By Dr. Geoffrey Modest
UK report on primary care from the House of Commons Health Committee (http://www.publications.parliament.uk/pa/cm201516/cmselect/cmhealth/408/408.pdf)
Basic issues addressed in the report:
- Improve access to primary care by extending hours of service, reaching out to those currently disenfranchised by the existing model of care
- Improve record keeping and access to medical records as a means to improve patient safety, with patient consent for more general access to records
- Facilitate phone and IT access for patients and for consultations
- Quality improvement initiatives: Care Quality Commission inspection of primary care practices, helping practices improve
- “Ten-minute appointments do not allow adequate time for safe practice or to address whole person care. Relentless time pressure from short appointments tends to restrict patients to discussing only one problem with their GP and clinicians to working in a reactive rather than proactive manner. Given the increasing complexity of the long term conditions that are managed in primary care, allowing time to provide safe and holistic care must be a priority. We agree with the Primary Care Workforce Commission that reshaping primary care to give patients sufficient time to discuss their conditions with health professionals should be a central aim of the new models of care.”
- Develop and extend the use of team-based care, including using “physician associates”
- Increase access to consultant psychiatrists. increase communication with specialists overall by email and messaging
- Continued vigilance at national and local level to make sure that conflicts of interest are not influencing decisions
- Significantly increase the number of primary care doctors by attracting more doctors into the field. Look carefully at why doctors quit.
- Promote primary care in medical schools, including expanding the criteria for med school admissions (e.g., including commitment to providing care to a community, not just purely scientific qualifications), increasing teaching of general practice, and stress that the career is as intellectually rewarding as any specialization
- Use financial incentives/loan repayment to help place MDs and nurses in areas that historically have had trouble attracting them
- Many similar approaches as above for attracting and retention of nurses, physician associates, physiotherapists, pharmacists in primary care
- Look at other funding mechanisms, including capitated payment systems within primary care federations
- A larger proportion of the health care money should go to primary care
- Make sure that financial mechanisms reinforce primary care, instead of diverting patients inappropriately to secondary care
So, pretty impressive in many ways. Not only does it reinforce primary care as the crux of the health care system, but it suggests several specific reforms to enable that. Unfortunately, in the US we not only do not have a coherent and integrated system of care with universal access, but we have a system dominated by hospitals and procedure-oriented specialists. Even the move to capitation seems to situate hospitals and not primary care at its center. and the decision-makers for our reimbursement system is dominated by those who make lots of money from procedures (and, as I have said before, injecting a patient for carpal tunnel syndrome or painful joints takes me a few minutes and is not very complex. Taking care of my patient with uncontrolled hypertension, diabetes, etc., who is in an untenable social situation, and is depressed, is really intellectually and emotionally difficult and very time-consuming). But I think the kernel of the current UK initiatives is central to a major reorientation of our health care system (and extending the system to one of universal access is certainly another essential aspect).