The New GP Contract: We need relationship based care and more citizen governance

Written by: Cath Cooney, Director of Development and Improvement, the ALLIANCE

Published: 05/12/2017

Cath welcomes the new General Medical Services Contract with the hope that it will bring with it a more empowering approach.

Having a general practice system that works for people and the workforce really matters. It’s been a long time in the making, but the document that describes the elements of the new General Medical Services Contract is now here. It’s been a hot topic of conversation these past few weeks and much of what I’ve heard has been positive.

The language used in the new proposal echoes Realistic Medicine (this link will take you away from our website) with a will to develop a more equal relationship through personalised care and shared decision making. It’s good to see that person centred care is prominent, the need for supported self management is acknowledged, and the importance of valuing relationship-based care features. All good and welcome statements of what to do but it’s the nature of the how to do and testing of the want to do that unfold over the coming year that will determine the success of that more collaborative ambition.

Over the past 18 months in my role as ALLIANCE lead for the national House of Care programme, I’ve met many committed staff who understand that it’s about changing the nature of the conversation at the heart of the house. In primary care teams in adopter sites across Scotland there are GPs, Practice Nurses, Health Care Assistants and Pharmacists who have been trained in using a clinical method of care and support planning that supports staff to be prepared for that different kind of conversation, where the person is supported and prepared to engage in a more collaborative way (see YOCP (this link will take you away from our website)).

The aim is to make care and support planning conversations routine for people living with long term conditions, with supported self management at the heart. We increasingly share a common language around person centred care and supported self management, but it’s become clear to me that we often mean different things. If we see this as a continuum, then at one end self management can be seen as supporting a person to manage their condition, but at the other end it’s much more about creating the conditions so that the person has what they need to live, and die, well with their condition.  What is rarely talked about however, is the imbalance of power in those relationships and the importance of ceding power.

The nature of power was the focus of this week’s Glasgow Centre for Population Health (GCPH) hosted Glasgow Healthier Futures Forum as part of Co-production Week. We were reminded of the WHO Four forms of power (this link will take you away from our website) and how power doesn’t belong to any one person, but exists in the relationship between people. It’s given me pause to reflect on how traditional primary care models might be described in terms of power:

  • Power Over: the prevailing fix it model
  • Power To and Power Within: might describe those empowerment aspirations of supported self management approaches
  • Power With: collective power of communities or organisations.

Ultimately I believe we are aiming for a more empowering approach, with people being valued for their own expertise in their long term conditions and working alongside and supported by the wider Multi Disciplinary Team who themselves feel valued, prepared and supported to work in this way – every day and with every person they meet.

The additional time that will be offered within the GMS Contract for consultations with people living with multiple conditions is welcome, but the nature of those conversations will be key. At that GCPH session, Oliver Escobar spoke about Deliberative Democracy (this link will take you away from our website) and offered power frameworks that could assist our thinking. He spoke of internal and external power themes and how yes, the first important step (for the patient perhaps) is to be included and in the room, but moving to the next step of inclusion is about being able to contribute and shape the conversation. For me, this is the vital step in building that shared decision making approach.

Rebuilding trust with people and communities is necessary if new models of care are to be valued and understood by people. I was reminded of this at a recent NHS Lothian and Thistle House of Care Collaborative Learning session with GP Practices, where a member of staff described how a woman reacted to the news that she would be having a different kind of collaborative care and support conversation with a member of the Practice Team.

“I had one patient who said she hated being here but had changed her mind by the end of the conversation.”

“Newer patients tend to say ‘this is fantastic’ while ones who have been with the practice for years don’t like change.”

It’s good to see that there is a recognition within the new GMS Contract of the importance of allowing change to happen over a number of years. Managing change takes time and staff, and people, need support to develop skills to cope and manage that change process well.

In the world of current financial constraints, decisions about what to support and implement in health and social care are pressured and complex, but I believe that involving people of lived experience and the third sector fully in the detail of implementation is vital to achieving a transformational, third era change (this link will take you away from this website). We need greater recognition and sustainable resourcing of the third sector that strengthens the ‘more than medicine’ of health and social care.

I’ve been heartened to hear echoes of this recognition from health and social care leaders at recent national conferences on priorities for the NHS in Scotland:

“We need more relationship based care in a future primary care system… we also need more citizen governance.”

The findings from the recent Our Voice citizens panels tell us more about what people value in their health care and the forthcoming citizens juries will allow people to have a stronger voice in describing what shared decision means for them.

Following the outcome of the vote on the GMS Contract by GPs in early 2018, I look forward to hearing how citizens will be included as partners in shaping the how to do and want to do of emerging models of general practice and the wider primary care landscape.


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