Paradigm shifting and a day at the races

• Written by: Dr Graham Kramer — — GP and Clinical Lead for Scotland’s House of Care
• Published: 15th October 2018

Graham offers his reflections on the British Heart Foundation House of Care Legacy event in York last week.

On 9 October 2018 I found myself at a very sunny York Racecourse. I had the pleasure of attending the British Heart Foundation’s (BHF) House of Care Programme (this link will take you away from our website) Legacy event along with many colleagues involved in Scotland’s House of Care. Four years earlier we had been very excited to learn about BHF’s ambitions to help support GP practices in delivering care and support planning (C&SP) with people living with long term conditions (LTCs), particularly those affected by, or at risk from, heart disease. We were delighted that, along with Gateshead and Hardwick in England, they agreed to partner our work in Scotland that was promoting the adoption of C&SP in Lothian, Tayside and Greater Glasgow and Clyde. The legacy event was a collection of excellent presentations describing C&SP and its place in person centred care, details of the three-year programme, sharing the lessons learned and the key gains from the independent evaluation (this link will take you away from our website). It was heartening to hear the positive feedback from patients and practitioners. Will Griffiths ably described the contribution from the ALLIANCE in building relationships with GP practices and community support for self-management (“more than medicine”).

It can sometimes be difficult for project teams, programme managers, funders and implementers to fully appreciate what they’ve achieved over the three-year lifespan of a piece of work, what difference they have made and what will become of it all. Sometimes there can be a sense of anti-climax and “what’s next?”. However, for me I felt quite euphoric and I wish to explain why.

As a GP at the autumn of my career I have long held an interest in caring for people living with long term conditions. I graduated from medical school in the mid-1980s nearly a decade after George Engel first described a need for a paradigm shift to embrace a different, “biopsychosocial” model of medical practice. It wasn’t until I entered General Practice in the 1990s that I learned of Engel and was introduced to more holistic ways of consulting, but mainly limited to the enquiry of people with short term (acute) illness. Around that time evidence was being published, mainly from North America, regarding the positive outcomes of personalised approaches for people with long term health problems. It wasn’t until a decade later, in 2004, that I studied this on a year-long sabbatical in New Zealand. I began to understand the benefits of strong therapeutic relationships. Key to successful encounters for people with LTCs and their professionals is when personalised information is shared with them that is responsive to their health literacy, are encouraged to set their own mutually agreed goals and where their participation and collaboration in the consultation is actively promoted along with positivity and empathy. This type of practice is all about bringing the best out of people.

I returned to the in UK in 2005, 9 months after the introduction of the Quality and Outcomes Framework (QOF). Evidence based medicine had encouraged the proliferation of guidelines to encourage best medical practice for many individual diseases. Through QOF, GPs were incentivised to ensure people with long term conditions were receiving these medical processes of care. This created a tick box approach focussing on data collection but undermined personalisation of care by overpromoting biomedical targets and perpetuated people as being passive recipients of surveillance. As someone trying to embrace Engel’s vision it had, if anything, got a whole lot harder and more elusive.

A decade on, the rhetoric of policy in Scotland, echoing the patient voice, has strongly supported the personalisation agenda and I’m sure Engel would have approved. These include the person-centred Healthcare Quality ambition, Gaun Yersel and support for self-management, Health and Social Integration, “What Matters to Me”, Realistic Medicine and a new GP contract.

So, whilst the BHF project lasted three years, what it represented to me was an attempt to build on the previous 40 years and truly implement, within GP surgeries, a “holy grail” of medical practice: an empathic, holistic, enabling, relationship and personal outcome based, co-produced, realistic method. The BHF project has built on the work of Year of Care Partnerships (this link will take you away from our website) that distils this approach into a practical pathway and a teachable, collaborative consultation model that works in General Practice. This process was developed and piloted early in the QOF-era back in 2007. Key to this has been aligning the values and underpinning philosophy across practice teams who have worked to change their systems and processes. All this has been achieved together with people living with long term conditions. The contribution of the BHF, and our partnership in Scotland with The ALLIANCE, cannot be overstated. The fact that this process is being achieved against the prevailing pressures in General Practice is remarkable.

For the first time in my career it feels the paradigm is truly shifting. There is some way to go and it will perhaps be another decade or so before care and support planning is the norm across Scottish General Practice. The legacy of the BHF programme, Scotland’s House of Care, and all those pioneers involved in the early adopter practices is that they will have been at its vanguard. We are out of the starting gate, there are still fences to clear, but the final furlong is getting nearer!

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