On the Origin of Species

by reestheskin on 30/06/2020

Comments are disabled

Once there was General Practice, medicine in the image of the late and great Julian Tudor-Hart. Then there was Primary Care. The following article from Pulse made me sit up and wonder whether we have got it right.

Under the five-year contract announced last year, networks were to receive 70% of the funding to employ a pharmacist, a paramedic, a physiotherapist and a physician associate, and 100% of the funding for a hiring social prescriber, by 2023/24… Six more roles will now be added to the scheme from April  ‘at the request of PCN clinical directors’ – pharmacy technicians, care co-ordinators, health coaches, dietitians, podiatrists and occupational therapists…PCNs can choose to recruit from the expanded list to ‘make up the workforce they need’…The document added that mental health professionals, including Improving Access to Psychological Therapy (IAPT) therapists, will be added from April 2021 following current pilots…NHS England will also explore the feasibility of adding advanced nurse practitioners (ANPs) to the scheme [emphasis added].

PCNs to get 100% funding for all extra clinical staff as further roles are added | News Article | Pulse Today

Adam Smith among others pointed out the advantages of specialisation. We owe virtually all of the modern capitalist world to the power of this insight. But we also know that there are opposing forces — and not just those of the Luddites. Just think back to Ronald Coase and the Theory of the Firm. Why do companies not outsource everything? Why are there companies at all? Simply because under some circumstances transaction costs and formalisation of roles and contracts limit outsourcing 1. Contra the English approach is that of the Buurtzorg (links here, here and here) in the Netherlands where it is explicit that many of the tasks undertaken by highly skilled staff do not require high level skills. But — so the argument goes — the approach is more successful, robust and rewarding for both patients and staff. This is closer to the Tudor-Hart model. It really does depend on what sort of widgets you are dealing with, and whether fragmentation of activity improves outcomes, or merely diminishes costs in situations where outcomes are hard to define in an Excel spreadsheet.

  1. I realise I am speaking more metaphorically here than literally in terms of Coase’s work. My argument is about transaction costs in domains where much knowledge is not explicit or capable of easy formalisation, and where there is in one sense path dependency between patient and clinician.