WHO WILL CARE IN 2025?

By Una Macleod
Contact the author by e-mail at christopher.johnstone@ntlworld.com

Recently Greater Glasgow and Clyde Primary Care Palliative Care team held a meeting called 'Who will care in 2025?' This got me thinking about the usefulness of contemplating what the future might hold, not just for palliative care, but more broadly for general practice. I reflected on how useful the thought of an Orwellian 1984 had been at the time, in drawing attention to a picture of a place where readers might not want to go. Are there places we might not want to go? And are we already on the road to them anyway? Thinking ahead from where we are now, a number of scenarios emerge, some of which are more likely than others. If we take some examples of some current issues how might these develop over the next couple of decades?

The last couple of decades have been marked by the rise of evidence based medicine. This is now firmly established within contractual arrangements, with fairly general agreement as to the positive effects on delivery of care, particularly with respect to the management of chronic diseases. But what about the future? There is little doubt that population demographics will change over the next couple of decades with proportionately more older people than now. This in turn will result in the health service caring for many more people with chronic diseases and more people with co-morbidity. How will the associated costs of this be dealt with?

Suggested solutions to this such as self care are only likely to go part way to solving the problem. Will we see a strengthened primary care taking responsibility as generalists in managing chronic disease? Or, will we see first class care for those with conditions for which good evidence exists, but poor or little care for conditions where evidence is less strong? Taking this scenario a step further, can we see the point at which health service costs will be dealt with using algorithms to determine whether your symptoms or condition(s) qualify you for 'free at the point of need?' Will targets end up as a means to the end of ensuring high quality care as they have been sold to us now, or will they be a cost cutting exercise? Will the delivery of these targets be our primary (or only) obsession? Further how will the health service deal with new evidence as it emerges, and in particular how will decisions be made about what evidence to believe and what to fund? Will the example of the recent inclusion of chronic kidney disease (CKD) in QOF, of clear benefit to some patients, but of dubious benefit to others with significant impact on workload and with relatively poor guidance, become the standard model for incorporating evidence into practice?

Think also about the possibilities and limitations of information technology. Will we have had a successfully delivered public sector IT project by 2025? Will we have met the challenge of using and developing new technology to enhance patient care and not just simply because we can? Will Google replace many current functions of GPs? Google health perhaps - enter your symptoms here let Dr Google diagnose your illness. But, no he can't give you a sick line, so see your GP for that. But perhaps you won't have a GP. You will have your health data (and relevant social data and who knows what else) stored in a biometric card, which you can take to any GP who will see you. Personal care abandoned at the alters of technology and progress.

No doubt there will also be changes in professional structures and roles, organisational contexts and perhaps even in how we relate to secondary care. Most worryingly some professional roles, now working well, such as community nursing, may become unrecognisable. And how will we relate, not only to other professionals but also to patients and the public?

Expectations are likely to increase as we have access to more possible treatments; how will we respond to these? Will we have solved issues over appropriate access to primary care, so that patients get seen when they need to be seen? What of patient and public involvement in the NHS and in health care decision making? We know that lay representation will form a significant part of the General Medical Council, for example: what kind of impact will this have on the direction and decisions of the GMC? Perhaps this lay or patient involvement may be what actually keeps professional focus on patient care and from the NHS been run by a few private companies.

With respect to public - professional relationships, we can foresee many media debates along the lines of the recent Herceptin debate - where trial by media and public may determine the outcome of a health care decision, begging the questions of whether this results in appropriate decisions and more importantly whether this is an appropriate way to determine health care spending. Will this not result in the powerful lobbies getting positive results and those with less powerful or no such lobbies missing out? Perhaps we just need to develop better ways of understanding risk ourselves and then presenting it clearly to patients.

In the midst of all this uncertainty it is likely however that the skill of general practice will remain the ability to juggle competing priorities. So, is the title 'General Practice in 2025' an oxymoron? I hope not, but time will tell. What other CKD's await around the corner? And who will deal with them, if not, general practice.

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.