General Practice Leadership in the NHS

A few days ago I wrote about the split in U.S. health policy between concepts of physician-led reform and market-driven/consumer-led reform.

In England, the new Conservative-Liberal Democrat coalition has opted for a degree of physician-leadership that couldn't be imagined in the U.S. It envisions reorganizing the National Health Service around GP consortia that will "commission" (in U.S. lingo, "purchase") secondary health care services for populations of 100,000 to 750,000. Here's what the new government's White Paper says about GP commissioning:

This change will build on the pivotal and trusted role that primary care professionals already play in coordinating patient care...Primary care professionals coordinate all the services that patients receive, helping them to navigate the system and ensure they get the best care (of course, they do not deliver all the care themselves). For this reason they are best placed to coordinate the commissioning of care for their patients...

In the U.K. approximately 50% of the physician workforce is in primary care, and the numbers are holding steady. In the U.S., we've had a 50% drop in the number of medical students going into primary care in the last ten years. I know from interviewing residency applicants that many would prefer to make a career in primary care, but a combination of the monstrous debts they graduate with, the poor compensation of PCPs relative to specialists, and the increasingly harried worklife of the PCP, drive them away.

We in U.S. talk out of both sides of our mouths with regard to primary care. We construct elegant conceptual models for how primary care would ideally function, but we systematically devalue the field through the way we govern our health system.

Given the declining number of primary care physicians, the concept of consumer/patients who coordinate their own care and shop for a package of services to meet their self-perceived needs, is filling a vacuum. Without consciously intending it, we've been putting patients into the position of "disintermediating" primary care physicians as unnecessary middlemen in the care system. The Conservative-Liberal Democrat White Paper dramatizes just how much we've marginalized general practice here in the U.S.

Not every member of our population wants to have a PCP as care coordinator. Millennials have imbibed the internet along with mother's milk, and many take readily to the consumer model of patient care. But Millenial PCPs, along with Millennially-minded older PCPs, know how to partner with activist patients and thrive in that kind of partnership.

Activist patients partnering with primary care physicians is where our health system needs to go.

(To learn more about GP-led commissioning in the National Health Service see this recent New England Journal article, the full government White Paper, or this analysis from the British Medical Association.)