Francesco Carelli

Professor of Family Medicine, University of Milan and Rome

EURACT Council, Director of Communications

Family doctors are better  placed than other professions to see what is wrong with all parts of healthcare and better placed to recognise the value of collaborative solutions. Most of the world came to recognise this as long ago as 1978 at the Alma Ata consensus conference and Starfield has demonstrated it in her comparison of healthcare systems – high quality, cost – efficient healthcare needs to have broad – visioned primary care at its heart.


The reason is that generalists have everyday experience of the causes of failure and ingredients of success.  Primary care generalist (not just family doctors) witness the causes of system failure all the time because patients come to complain about them – not merely failures in one discipline or one hospital, but full range of healthcare experience.  Also, primary care doctors often appreciate, better than specialists, that long – term success requires working with others – with families and communities to improve social support, with many varieties of specialist to improve care pathways, with extended primary care teams to deal with a full range of problems.

It may be true that competition is helpful for quality treatment of discrete episodes, but in more complicated situations (that is most situations) collaboration between disciplines is a more powerful determinant of quality.

The heightened sensitivity of family doctors to the multiple impacts on health and disease comes from spending so much time teasing apart complex entanglements of social, emotional and medical diseases of patients who present, every few minutes, another “universe of meaning“ who walks into a family doctor consulting room, often containing myriad intertwined issues, many of which are better suited to low-tech, coordinated local solutions than to expensive specialist referral.

Heightened awareness of the problems does not mean that family doctors are the best people to solve them. Taking family doctors away from consulting rooms takes away the experience that makes their insights so valuable.  Historical processes have prevented systematic exploration of the world beyond the practice front door and this has inhibited understanding of how to make whole systems work. General practice is not acting as part of a wider system of care even to support the co-ordination of core general practice work such as end-of-life care.

An early task is to work out which bits family doctors should do and which bits others should be done in partnership with others. Success requires that all family doctors and managers increase understanding about broader issues than the treatment of diseases within general practice.  It would be a waste of time for family doctors to divert energy towards the cat and mouse game of hospital system for payments. On the hand family doctors are likely to spot the gaming quicker than others, so a hot line to divert someone else’s attention to it is a good idea.

Effective commissioning will facilitate broad and visionary partnerships for well being and social support. It will monitor existing care pathways and engage with the complexity of redesigning them to become better value. It will cause a culture of reflection and inquiry and increase local skills of applied research, including service evaluations.  There needs to be a collective effort to work out how to di these things that includes primary care insights without taking too much of their time.

Commissioning is much more than buying services – it requires annual cycles of collective reflection and coordinated action for a raft of improvements that engage a multitude of people. To facilitate such complex collaborative improvements, we need to become skilled at unfamiliar techniques that help whole organisations, systems and networks to learn and co-evolve, systems  mapping, coordinated data capture, large group interventions, learning networks. These will allow large numbers of doctors and managers to meaningfully engage with the complexities of whole system improvement, spreading the load in a way that has high impact of culture and low impact on personal time. There are three stages of commissioning a new service. First to identify what is wrong with the present situation, second to pilot better ways to do things, then to improve relationships between different services to redesign them.  It is not enough to merely apply evidence generated in another place because every context is different, with different needs, different range of exiting services and different competencies. In any case, every innovation has unexpected impacts, both good and bad, we need to have alert minds to see these.

We live at a dangerous and dismantling time of history.  What happens next could destroy the NHS completely as chasing invoices and over-emphasis on technical fixes makes us sleepwalk into the same mistakes made by insurance policy dependent, disparity filled American health care. Conversely, imaginative and courageous family doctors could lead the renaissance of the NHS, redefining “ public service ethos “ as a disciplined adherence to processes of collaborative improvements.  It could set traditional general practice values of family & community care in a modern context where relationships really matter and where the simplistic notion of markets and targets is set inside broad consensus, fuelled by ongoing relationships building across disciplinary and institutional boundaries.

We face a new conceptual challenge in health care and in educating the next generation of primary care providers. A new pedagogy of flexible thinking skills and collaborative practice will be needed to embrace the transformation we are part of, welcome or not. Technology like the internet is more than a form of information exchange, it can empower creative thinking in shared dialogic spaces beyond time and physical limitations.   We are all busy. There is a tremendous amount of excellent material available to us in libraries and web pages around the world. Many professionals are learning new ways of thinking, with new tools for joined up working to provide excellent and personalized care for the real people presenting to us each day.