IT is 70 years since the legislation of the National Health Service Act 1946 became operational, transforming the health care provision of the 1911 National Health Insurance Act and birthing our NHS. Why then has general practice been stuck at a crossroads since 1950, recycling intractable issues for the successive generations of GPs to grapple with?

History Matters in Scotland
SCOTLAND has always had its own distinct health service delivering general medical care. Universal health care had been provided for some time in Scotland by the Highlands and Islands Medical Service following the publication of The Dewar Report (1912). The Cathcart Report (1936) went further and proposed a National Health Service for Scotland with co-ordinated general practice services extended to the whole population. The Act which created the NHS enshrined many of Cathcart’s recommendations and was passed in 1947. The NHS was founded in 1948.

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The major change for general practice then was the extension of free-at-the-point-of-access health care to everyone (and not just a small number of insured working-class men). The creation of the NHS coincided with extensive welfare reforms that resulted in cohesive state action in relation to the rights of citizenship, equality and security across everything from education to housing. These essential ingredients created a system of social support that marked an optimistic future of social mobility and aspiration for generations of British citizens. The inequality gap began to narrow.

The NHS was declared the jewel in the crown of the welfare state but its complex organisational and legal framework mean it is vulnerable to exploitation if politicians abandon the principle that everyone is of equal value and worth. Damaging one of the founding pillars of the welfare state will damage everyone’s health. Thankfully, this is not the aim of the Scottish Government.

The Essence of General Practice
PRIMARY care in Scotland has grown apart from England. General practice here has no internal market, but still faces issues in securing enough funding to make the positive changes we need. It is the natural hub of community services with a distinct but collegiate role with other allied professionals. Close working with allied professionals in the community can make huge differences to a patient’s journey.

All patients with complex problems need occasional specialist advice but mainly, unconditional, personalised care that is delivered by a small team of professionals whom they know and trust. This feature of general practice is hugely important for the provision of effective health care. Boosting this generalist function would be a welcomed U-turn of the recent trend of investment in specialist services.

SPECIALIST services in hospital and the community have had a 50% increase in funding over the last 15 years. A steady rise in consultant numbers is in part fuelled by the reliance on hospital-based performance targets and worsening pressures on community services. The GP establishment has received level funding despite 90% of NHS activity taking place in primary care. A consequence of this is that general practice is less able to hold patient’s problems in the community and demand for A+E and out-of-hours services rises. For many patients, the ideal situation is having extended care near home, but pressures on GPs does not allow this. We should all be interested in the challenge of providing extended care in the community – most of us will need this during our lifetime.

GPs are working throughout Scotland in remote and rural areas, affluent or deprived communities and one common challenge is meeting the health and social care needs of an aging population with no further professional capacity. This is testing the limits of general practice. Imbalanced NHS spending means that general practice cannot maximise its role in health care to address the Inverse Care Law – whereby the availability of good medical or social care tends to be most available in the communities which need it the least. For example, affluent areas often have large proportions of older residents who enjoy long disability-free life expectancy, but those patients in more socioeconomically deprived groups have much shorter disability-free or healthy life expectancy. Chronological age does not necessarily correlate with “health-age” in vulnerable patients with limited life chances. Younger patients who present with complex conditions are often unable to access services because they do not meet the age determined thresholds. This is one example of the Inverse Care Law in action.

Real Solutions to Big Problems
WE know that patients want effective communication and explanation about conditions and treatment but they also want caring and compassionate staff. GPs are more empathetic if they have time to care, but time seems to be a forgotten resource in healthcare spending.

GPs at the Deep End – a group of the 100 most deprived practices in Scotland – have developed new approaches to move away from specialism in NHS Scotland to avoid the unnecessary fragmentation of care of patients with complex health issues. The Govan SHIP project creates around 10% extra clinical capacity for GPs and by using this additional time effectively means that GPs have more time to help patients with complex needs and to co-ordinate integrated care from the ground up. The projects are showing that it is possible to address the Inverse Care Law by changing the way we think about how general practice works.

Other Deep End projects such as Links, Pioneer and the Parkhead “embedded welfare worker” also have a common purpose in improving resilience in communities by giving patients confidence to manage their problems and access available resources and services. Experience from these projects show that links to community support are more effective if attached workers are embedded within the practice team and are seen as an extension of the GP practice.

These projects are setting the bar very high for primary health care in Scotland and will be key to recruiting the GPs of the future who will experience working in teams who are passionate about their work and supported in doing it. SHIP and Pioneer should be recognised as providing many of the solutions to the ambitious national agenda of integrated health and social care in Scotland.

Our Future Horizon
SCOTLAND needs to train more GPs, retain newly qualified and experienced colleagues, re-examine the relationship between daytime and out-of-hours services and strengthen the ability of GPs to keep patients in the community. Whilst increasing the role and numbers of non-medically qualified healthcare staff to support GPs is very welcome in the modern NHS, it cannot be at the expense of an expanded GP workforce.

Our ethos should be that the “best anywhere becomes the standard everywhere”, but there is a long way to go before the national structures are in place to support this. Developing cross-working between practices and applying lessons from Deep End projects is an important step in developing a primary care service that is fit for the present and the future.

We all work in or are patients of the NHS (often both) and have a vested interest in maintaining the founding principles of the NHS. Wherever we live in Scotland, access to adequate healthcare is a human right, it is fundamental to a functioning society. General practice, the primary care team and the provision of care in the community is the solid foundation that underpins the NHS and we cannot afford to let it fracture.

Dr Anne Mullin is a GP in Glasgow and member of NHSforYES