A GP named A J Cronin blessed us in the 1960s and early 1970s with Dr Finlay’s Casebook, a grainy black and white televised account of family doctors in the Scottish Highlands of the 1920s. Gouty old Doctor Cameron could not suppress either the charm or the good humour of the suave young Finlay, whilst their housekeeper Janet kept the peace and made the cake. She was also their de facto receptionist, answering the wall mounted upright telephone with some trepidation. Theirs was a 24/7 service in which they were ably assisted by a District Nurse (“Mistress” Niven) and a cantankerous locum who had designs on Janet’s apron strings.
That was primary care from nearly a hundred years ago, as reproduced for early television audiences. It was instantly recognisable and offered place based, integrated care with exceptional emphasis on continuity; more than once we would see the redoubtable doctors in their striped pyjamas, summoned from a warm bed to go visit a child with suspected smallpox in the wee small hours. But it was never once referred to as primary care – or rather cùram bun-sgoile as it would be in the Scottish Gaelic. You don’t need to describe something as obvious as a front line family health service with words that so obviously confuse that which you are trying to convey. And as if to prove the point, an NHS Alliance survey dating from 2014 showed that the very phrase “Primary Care” was poorly understood by the British public, who in large numbers took it to include (amongst other things) A&E. And why not? The word primary generally means either first up or most important, and your local hospital often falls nicely into both of those categories.
Go back a little further in recent history to 2005 and The King’s Fund’s “The Future of Primary Care” contains content that is very contemporary in terms of some of its themes. NHS reforms are aimed at “delivering more services in a community setting; making more effort to ‘manage demand’ for NHS care effectively … and reducing health inequalities”. The quality of primary care (although on average high) “is variable on a practice-by-practice basis”.
Less than fifteen years ago of course the underlying mechanism was market forces; but there is a coy reference there to the (US) Kaiser Permanente approach to integration and a view that “such a model could be anglicised …. Effective developments could be initiated in the shape of multi-specialty groups (including primary care physicians) or networks.” The wheel spins full circle. From a patient’s perspective Primary Care is where you go first for something you can trust. That is the challenge for Primary Care Networks. The language is unimportant, confidence in the system is everything. Doctors Finlay and Cameron offered a single point of access and continuity of care and that is still what matters.
Cronin’s other great achievement was a rip-roaring novel called The Citadel. It told the story of a fresh faced country doctor who gravitates to Harley Street and ends up consumed with self loathing after he has sold out his good intentions for the sake of his rich clientele. But in his first job he connives with an older doctor in a small Welsh town to blow up the sewer which is poisoning the wells of the poor who live at the wrong end of town. They stuff dynamite stolen from a local colliery into cocoa tins and blame the resulting explosion on underground gases. Typhoid cases drop dramatically due to this drastic public health intervention (prompted as it was by a failure of authority to replace the sewer in the first place).
No-one of course is suggesting that modern primary care practitioners should resort to anything as drastic. But if they can get the essential interventions right, Primary Care networks – incentivised by the new GP contractual arrangements – might also be able to address a few modern public health scourges. Replace dynamite with data and light the fuse with digital technology and you may be able make some real progress.
Dr Claire Fuller