The fragmented jigsaw puzzle of today’s NHS General Practice

Patients very rightly protest when a General Practitioner is not paid for carrying out a postnatal examination on a woman at six weeks, presenting with their new baby. This is simply not in the GPs contract!

But why has NHS general practice come to this?

I recently read a brief letter to the Guardian, from Prof Helen Stokes-Lampard, Chair of the Royal College of General Practitioners, Prof Lesley Regan of the Royal College of Obstetricians and Gynaecologists, and Dr Trudi Seneviratne of the College of Psychiatrists. This was in response to an article titled New Mothers’ Mental Health Problems Go Undetected. In the letter, the group asks for ‘a funded postnatal medical appointment at 6 to 8 weeks, specifically to assess new mothers physical and mental health.’ They state that this is ‘a major opportunity to improve postnatal support for mothers’ and ‘urge the relevant health authorities to implement this important proposal.’

I came into medicine after qualifying in 1967. I switched after five years from hospital medicine, with my entry into specialist practice reasonably sure, as a Senior Registrar with membership of the College of Physicians. I later moved to General Practice, and was inspired by a wonderful document produced in 1975 by the College of General Practitioners titled The Future General Practitioner.

The conclusion then (as outlined in The Future General Practitioner) was to see General Practice as the specialty of the generalist. A person is seen at their point of need, and early diagnosis of serious disease in the initial stages is paramount. The patient however, is often at the limit of tolerance for the situation they find themselves in, and needs to be understood within the context of their presentation (so often a result of anxiety). If the science of stress medicine was included in the medical curriculum, then rightful explanation for the onset of symptoms that can be explained by the stress and struggles of the patient’s life situation would possible. It is estimated that 50% of consultations in General Practice do not have any structural pathology as their root cause. I have discussed this in a previous blog detailing the links between stress and dis-ease.

These approaches would help the development and implementation of recovery plans – without medicalising symptoms that would be best placed in the health and well-being sector. The opportunities for social prescribing make this possible. With this in mind, myself and colleagues have taken the experience of two expert patients who recovered from prolonged (i.e. more than 10 years) sustained ill-health due to Chronic Fatigue Syndrome. This forms the basis for our book Reclaim Health. It details a process where, with mindfulness-based cognitive behavioural approaches and without drugs, people can recover their wellbeing. This is done by changing the physiological state in which their illness developed and which is still present, i.e. disturbed PNI. They are then able to coach themselves to achieve their objectives of returning to good health and well-being.

Fragmentation rather than continuity?

I am for the NHS, but not for the bureaucracy and itemisation of service payment that has developed within the purchaser / provider separation of contracts. I think that the authors of The Future General Practitioner (John Horder, Patrick Byrne, Paul Freeling, Conrad Harris, Donald Irvine and Marshall Marinker) would be appalled at the current situation of General Practice.  

The current GPs contract rewards general practices for items of service like the six-week postnatal check of the baby, but does not include the mother’s health review! It encourages a tick-box mentality rather than a ‘whole person or whole family approach’.

I hope that our present political upheavals may see the replacement of centralised control of health policy, obsessed with targets and Quality Outcome Framework. This should be superseded by General Practitioners paying attention to the whole person’s overall wellbeing, with the skill of early diagnosis of serious pathology at its core.

Please do comment on your experiences of good care and continuity within the NHS, as well as instances where you feel care has been fragmented. Join the conversation!