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Tagged: primary care doctors shortage

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  • People are using A&E departments as convenient drop-in clinics for minor ailments because they cannot get GP appointments
  • In January 2017 the British Red Cross said A&E was struggling with a "humanitarian crisis" to keep up with a rush of patients over  the winter
  • UK’s Prime Minister suggests that all GP surgeries should open from 8am to 8pm, 7 days a week 
  • Primary care in England is in crisis, fuelled by a large and increasing demand and a shrinking supply of GPs
  • 75% of GPs across 540 general practices over the age of 55 are nearing retirement, and newly trained GPs are seeking employment abroad
  • By 2020 there could be a shortfall of 10,000 GPs in England
  • Curing the primary care crisis would relieve pressure on A&E departments
  • A simple, cheap and easy-to-use online dashboard could help relieve the primary healthcare crisis
 
A smarter approach to the UK’s GP crisis
 
Could the vast and escalating primary care crisis in England be helped with a new and innovative online dashboard, which automatically sends short videos contributed by clinicians to patients’ mobiles to address their FAQs?
 
Dr Seth Rankin an experienced GP thinks it can. Click on the photo below to access a short video, which demonstrates how the dashboard works.

 
 
 

UK’s Secretary of State predicted the healthcare crisis
 
The UK’s Secretary of Health has frequently stressed the urgent need for more innovation in healthcare. In 2015 he said: “If we do not find better, smarter ways to help our growing elderly population remain healthy and independent, our hospitals will be overwhelmed – which is why we need effective, strong and expanding general practice more than ever before in the history of the NHS.
 
An easy and effective way to improve GP services

Most patients don’t remember half of what is said in short GP consultations. This is why videos are so important. Unlike doctors and pamphlets videos never get tired, never wear out, and are available 24/7, 365 days a year. Unlike the Internet, the dashboard provides premium reliable healthcare information, which easily can be consumed by patients and shared among family, friends and carers. The video content can be viewed many times, from anywhere, and at anytime. The dashboard is fully automated [see figure below], relieves GPs of a lot of unnecessary work, and importantly, reports on how patients’ use the different videos,” says Rankin; CEO of the London Doctors Clinic; and formally the managing partner of the Wandsworth Medical Centre, and co-chair of Wandsworth CCG’s Diabetes Group.
 
A fully automated dashboard to improve efficiency and increase the quality of care
 
 
Reducing unnecessary A&E visits

‘The dashboard uses videos of local healthcare professionals because both patients and doctors want to improve their connectivity. The dashboard is embedded with about 120 short, 60 to 80 second, talking-head videos, which address patients’ frequently asked questions. Research suggests that the average attention span for people watching videos on mobiles is between 60 to 80 seconds. The dashboard has been specifically designed to help increase patients’ knowledge of their condition, propel them towards self-management, slow the onset of complications, lower the number of unnecessary visits to A&E, reduce face-time with GPs, and enhance the quality of care,” says Rankin.
 
Essential behavioral techniques

The efficacy of healthcare education is enhanced by embedded behavioral techniques, which nudge people to change their diets and lifestyles, improve self-monitoring of their condition, and increase adherence to medications.  The HealthPad dashboard benefits from such behavioral techniques.
 
Part of comprehensive communications system

The dashboard has been developed by health professionals with significant patient input, and aims to get effective educational content to the largest number of people at the lowest price possible; and without requiring effort from health professionals to mediate or facilitate the flow of the knowledge. To achieve this the dashboard is not a “lock-in” system, but designed to be easily and cheaply re-engineered to integrate with various other communications systems, see diagram below. The only thing that the dashboard requires is a connection to the Internet. 
 

 
GP surgeries at saturation point

A 2016 study published in The Lancet suggests that between 2007 and 2014 the workload in NHS general practice in England had increased by 16%, and that it is now reaching saturation point. According to Professor Richard Hobbs of Oxford University and lead author of the study, "For many years, doctors and nurses have reported increasing workloads, but for the first time, we are able to provide objective data that this is indeed the case . . . . . As currently delivered, the system [general practice in England] seems to be approaching saturation point . . . . . Current trends in population growth, low levels of recruitment and the demands of an ageing population with more complex needs will mean consultation rates will continue to rise.”
 
More than 1m patients visit GPs every day

A 2014 Deloitte’s report commissioned by the Royal College of General Practitioners (RCGP) suggests that the GP crisis in England is the result of chronic under-funding and under-investment when the demand for GP services is increasing as the population is ageing, and there is a higher prevalence of long-term conditions and multi-morbidities.
 
Each day in England, more than 1m patients visit their GPs. Some GPs routinely see between 40 to 60 patients daily. Over the past 5 years, the number of GP consultations has increased by 60m each year, and now stands at about 370m a year. Over the same period, the number of GPs has grown by only 4.1%.
 
Stress levels among GPs are high and increasing

Deloitte’s findings are confirmed by of a 2016 comparative study undertaken by the prestigious Washington DC-based Commonwealth Fund, which concluded that increasing workloads, bureaucracy and the shortest time with patients has led to 59% of NHS GPs finding their work either “extremely” or “very” stressful: significantly higher stress levels than in any other western nation. GP stress levels are likely to increase.
 
In a speech made in June 2015, the UK’s Secretary of Health said, “Within 5 years we will be looking after a million more over-70s. The number of people with three or more long term conditions is set to increase by 50% to nearly three million by 2018. By 2020, nearly 100,000 more people will need to be cared for at home.” Dr. Maureen Baker, the former chair of the Royal College of General Practitioners (RCGP) has warned that, “Rising patient demand, excessive bureaucracy, fewer resources, and a chronic shortage of GPs are resulting in worn-out doctors, some of whom are so fatigued that they can no longer guarantee to provide safe care to patients.” And Dr  Helen Stokes-Lampard, the new head of the RCGP, warns that patients are being put at risk because they often have to wait for a month before they can see a GP.

 
Newly trained GPs are seeking employment abroad

Trainee GPs are dwindling and young GPs are moving abroad. According to data from the General Medical Council (GMC), between 2008 and 2014 an average of 2,852 certificates were issued annually to enable British doctors to work abroad. We now have a dangerous situation where there are hundreds of vacancies for GP trainees. Meanwhile, findings from a 2015 British Medical Association (BMA) poll of 15,560 GPs, found that 34% of respondents plan to retire in the next five years because of high stress levels, unmanageable workloads, and too little time with patients.
 
5,000 more GPs by 2020

In 2016 the government announced a rescue package that will see an extra £2.4bn a year ploughed into primary care services by 2020. This is expected to pay for 5,000 more GPs and extra staff to boost practices. When the Secretary of Health trailed this in 2015, doctors’ leaders did not view it as a viable solution. Dr Chaand Nagpaul, chair of the BMA’s GP committee, warned that, “delivering 5,000 extra GPs in five years, when training a GP takes 10 years, was a practical impossibility and would never be achieved.” In 2016, Pulse, a publication for GPs, suggested that the Health Secretary understands that he cannot deliver on his election promise of 5,000 new doctors by 2020, and is negotiating with Apollo Hospitals, an Indian hospital chain, to bring 400 Indian GPs to England.
 
Pharmacists in GP surgeries
 
In July 2015 the NHS launched a £15m pilot scheme, supported by the RCGP and the Royal Pharmaceutical Society (RPS), to fund, recruit and employ clinical pharmacists in GP surgeries to provide patients with additional support for managing medications and better access to health checks.
 
Dr Maureen Baker said, “GPs are struggling to cope with unprecedented workloads and patients in some parts of the country are having to wait weeks for a GP appointment yet we have a ‘hidden army’ of highly trained pharmacists who could provide a solution”. Ash Soni, former president of the RPS suggested that it makes sense for pharmacists to help relieve the pressure on GPs, and said, “Around 18m GP consultations every year are for minor ailments. Research has shown that minor aliment services provided by pharmacists can provide the same treatment results for patients, but at lower cost than at a GP surgery.”
 
Progressive and helpful move
 
The efficacy for an enhanced role for pharmacists in primary care has already been established in the US, where retail giants such as CVS, Walgreens and Rite Aid provide convenient walk-in clinics staffed by pharmacists and nurse practitioners. Over time, Americans have grown to trust and value their relations with pharmacists, which has significantly increased adherence to medications, and provided GPs more time to devote to more complex cases. Non-adherence is costly, and can lead to increased visits to A&E, unnecessary complications, and sometimes death. According to a New England Healthcare Institute report, Thinking Beyond the Pillbox, failure to take medication correctly, costs the US healthcare system $300bn annually, and results in 125,000 deaths every year. 
 
Takeaway

People with complex conditions deserve to be seen by a GP who is not stressed and who can devote the time and attention they need. “Videos could play a similar role to practice-based pharmacists. Both deal with simple day-to-day patient questions, and relieve pressure on GPs, which allows them to focus their skills where they are most needed,” says Rankin.
 
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Cost-effective asset to relieve growing pressure on GPs

Can the escalating primary care crisis in England be helped with a new and innovative online dashboard, which automatically sends short videos contributed by clinicians to patients’ mobiles to address their FAQs?
 
Dr Seth Rankin, Managing Partner of the Wandsworth Medical Centre, and co-chair of Wandsworth CCG’s diabetes group, who has spearheaded the dashboard, thinks it can. Click on the photo below to view a short video that describes how health professionals can use the dashboard:
 
 
 
New and innovative dashboard
 
A 24/7 fully automated service that never wears out
We were motivated to do something about the increasing pressure on GPs, and the impact this has on the quality of our care. Patients may have to wait a couple of days for an appointment with a GP, but they can receive our videos within minutes of their request,” says Rankin. He continues: “A pilot study we carried out in two London primary care practices suggested that video is a patient’s preferred format if they can’t see a GP. Further, patients often don’t retain what you tell them in a 10-minute face-to-face consultation, and they tend not to read pamphlets, which also are expensive to produce. 53% of patients regularly search the Internet for healthcare information, but 81% can’t differentiate between good and bogus information. 72% prefer healthcare information from their GP, and like healthcare videos delivered directly to their mobiles. 70% want access to healthcare information at any time, from anywhere, on their mobiles.
 
“Unlike the Internet, our dashboard provides premium reliable information, which can be easily consumed and shared among family, friends and carers. Also, the videos can be viewed many times, from anywhere, and unlike pamphlets and doctors, they never get tired, never wear out, and are available 24/7, 365 days a year. The dashboard is fully automated [see figure below], relieves GPs of a lot of unnecessary work, and, importantly, reports on how our patients’ are using the different videos.”
 
Automated system that encourages engagement behaviours
 
Local experts
“We used local medical experts in our videos because we were keen to increase their connectivity with our patients. The videos provide 60 to 80 second talking-head answers to patients’ questions, and are designed to increase patients’ knowledge of their condition, propel them towards self-management, slow the onset of complications, and reduce face-time with GPs, while enhancing the quality of our care,” says Rankin.
 
Diabetes
He continues: “Although the dashboard easily can be used for any disease state, we started with T2DM as it represents our largest group of patients. Also, we know that: (i) T2DM is preventable with effective education that encourages diet and lifestyle changes, (ii) current diabetes education fails, and over the past decade, the incidence rate of the condition has increased by 65%, (iii) only 16% of the 120,000 people diagnosed each year with diabetes in England are offered structured educational courses, and (iv) only 2% of those offered courses actually enrol in them. So, we created our own bespoke dashboard and content library of about 120 videos, which we organised under 10 headings that we know interest our patients. Each heading has a cluster of ‘essential’ and ‘in-depth’ videos. We use the dashboard to relieve some of the pressure on our health professionals.”
 
Unprecedented crisis
 
Saturation point
A 2016 study published in The Lancet suggests that between 2007 and 2014 the workload in NHS general practice had increased by 16%, and that it is now reaching saturation point. According to Professor Richard Hobbs of Oxford University and lead author of the study, "For many years, doctors and nurses have reported increasing workloads, but for the first time, we are able to provide objective data that this is indeed the case . . . . . As currently delivered, the system [general practice in England] seems to be approaching saturation point . . . . . Current trends in population growth, low levels of recruitment and the demands of an ageing population with more complex needs will mean consultation rates will continue to rise.”
 
More than 1m patients visit GP every day
A 2014 Deloitte’s report commissioned by the Royal College of General Practitioners (RCGP) suggests that the GP crisis in England is the result of chronic under-funding and under-investment in primary care at a time when the demand for GP services is increasing as the population is ageing, and there is a higher prevalence of long term conditions and multi-morbidity.
 
According to the RCGP, over the past five years the number of annual GP consultations has increased by 60 million to around 370 million, while over the same period the number of GPs has grown by only 4.1%. More than one million patients a day visit their GP surgeries, with some GPs now routinely seeing between 40 to 60 patients daily.
 
GPs are extremely stressed
Deloitte’s findings are confirmed by a 2016 comparative study undertaken by the prestigious Washington DC-based Commonwealth Fund, which concludes that increasing workloads, bureaucracy and the shortest time with patients has led to 59% of NHS GPs finding their work either “extremely” or “very” stressful: significantly higher stress levels than in any other western nation. GP stress levels are likely to increase. In a speech made in June 2015, the UK’s Secretary of Health said, “Within 5 years we will be looking after a million more over-70s. The number of people with three or more long term conditions is set to increase by 50% to nearly three million by 2018. By 2020, nearly 100,000 more people will need to be cared for at home.” According to Dr Maureen Baker, chair of RCGP, “Rising patient demand, excessive bureaucracy, fewer resources, and a chronic shortage of GPs are resulting in worn-out doctors, some of whom are so fatigued that they can no longer guarantee to provide safe care to patients.”
 
Causes and consequences
 
GP exodus
Trainee GPs are dwindling and young GPs are moving abroad. According to data from the General Medical Council (GMC), between 2008 and 2014 an average of 2,852 certificates were issued annually to enable British doctors to work abroad. We now have a dangerous situation where there are hundreds of vacancies for GP trainees. Meanwhile, findings from a 2015 British Medical Association (BMA) poll of 15,560 GPs found that 34% of respondents plan to retire in the next five years because of high stress levels, unmanageable workloads, and too little time with patients.
 
Suggested solutions
 
5,000 more GPs by 2020
In the run up to the UK’s 2015 General Election the Secretary of Health pledged “to train and retain an extra 5,000 GPs by 2020” to ease the primary care crisis, but doctors’ leaders did not see this as a solution. Dr Maureen Baker said, "Even if we were to get an urgent influx of extra funding and more GPs, we could not turn around the situation [the GP crisis] overnight due to the length of time it takes to train a GP,” And Dr Chaand Nagpaul, chair of the BMA GPs’ committee, warned later that, “delivering 5,000 extra GPs in five years, when training a GP takes 10 years, was a practical impossibility that was never going to be achieved.” After the election the Health Secretary softened his promise and suggested that it would be ‘a maximum' of 5,000 by 2020.

In 2016, Pulse, a publication for GPs, suggested that the Health Secretary knows he cannot deliver his promise of 5,000 new doctors by 2020, and is negotiating with Apollo Hospitals, an Indian hospital chain, to bring 400 Indian GPs to England.
 
A more innovative approach

Better and smarter solutions needed
While searching for an immediate temporary solution to the GP crisis the Secretary of Health seems to understand that a more innovative approach is required for the medium to long term. In his June 2015 speech he said, “If we do not find better, smarter ways to help our growing elderly population remain healthy and independent, our hospitals will be overwhelmed – which is why we need effective, strong and expanding general practice more than ever before in the history of the NHS. Innovation in the workforce skill mix will be vital too in order to make sure GPs are supported in their work by other practitioners.”
 
Pharmacists in GP surgeries
In July 2015 the NHS launched a £15m pilot scheme, supported by the RCGP and the Royal Pharmaceutical Society (RPS), to fund, recruit and employ clinical pharmacists in GP surgeries to provide patients with additional support for managing medications and better access to health checks.
 
Dr Maureen Baker said, “GPs are struggling to cope with unprecedented workloads and patients in some parts of the country are having to wait weeks for a GP appointment yet we have a ‘hidden army’ of highly trained pharmacists who could provide a solution”. Dr David Branford, former Chair of the RPS said, “It’s a win-win situation . . . .  We will be doing everything we can to support the GPs and make sure this pilot is successful. In time, I hope pharmacists will be working in every GP practice in the country.” Ash Soni, president of the RPS suggests that it makes sense for pharmacists to help relieve the pressure on GPs, and says, “Around 18m GP consultations every year are for minor ailments. Research has shown that minor aliment services provided by pharmacists can provide the same treatment results for patients, but at lower cost than at a GP surgery.”
 
Progressive and helpful move
The efficacy for an enhanced role of pharmacists in primary care has already been established in the US, where retail giants such as CVS, Walgreens and Rite Aid have led the charge in providing convenient walk-in clinics staffed by pharmacists and nurse practitioners. Over time, Americans have grown to trust and value their relations with pharmacists, which has significantly increased adherence to medications, and provided GPs more time to devote to more complex cases. Non-adherence is costly, and can lead to increased visits to A&E, unnecessary complications, and sometimes death. According to a New England Healthcare Institute report, Thinking Beyond the Pillbox, failure to take medication correctly, costs the US healthcare system $300 billion annually, and results in 125,000 deaths every year. 
 
Takeaway
 
Introducing pharmacists into GP surgeries is a progressive and potentially helpful move forward, because, as Dr Maurine Baker suggests, “It is in everyone’s best interests to be seen by a GP who is not stressed or fraught and who can focus on giving their patients the time, attention and energy they need”. However, even more could be achieved if the dashboard described by Dr Seth Rankin were more widely introduced. “Videos play a similar role to practice-based pharmacists. Both deal with simple day-to-day patient questions, and relieve pressure on GPs, which allows them to focus their skills where they are most needed,” says Rankin.
.
 
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The convenient quality healthcare revolution

  • Demand for primary care services outstrips supply

  • People want affordable convenient, quality healthcare

  • The retailization of healthcare is large and growing fast

  • US Minute Clinics in CVS retail outlets expect 6 million visits in 2015

  • Traditional health providers can’t stop the convenience healthcare revolution, but they can encourage it 

“It” is larger, and growing faster than most people think. “It” is driven by the combined burdens of heightened patient expectations, disproportionate growing and ageing populations, and finite resources. “It” will significantly impact healthcare systems throughout the world. “It” . . . . is the ‘retailization of healthcare’, which uses pharmacists, and nurse practitioners to provide a range of healthcare services in diverse retail locations.
 

A convenience revolution

In 2010, Rite Aid, the US retail pharmacist, partnered with American Well, a company providing online access to doctors 24-7; 365 days a year, to test a service, which allows consumers to interact directly with Rite Aid pharmacies for medication advice, and results in an electronic record, which is shared with primary care doctors.

Larry Merlo, the CEO of CVS, the second largest drugstore chain in the US, which has 100 million customers each year, is leading the charge to create more healthcare services in CVS stores. Already, CVS has 960 walk-in Minute Clinics staffed by pharmacists and nurse practitioners. The clinics are open on nights and weekends with no appointments. Prices are between 40% to 60% lower than traditional US doctors, and a fraction of the cost of A&E. This year, Minute Clinics expect some six million visits, and CVS plans to open a further 500 such clinics by 2017. In 2014, at CVS stores, more than 700 million prescriptions and five million flu injections were administered. 

Walgreens, the largest drug chain in the US with 8,217 stores in 50 states, has also set-up healthcare clinics, and similar initiatives, are afoot in the UK. These, together with other retail initiatives, constitute a convenience revolution in healthcare. 

“US and UK healthcare systems will go bankrupt if they don’t change their current healthcare delivery models,” says Devi Shetty, world renowned heart surgeon, founder and chairman of Narayana Health, India, which provides affordable quality healthcare. 


       Watch video

 (click on the image to play the video)


Adherence to medication

People like the fact that pharmacists are accessible friendly health professionals, and over time grow trusting, personal and valued healthcare relationships with them, which enhance adherence to medications. Non adherence is costly, and can lead to increased visits to A&E, unnecessary complications, and sometimes death. According to a New England Healthcare Institute report, Thinking Beyond the Pillbox, failure to take medication correctly, costs the US healthcare system $300 billion, and results in 125,000 deaths every year. 

Rajiv Dhir a senior prescribing pharmacist working for NHS England describes the importance of patients being able to discuss their drug regimens with pharmacists:



   View video

   (click on the image to play the video)     
                           

Primary care environment 

In the UK and elsewhere the demand for rapid and convenient primary care, outstrips it's supply. For instance, the UK is experiencing an exodus of GPs. In just five years, 40% have left to work abroad, and around 22,400 GPs – more than half of England’s 40,200 family doctors – want to retire before the usual age of 60. Younger doctors are not filling the gaps, with up to one in eight GP training posts unfilled. They are instead either choosing careers as hospital specialists or going to work abroad. Today, some 1,063 GPs are needed in England just to return to the patient-doctor ratio of 2009.
 

Coordination between primary and secondary healthcare

Walk-in retail clinics can provide a valuable link between primary and secondary care. CVS has partnered with over 50 secondary health providers including the Cleveland Clinic, which offer their Minute Clinics follow-up services, and answer questions a nurse practitioner might have over the telephone. Such relationships are well positioned to be enhanced by increased electronic sharing of patient data.
 

Takeaway

Traditional health providers can’t stop the convenience healthcare revolution, but they can encourage it.

 
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Gordon Moore
Professor, Harvard University Medical School and world renowned authority on the design and implementation of healthcare delivery systems 
 

'Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer, connect the participants up in real time, and create smart, real-time process support.'

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Curing the Problems of General Practice

The Royal College of General Practice (RCGP) and the Centre for Workforce Intelligence (CFWI) agree: too small a supply of GPs will meet a rising tide of demand.  In the UK, spotty shortages exist now, but will become widespread over the next decade.

The causes of rising clinical demand are well known:
  • Continued growth of the things medicine can do
  • Surge of lifestyle diseases
  • Burgeoning patient devices that collect data and require monitoring by clinicians
  • Increased public expectations for access to GPs 
  • Aging of the population
  • Emergence of multiple, complex chronic illness
  • Diversion of GPs to management activities such as commissioning

Little analysis of root causes
Less is known about the underlying causes of the shortfall of supply in GPs.   The RCGP cites lagging GP incomes as a source of dissatisfaction, with consequent dampening effects on medical student choices of general practice specialist careers.   The CFWI models GP supply, but offers little analysis of the root causes of the declining intake to GP careers.  

While both the RCGP and the CFWI repeatedly emphasize the need to make general practice more attractive and increase its uptake, they have few suggestions about how to do so other than promoting it better.  In the meantime, they advocate, as does the NHS, that larger, multi-skilled teams must grow to service the increasing need, and that the key barrier to effective teamwork is lack of integration.

Concerns
I want to raise two significant policy concerns about the direction that the UK is taking to mitigate the primary care “crisis”.  First, I postulate that the reason that medical students are not choosing general practice is less a matter of money than of increasing practice complexity and life style.   Second, I suggest that the “solution” of larger, better-integrated teams is unproven and, further, may actually diminish productivity, and worsen, rather than relieve, the stress of work on GPs while their satisfactions further diminish.  

Lifestyle challenges
There is little evidence that medical students will select GP careers if they earned more.  In fact, over the past five years, during the rapid upturn in GP incomes, dissatisfaction among GPs grew and fewer medical students, especially men, chose to enter general practice.  In the US, studies have shown that life style is an important factor in the diminishing number of medical students entering primary care.   At the same time, corporate primary care is growing, and larger practices with more salaried doctors are becoming the work choice of preference. 

This suggests that young doctors are put-off by the complexity, responsibility, the long hours, and the stress of general practice, and seek to transfer those risks to someone else.  Without fixing this, throwing more money at the problem is unlikely to reverse the trend.   Money, of course, is important, but it’s merely an enabler of career choice and a deterrent if too low. Compensation alone doesn't appear to be a sufficient incentive to chose primary care.   

Multi-purpose teams failing
The idea is seductive that integrated, multl-manpower teams are a solution to the GP shortfall. However, early evidence from America doesn’t suggest that the US-version of integrated, primary care teams (the patient-centered medical home) is achieving the efficiencies and improved care that they were touted to deliver.  Recent studies  (see: Friedberg M.W., 26th February 2014, Journal of the American Medical Association) show some small improvements in quality measures, but no change in cost-effectiveness in a group of enthusiastic early adopters.   

There are many reasons to doubt that simple team integration occurs by encouraging it among those working together, and much to suggest that the cost of integration is a major barrier to a cost-effective strategy to increase manpower.   Information technology, as a field, discovered years ago that taking complex tasks and dividing them among many different subgroups was dis-economic.

Additional manpower not the answer
As long ago as 1975, Frederick Brooks in The Mythical Man-Month argued convincingly that by, “adding manpower to a late project makes it later”.  No surprise then that when one counts the cost of personnel, the coordination mismatches, the communication time, the complexity of handoffs, and duplication of services, teamwork is more a theoretical concept than a practical working model. 

Adopt best practice
What, then, might one consider as a possible solution to the increasing stress, complexity, and uncertainty of life as a GP? What is needed to facilitate integration among and between team members and patients?  Surely, we can draw lessons from other industries.  Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer (think of Cash Points), connect the participants up in real time, and create smart, real-time process support. 

The role of technology
Digital infrastructure for general practice has failed to keep up with the rest of the world.  The electronic medical record documents what has been done but does little to help doctors and other health workers to do their work. There is no infrastructure to help patients. Information technology should be providing an infrastructure to make general practice easier and better to do. 

Merely throwing non-GP manpower at their problems will make the life of the GP more complicated and less satisfying.   It is time to invest in true infrastructure innovation in the NHS.  It won’t be cheap, but it is the only answer to the threat that general practice will fail to meet the needs of the population in future.    
 
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