Harriet Vickers: The one in front of me, or all of them out there?

Harriet VickersAs the government’s white paper promises to change the role and duties of GPs, this week’s King’s Fund conference asked “do clinicians have a responsibility for the population as well as the individual patient?”

From all the speakers the answer was a resounding “yes,” however each had their own perspective on how this could fit into healthcare, and how it could be harnessed by a future NHS.

“For clinicians working in a national tax-funded service, obviously yes, it couldn’t be anything else,” said Dr Iona Heath, president of the Royal College of General Practitioners. She sees doctors as constantly oscillating between polarities, of which patient-population is just one. However with commissioning, doctors who have so far avoided a community regard will no longer be able to. They must, with support, be able to go between the two: “reality is the particular patient in the consulting room with the doctor, justice is all the patients who are not there.”

She also pointed out that maintaining registered lists is imperative, to make it clear who is whose responsibility.

“Many of the causes of ill-health that clinicians see and treat, they often lie beyond the individual. I think clinicians do have a duty to treat health as well as disease, and that means taking a population, as well as an individual perspective,” – another “yes” from Dr Anna Dixon, director of policy at the King’s Fund. She sees commissioning as “basically a financial responsibility for meeting the health needs of the population.”

For a practical perspective, Dr Dixon drew on research from the London School of Hygiene and Tropical Medicine which highlights barriers to GPs effectively caring for the health of a population. The first of these was that the quality and outcomes framework (QOF) focuses too much on secondary care in this respect, and doesn’t have enough incentives for primary work. Secondly few GPs, even in primary care trusts where reducing inequality was a priority, believed they had a duty to the health of a community. Thirdly, QOF prompted little case-finding, and there was scant evidence of GPs using population data to target at-risk patients.

In Dr Dixon’s view, different incentives, innovative use of data and time to step back are “needed more than ever.”

Sir Muir Gray also had a pragmatic solution for getting clinicians to care better for community health. However he wanted dedicated individuals to focus on population health, “3000 of them…with their map on the wall, thinking where the action isn’t.” The NHS Atlas of Variation, published yesterday, shows huge variation in the proportion being seen in different communities. His proposed solution is to give chosen clinicians or scientists time each week to look into the geographical prevalence and risk of certain conditions. Each clinical directorate would have one, and they would look at the public information available, identify new GPs in the area and briefing them, train pharmacists and produce an annual report.

For Professor Elisabeth Paice, dean director, London Deanery, “our last untapped resource in the health service is our young population of trainees.” She believes our doctors-in-training, “have a habit of communicating. They maintain big networks of friends and colleagues, and are collaborative, passionate about social responsibility, innovative and have high expectations.”

She summarised writing from Simon Sinclair, who wrote that junior doctors come into medicine with very strong personal values. However these were replaced after a year with professional values – those of autonomy, power, status. Their sense of shared responsibility was eroded, and they lost contact with the outside world.

Professor Paice doesn’t want, or see, this happening to our future, better-connected, clinicians. “The consequence of that, I think, is playing out. I think a generation of young doctors who do have a work-life balance, are not chronically sleep deprived and do have time for their friends and family, will stay much more in touch with the values of patients and the public.”

As some GPs express anxiety over the details of commissioning, let’s hope these views settle some nerves.

Harriet Vickers is a multimedia intern with the BMJ.