Senior Partner Hurley Group, Medical Director PHP , National Medical Director GPH, Member of BMA council, Member of RCGP council, Member of GPC council, Hon Sec Medical Women's Federation, Ex Chair RCGP National Order Merit, Malta
I was recently asked to think of my top ten innovations in therapies, technologies and practices from the last decade. This too mark the 70th anniversary of the NHS. I decided to stick to what I know best and restrict my thinking to general practice. When I began, I was amazed by how much had changed, but also how much has stayed the same. It’s worth reminding ourselves, though, what our core role is. Since we became a speciality of family doctors, our role has been to connect with patients in the context of their families and communities from cradle to grave, providing care across physical, social, psychological and increasingly existential domains. We provide first contact care for undifferentiated problems and continuing care for all. The tool of our trade is the medical record – which we must never relinquish. We are tasked with providing our patients with access, care co-ordination (which includes continuity of care), proactive care and when the time comes, care at the end of our patients’ lives. General practitioners do all of this. With this in mind, I measure success of any innovations against how well we can continue to deliver these basic tenants of our profession.
So, my top 10. They surprised me – some in their simplicity, some because I had thought they had been around forever and some because I can recall at the time how much they were opposed by our profession. I leave you to guess to which category each belongs.
The first, general practitioners working at scale. Whether as a part of federations, super practices or accredited care organisations, general practitioners are joining up and sharing services across their communities. Now patients can choose between seeing any doctor and being seen sooner (e.g. at a GP Hub, Urgent Care Centre), or waiting to see the doctor of their choice at their own registered practice. These models will grow and mature over the next decade and become both provider and commissioning organisations.
My second innovation is electronic prescribing. The NHS Electronic Prescription Service (EPS) enables the electronic transfer of medical prescriptions from doctors (or other prescribers) to a pharmacy of the patient’s choosing and also dispenses an electronic notification to the reimbursement agency. In my professional life, I have moved from handwriting all prescriptions (it would take 2 hours per day per doctor) to pressing buttons and using a pen only on a few hand-signed (mainly acute or controlled drug) prescriptions.
My third is social prescribing. Essential to a general practitioner’s role is supporting patients in their community and addressing public health through addressing social factors. Perhaps the greatest book ever written on general practice, John Berger’s A Fortunate Man; The story of a country doctor, examines the work of John Sassall, a GP working in a deprived rural mining community. Sassall lived and worked in his community and used his influence not just to treat patients in their consulting rooms but also to address the determinants of their ill health and to try and influence change. He was also mindful that most of what he saw could not be addressed by conventional medicine and that social factors were just as important. The general practice in Bromley-by-Bow took this concept one massive step forward. Starting in the mid 1970’s it engaged with the community to address the massive health issues the clinicians were seeing in their consulting rooms. By providing gardening clubs, social clubs, cookery classes and more, alongside standard clinical medicine, the surgery helped transform the concept of general practice. Other practices across England did similar work. In the last decade, social prescribing has been firmly established as a way of linking patients in primary care with sources of support within the community. It provides GPs with a non-medical referral option that can operate alongside existing treatments to improve health and well-being. People are living longer and as they get older, are developing long term health conditions. Their health is affected by a wide range of factors including employment, housing, debt, social isolation and culture. These factors are not readily aided by traditional health interventions. Social prescribing presents the NHS and local authorities with an opportunity to radically increase prevention and public health.
My fourth (and here I have a conflict of interest in being a share holder of e-consult) is digital or virtual consulting. Until recently, the GP consulting model hadn’t changed since 1948. However, the pressure on both patients and doctors has changed beyond recognition and harnessing technology and digital innovation is critical to the future of the NHS. This decade has seen the advent of digital health and its ability to deliver continuity whilst reducing demand, what must be considered he holy grail of general practice. Digital technology is disrupting every aspect of our lives. From banking and shopping online to Uber and Airbnb, technology has created a new normal. The public / people will expect access to digital healthcare advice to become another new normal with ‘e’ consulting being as (if not more common) than face-to-face consults. Digital is good for people and good for the NHS. GP at hand is one innovative model which uses AI, eConsult is another model. Digital consulting is set to transform how patients interact with their GPs. This is not about opening another lane in an already busy primary care motorway, but helping patients leave the motorway completely. Electronic consultations will safely guide patients to the best part of the primary care system (self-care, 111, pharmacy, nurse, face to face GP, AE, telephone advice) without the patient having to come into the surgery.
My fifth is independent (non-medical) prescribing. Initially launched in 2006 over the last decade the range of who, with appropriate additional qualifications, can prescribe any licensed drug from the BNF has expanded to include, for example, nurses, pharmacists, podiatrists, optometrists and physiotherapists. Independent prescribing has allowed the development of new roles, allowed genuine autonomy, and benefited services and patients.
My sixth, is online referrals (Chose and Book, letter templates, etc.). When I started general practice, we dictated all letters into a machine, to be typed up later by our secretaries. Now this is all done via templates using computer consultations and transmitted via email. Over the last decade, how we interact with secondary care and make referrals has been transformed.
My seventh is patient self-referral: especially to IAPTs and Termination of Pregnancy. This has cut out delays (which can be serious for both mental illness and where a woman wishes to terminate her pregnancy). It has meant that the patient is in control and that the GP can focus on counselling the patient rather than making a referral.
My eighth is another where I have a conflict of interest. It is the Practitioner Health Programme (www.php.nhs.uk). Now entering its 10th year, the NHS Practitioner Health Programme is a confidential, mental health and addiction service for doctors and dentists in England (all doctors and dentists in London, and all GPs across England). It is integrated (in that the multi disciplinary team work together, share physical space, medical records, learning and patients); GP-led; holistic (in that it provides care from prevention through to treatment [pharmacological and psychological]); the first mental health service of its kind for doctors in Europe. The service has addressed the problems related to doctors being reluctant patients and having structural and other barriers placed in their way when they try and access confidential care. The service has seen around 10% of all London doctors and since its launch in Jan 2017 2% of all GPs in England. It has been shown through independent analysis to provide value for money with remarkable health, return to work, social functioning outcomes and by implication (safer doctors make for safer patients) better quality of care for patient.
My ninth has to be the increase skill mix in our practices – especially the pharmacist.
My tenth, last but by no means least, is allowing GPs to work in extended (special interest) roles. I worked as a GP in mental health, care of the homeless and drug misuse and now many GPs work in extended roles across the NHS. This adds value and helps with career development – important if we are to retain our profession.
These are my ten. They are by no means the only innovations and I am sure many of you have others which you can add. I have been a GP for 26 years now (and have been involved in general practice in some form for 40 years as I worked as a Saturday receptionist before starting medical school). My life as a GP has transformed. It is now safer, more efficient, higher quality. For GPs entering now they have more choice in how, where, and when they work. Despite its difficulties, general practice has a bright future and I wish the next generation well. I hope that they have as fulfilling career as I have had and maybe in a quarter of a century my top ten innovations will seem like the stone age.