Written evidence submitted by Professor Joanne Reeve (FGP0218)

Executive Summary

1. My evidence is based on 20 years’ expertise in primary care redesign for whole person healthcare. I am a practising inner city GP (salaried) and professor of primary care at Hull York Medical School. I am internationally known for my expertise on the distinct knowledge work of medical generalism.

2. Key points in my evidence:

• Medical generalism describes the distinct expertise of whole person medicine.
• Strengthening medical generalism is recognised as an essential part of addressing modern healthcare challenges  - dealing with escalating levels of illness and treatment burden that cannot be addressed by traditional disease-focused models alone.
• The work of generalist medicine requires extended professional skills in generating, implementing and learning from tailored healthcare decisions. 
• This is the knowledge work of generalist practice
• It is a form of professional practice which challenges current models of GP training, practice design and health systems strategy and culture.
• To address the challenges facing today’s general practice, we need to re-design professional practice and service models on expert generalist principles.
• My evidence outlines examples of how we might achieve that including the potential positive impact on patient care and workforce retention.

General Practice needs to change

3. General Practice  is broken:

• Organisationally, it remains fundamentally modelled on the vision of general practice described by the 1948 contract – a transactional model of healthcare with a gatekeeper-to-hospital-care function. The model now contributes to escalating demand through failure to recognise and maintain the alternative, tailored-gatekeeper function [see #12] of expert generalist practice.

• Professionally, GP is premised on a ‘jack of all trades’ view of practice that relies on knowing a little bit about a lot of things. This outdated view is contributing to growing iatrogenic harm; the failure to both prevent and manage escalating demand; and  to diminishing professional morale and staff retention.

4. National and international voices recognise an urgent need for a shift towards whole-person, generalist healthcare systems. 90% of the work of the NHS is done in primary care, and the majority of those consultations (presented patient problems) require a whole-person, tailored (expert generalist) approach. 40% of GP consultations are for ‘medically unexplained symptoms; 10% of medicines are overprescribed and 40% of people taking 5+ medicines a day are burdened by their medication; treatment burden will outstrip multimorbidity as the biggest challenge facing patients and practitioners.

5. Strong voices will tell you that the General Practice model is fine, and able to deliver generalist care. The problem, they will argue, is simply chronic underinvestment. They will describe the importance of relationship-based care, including continuity, in delivering whole-person care. They will highlight the ‘flexibility’ and innovation of general practice to deal with escalating demand (e.g. role substitution, introducing new team members) and digital technological solutions to supporting coordinated delivery of multi-faceted care (e.g. digital triage solutions).

6. But these ‘solutions’ fail to tackle the changes needed to support a shift from the transactional, jack of all trades model to a modern practice based on the principles of expert generalist medicine [see #2]. My research has described 4 barriers to delivery of expert generalist medicine in the current general practice setting, summarised as the 4Ps.

• a lack of perceived Permission to deliver tailored (beyond-protocol) care
• a failure to Prioritise the distinct knowledge work (cognitive and emotional work) needed to deliver tailored care within the array of tasks designated to general practice/primary care
• a lack of Professional skills and confidence in using the skills of advanced generalist practice within the GP profession and primary care teams
• a failure of Performance Management to adequately support the learning culture needed to support and maintain tailored care

7. Twenty years of work to describe practice-based-evidence demonstrates why we can’t afford not to change (e.g. Kovandzic, Bryce, Andah) , but importantly also how we could (e.g. TAILOR, CATALYST, WISE GP). My submission will describe how a shift to an expert generalist model of general practice can address the challenges you seek answers for; offer evidence of how we are already doing elements of that; and so invite a conversation on how we can scale further.

Addressing your key challenges

8. Your call for evidence highlights key challenges you seek to address. I start by considering how 3 of these (access, workforce, and practice/contractual design) constitute further evidence of a need to shift to an expert generalist model.             

9. ADDRESSING ACCESS

• Modern general practice confuses availability with access.
• General practice has never been more ‘available’. The equivalent of more than half the population of England visit their general practice every month. We are using technological solutions and creating new staff roles to ‘do more of the same’: creating pathways of care focused on the ‘command and control of disease’ that exacerbate the problems.
• To use a public health analogy, we are so busy pulling people out of the river, we have forgotten to go and find out why they are falling in.
• In redesigning general practice, we must re-engage with the ‘prevention agenda’ – strengthening public health, mobilising community care, but also preventing overmedicalisation.
• Addressing the prevention agenda means expanding our capacity for tailored care – the expert generalist role – and so prevention of overdiagnosis and too much medicine.
• General practice and primary care is potentially well placed to deliver this care, but capacity is drowned out by the demand for transactional and technical care.
• Research has described the mechanisms needed to support whole-person-centred access to care: candidacy (recognising potential to benefit from care), concordance (co-management of care), and recursivity (enhanced future self-management). Application of these 3 principles has been shown to improve access to primary mental health care, tackling unmet need.
• These principles should inform general practice redesign to support a shift from technical/transactional/disease-focused care to whole-person generalist care.

10. WORKFORCE
• Established evidence explains our current workforce crisis, and why existing strategies such as golden handshakes (financial incentives) are not working.
• Retention of motivated staff requires attention to the 3M’s of Meaning (the purpose and value of the work we do); Mastery (opportunities to fully utilise and extend professional expertise); and Membership of a recognised community of practice.
• Evidence describes how current roles and career pathways in general practice undermine all 3. Students do not recognise the intellectual stimulation and value of careers in general  practice; GPs and general practice staff feel unable to utilise and extend their professional skills within current contractual models.
• Our work in the CATALYST programme demonstrates how generalist redesign in career planning and practice delivery may offer a more successful alternative [see #14].

11. PRACTICE/CONTRACTUAL DESIGN

• The current general practice model fails to understand and reflect the complexity of modern professional practice in the delivery of expert generalist care.
• The general practice contract is fundamentally a transactional model of care: utilising an externally defined evidence base to define and drive care delivery. Contractual mechanisms provide general practice with guidelines and pathways of care, and expect it to navigate patients through.
• In reality, modern general practice manages some of the most complex health and care needs in the NHS. It is the primary point of care for people living with the illness and treatment burden associated with multimorbidity and medically unexplained symptoms. The knowledge work of modern patient care is far beyond the linear, transactional models typically described within current contracts.
• The gaps between the work required by presented patient needs and the support offered by current practice models contributes to patient dissatisfaction; but also the frustration and demotivation of healthcare staff, and thus to workforce challenges.
• The current contractual model is insufficient to enable necessary change. Our evaluation of the introduction of an evidence-based frailty initiative in to 33 practices in the Midlands demonstrated why the current contractual model based on a ‘bolt on’ transactional view of practice failed to provide/support the expertise needed to translate external evidence into practice-based evidence for everyday care.
• Modern general practice needs a new contract that recognises and supports the complex interventions of modern practice.

Describing generalist alternatives

12. ADDRESSING DEMAND: THE GENERALIST GATEKEEPER

• Guideline-defined healthcare creates a ‘technical bypass’ of the distinct gatekeeper role of the expert generalist physician.
• This distinct role was described by Heath as a gatekeeper to medicalisation of illness. The expertise of the generalist clinician lies in interpreting when medicalisation of illness (including testing, diagnosis, and treatment) offers more benefit than harm in supporting health for daily living.
• The expert generalist gatekeeper works with their patient to consider not ‘could’ I diagnose this particular condition, but ‘should’ I?
• This role underpins the new models of care recognised as necessary to tackle the growing challenges of treatment burden, problematic polypharmacy and overprescribing, over testing, ‘too much medicine’…
• But it is not designed in to models of practice or training of practitioners. It is not taught in Vocational Training programmes.
• People in my research describe acquiring it through apprentice-type training in practice – ‘learning on the job’. Gabbay’s research described this daily knowledge work of front-line generalist care in action. But current changes to models of care threaten to undermine both the practice and acquisition of these skills, and so our capacity for current and future delivery of expert generalist care.
• Expert generalist skills can, however, by taught. Our unique CATALYST programme is helping new-to-practice GPs develop skills and confidence in the role through providing an evidence-informed understanding and legitimisation of this role. In turn, we see growing evidence of enhanced motivation for professional practice, with CATALYST GPs calling for recognition of their status as community Consultants in Primary Care Medicine.

13. TAILORING CARE: DEXTRUS REDESIGN OF GENERAL PRACTICE

• A key conclusion of the 2013 Kings Fund report on problematic polypharmacy was the need to incorporate compromise in to the way we design quality healthcare systems. Growing numbers of patients report that the medication intended to help them through managing disease/risk factors in reality diminishes their ‘health for daily living’. The role of the expert generalist clinician lies in working with an individual to weigh up all available data, construct a tailored understanding of the illness experience of an individual and the potential role of medicine in managing that, design and implement a management plan, and so follow up, evaluate impact, and potentially modify the plan. This is the generalist skill of Interpretive Medicine.
• We have recently completed an NIHR HTA funded evidence synthesis describing the organisational components needed to support this model of practice. The TAILOR synthesis has  described the need for a DExTruS redesign of general practice with four elements:
• Data: the provision of continuous, comprehensive access to data from across multidisciplinary teams which includes the CONTEXTUAL data needed to support tailored interpretations
• Explanation: professional capacity to construct tailored interpretations of need and the value of medicalisation
• Trust: recognised as both a mechanism of, and outcome of quality generalist care, our findings showed that trust is created by a capacity to LEARN – a model of practice built on an informed process of ‘trial and review’
• Supportive infrastructure: with health systems designed to support the complex knowledge work involved in construction, delivery and learning from tailored care

14. REDESIGNING THE GP ROLE
• Using the knowledge work of clinical practice – the ability to find, create, implement and learn from knowledge-in-practice-in-context - the expert generalist clinician is able to meet the needs of modern complex patients.
• This extended model of professional practice also enables the clinician to drive quality improvement at a practice level.
• These are the skills/roles we are describing and developing within the CATALYST programme and WISE GP, recognising the future GP as a consultant in primary care medicine; with a portfolio career that includes patient contact but also education, research, leadership, QI, system design. Initial findings from our evaluation of this work demonstrates improvements in morale and motivation.
• Scaling, and optimising the impact, of advancing generalist expertise in the general practice setting will need change at 3 levels: professional practice; practice organisation; and systems culture.

Where next: transitional arrangements

15. The 1948 model, even with modifications, is outdated. Plans to develop Integrated Care Systems won’t address the challenges recognised in this submission. We need a new model for general practice, and therefore a plan for a transitional stage. Transition allows us to start the work with the early adopters – giving  us opportunities to embed evaluation and learning organisation models within the new general practice set up – so we can refine the end model by a ‘trial and learn’ approach and embed a learning organisation approach in to the new models that emerge. I have started conversations with a local NHS Trust.
16. I welcome a conversation with the Health Select Committee on how my work can inform the plans under consideration.

December 2021