NHS working at Scale: The Donkey and The Racehorse
I was in a GP surgery recently and noticed that the treatment room nurse was looking decidedly frazzled. It transpired that the reason for this state of frazzlement was because the District Nursing team had announced that they couldn’t complete the blood tests they had been requested to do that day, and so had passed the work back to the GP practice, announcing that if they needed the bloods taken urgently, then someone at the practice would need to take them. Consequently, one of the HCAs had gone out to take the bloods, leaving the treatment room nurse to pick up their work and miss her lunch.
Why is it that some services can be full or at capacity, but general practice never is? Day in, day out, it picks up work that has been dumped by others in the health system. Nobody ever stops to think that the clinical teams working in practices may have no capacity, no free appointments to pick up the work that has been passed on, but yet the expectation is that while the doors are open, the amount of work that can be done is limitless.
It reminds me of the analogy of the racehorse and the donkey that I heard a speaker tell us at a recent event.
Racehorses are finicky and demanding creatures: expensive, pulling in significant resource both from a financial and a human point of view, and demanding a lot of attention. Now. The slightest bellyache and they will kick the stable door, upon which occurrence someone dashes along and calls the vet, regardless of the genuine need, or not. Nobody questions the need or otherwise. The racehorse wants the attention, and no expense is spared.
The donkey, on the other hand, plods along day in, day out, not making a fuss or complaining. And whilst no fuss is made, more and more is heaped upon it, and the fact that the donkey will just keep doing it is taken completely for granted. Until the donkey can take no more and collapses.
Which of these four-legged friends is the analogy for secondary care and which is the one for general practice, do you think?
The dumping of work on general practice is at an unprecedented level; much of it is not contracted, and consequently not resourced, and more importantly is at unsafe levels. The donkey’s legs are buckling, but nobody seems to care, as the expectation in many parts of the country is that general practice will just keep doing it.
The excellent BMA Quality First document very clearly outlines what is and is not core contract. Anything that is not should be properly contracted and resourced, and yet in so many places it isn’t, but CCGs and other providers get away with ignoring the problem because GPs believe it will harm their patients not to deliver the extra work that is being dumped on them. In many places they suck it up and CCGs and acute trusts know this; there is no incentive to change. Perversely, by not taking a stand against the tide of un-resourced and unsafe work, these practices could find themselves in the position of not being able to function, legs well and truly buckled; and that is going to do their patients the ultimate harm.
Fortunately there are some federations where GPs have taken a united front on this, stood shoulder to shoulder, had the clear support of their LMC, and said “no more”. They have either passed the work back from whence it came, or have had the un-resourced work properly commissioned, meaning that they can afford to employ staff to do the work and ensure that the service is delivered consistently, without unwarranted variation, and safely.
In areas where GPs have not presented a united front, despite being federated, the expectation from secondary care and CCGs is that they will continue to work for nothing. And many of these practices live up to that expectation, undermining the argument for their colleagues in other practices, and ultimately doing a disservice to their patients. Furthermore, whilst the volume of un-resourced and unsafe work isn’t the sole reason, these are often areas with higher than average GP vacancies; there is at least some degree of cause and effect.
Whilst the world of general practice in its entirety may not be ready for at-scale working, it is firmly on the agenda and with the current challenges that the NHS is facing is vital for survival. The areas that have truly embraced this concept are realising the benefits, both for their practices and their patients. Those that haven’t are very rapidly going to find themselves in the position of the donkey, if they aren’t already: collapsing, and ultimately unsustainable. And whilst CCGs must bear a lot of responsibility for their appalling treatment of general practice, equally general practice has a responsibility to itself and the patients it serves not to be passive in their acceptance of this treatment.
"You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, "I have lived through this horror. I can take the next thing that comes along." . . . You must do the thing you think you cannot do." Eleanor Roosevelt, Former First Lady
For general practice, my sense is that it needs to stop delivering unresourced work and start to accept that what is best for the patient is having a general practice that is sustainable for the long term, and doesn’t collapse under the volume of unrescourced, unsafe and unsustainable work.
In stopping the work, general practice then needs a voice at the negotiation table with the CCG and secondary care. However, that voice needs to be a united one, which genuinely represents the views of the practices at scale, with confidence, and an assurance that practices will act to support negotiators in the event of a breakdown in negotiation.
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