Working At Scale
General Practice / Primary Care has been around for a long time in the UK (since 1911). It is currently going through a massive transition due to funding cuts by the government, the pressures of having to deal with today’s needy patients and the increased work load being transferred from Secondary Care to Primary Care.
General Practice was traditionally provided by small Practices – often one or two doctors looking after the local community surrounding their surgery. This model of care which has survived over 100 years, is now being radically changed.
To deal with the modern landscape there is a push by the government for general practice doctors to combine to create “MCPs” and “ACOs”. These are large organisations which have a very different way of providing healthcare.
Traditionally, patients would register with their local GP and over the ensuing years they would build up a real relationship with their Family Doctor. This would allow GPs to provide a holistic approach to the care that was given. Having this connection with patients of course made it a very cost efficient way to provide healthcare as patients could be managed in an appropriate way, rather than the secondary care approach which entails carrying out a barrage of investigations and providing a ton of treatment in a cookie cutter fashion.
This model of care is still proving to be very efficient today – over 90% of patient contact by the healthcare system is carried out by primary care and they are only provided with around 7% of the NHS budget. That’s pretty good bang for your buck!
The new care organisations which are currently being created are turning GP surgeries into outpatient hospitals. They will be staffed by “Salaried GPs” who will work in them on a rota basis (much like hospitals). They will increasingly carry out the outpatient services traditionally ran by hospitals.
The hypothesis behind this shift is that “working at scale” will reduce costs for the healthcare service as a whole, as more conditions will be able to be looked after in the community. Instead of being referred to the hospital for that cough, you will instead be seen by a GP with a special interest in respiratory medicine and instead of seeing the GP on your first consultation, you will be seen by an advanced nurse practitioner or a trained Pharmacist.
Sounds great! Patients have more access to healthcare and more healthcare can be delivered at a lower cost.
However, the problem with this new model is that it is just a hypothesis, which is untested and since its inception has not provided the benefits that were promised.
The Lindy Effect
The reason healthcare is so hard to provide and also why it is so hard to change is because it is incredibly complex.
The NHS has to deal with the whole of the UK population and try to provide acceptable care to all people regardless of their backgrounds, it has to deal with the whole gamut of human diseases, psychological problems, social problems, economic problems, governmental initiatives and rules, different vested interests, market rules, changing demographics and so on. It also has to provide an increasing amount of treatments, social care, investigations, operations etc.
The Lindy effect is the concept that the future life expectancy of a non-perishable technology or idea is proportional to their current age.
For example, the Bible has been around for 2000 years, it is likely – due to the Lindy Effect – that it will be around for another 2000 years. It is not certain, but it is a statistical likelihood.
The reason the Lindy Effect is so potent is because it means that an idea or a technology has been put through the test of time and has had to have been through a whole host of iterations and complex challenges. This increases and verifies its robustness.
One can think of it as a type of natural selection. Put a piece of technology through a whole bunch of stressors, environmental changes, cultural changes, economic pressures and so on. The technology that survives can continue to exist.
Time also allows us to be as sure as possible that the piece of technology in question works and is as devoid of as many side effects and adverse outcomes as possible in comparison to an alternative solution*.
Exposure To Volatility
Good systems are exposed to volatility and are allowed to thrive or die. Primary care as we know it today has been exposed to a whole lot of volatility and as such it is a very robust and dependable system.
In the UK the government provides each GP Surgery with a certain sum of money each year. This mainly depends on the number of patients that are registered at the practice. With this sum of money the doctors in that surgery have to provide all the healthcare needed for their group of patients**, pay staff costs and run their business.
So in other words, for a limited amount of money, the NHS GP has to provide an unlimited number of appointments and services to meet their patients needs. Any business-type would run away from this type of responsibility as unlimited supply is not logically possible. However, this is the value that NHS patients are getting.
Each patient in the UK receives only around £90 of funding from the government. This is generally less than people spend to insure their pet dog.
So in effect Primary Care has had to survive each year under very difficult conditions. If demand and costs go up, GPs make less money. If GPs can’t work efficiently, they lose their business and contract.
Currently, it is a robust system and works incredibly well – no one can deny this.
Denial of Statistics & the Removal of Volatility
The governments proposal to make general practice work at scales denies the existence of the Lindy effect (i.e. it dismisses statistics as a whole).
The fact is that statistically speaking, coming up with a whole new system of providing healthcare in a boardroom is incredibly naive and there will be a ton of unforeseen consequences. I can guarantee that this will be at the detriment of patient care.
This type of “forward thinking” is a very “MBA type” of thinking. It is all based on hypotheses (aka guesses) by people in dark blue suits. It ignores the existence of complex systems, second and third order effects which are not predictable no matter how smart you are. It is the opposite approach to how successful businesses get created in the first place i.e. test a hypothesis and if it works then scale.
Not only is this new model of care worrying from this perspective, but it also removes the volatility faced by Primary Care currently.
As noted above, Primary care is exposed to the realities of having to provide care in a cost efficient manner. Recently, as the potentially infinite workload is increasing alongside an increasingly finite remuneration, GPs are leaving the UK to work elsewhere, work in the private sector or retiring early. In effect, the relatively reduced amount of funding is causing General Practice to fail. This is volatility at work and indicates that something should be done to continue to provide good healthcare.
These MBA types have come up with a solution which they think avoids simply funding general practice adequately. Their solution is to “work at scale” which involved GPs pooling resources together in the hope that this will somehow reduce costs. A more logical process would have been to observe that General Practice is incredibly robust and cost efficient and simply increase funding.
These large “MCPs” and “ACOs” usually have over 70,000 patients on their registered lists. These organisations if they fail economically and are not efficient will simply not be able to go out of business. The government will have to intervene and bail them out as otherwise whole regions of the UK will not have healthcare provision. Inevitably in the long run this will cost the tax payer/the government more than if they just persevered with the current system and funded it properly.
With these new systems as they will not go out of business, inefficiencies will increase. Just think of the inefficiencies faced in large hospitals and it becomes clear that these large MCPs which resemble hospitals will face the same issues.
People In Blue Suits
This lack of understanding of the Lindy Effect, the lack of understanding of healthcare and its complexities by MBA types in their dark blue suits fares poorly for the future of the NHS.
It is astounding that such important issues are left in the hands of people who simply have no idea of what needs to be done.
In the mean time it is the front line staff – nurses, pharmacists, administrative staff and patients themselves – that will have to bare the brunt of increased risk, uncertainty and poorer healthcare outcomes.
*Thinking of religion in this way is quite an interesting thought experiment. Could it possibly be that certain aspects of religion have benefits which we are unaware of, but due to the very fact that they have lasted for so long have untold benefits?
For example, many religions recommend fasting. Only recently are the benefits of fasting being demonstrated in scientific research.
** In the UK, GPs are not able to close their patient list. As a result anyone can go to a GP surgery in their region and register as a patient. GPs are swamped with work and would rather close their lists, than to have more patients, more revenue, but not be able to provide good healthcare.