General practice has seen enormous transformations in its 60 years of existence under the NHS. As a young GP, I was interested to read this well-considered book by the experienced GP and academic Dr Steve Iliffe who led me through a process he calls the ‘industrialisation of family medicine’.
He begins, by describing the sense of distress he views in current general practice with the transformation of family practice into a ‘production line process’. Through his book he goes on to explain how this process is unfolding, the many dimensions it incorporates and potential ways of managing the change. Chapter 1 describes the evolution of general practice and the stages of change that have led it to where it is today. Within this evolution he establishes that industrialisation likely began in 1990 with the introduction of the new contract. He goes on to give an in depth view of industrialisation itself including some interesting discussions regarding general practice with relation to franchises and co-operatives, patients as customers and, of course, the rise and fall of fund-holding.
In the following chapter, Dr Iliffe gives a balanced description of how bureaucracy is now a part of everyday general practice and how management can be seen as a threat to autonomy but is likely required in preserving a cost-effective gatekeeper role. He goes on to describe the roles of practice-based commissioning including pros and cons as well as the alternatives and their potential place in general practice. In subsequent chapters, we are led through forward integration and the need to respond to failures in gatekeeping by looking to provide more specialised services, working in more effective team settings and collaborations. The concept of mass production is tackled next with debate around the quality outcomes framework, quality incentives, performance indicators and the risks of transforming GPs into ‘data collectors’. Evidence-based medicine (EBM) is also debated and the ‘dark side’ of EBM is considered as well as the power it potentially wields, its role in guideline production and increased practice efficiency. This leads smoothly into a detailed chapter exploring clinical governance, its different forms and how it can be modified to future proof general practice. The penultimate chapter examines patients themselves and their role in industrialisation. A changing population is perceptively described and related to changing doctor–patient relationships. Patients are described as consumerists and Dr Iliffe takes time to explain new versus traditional concepts in this part of industrialisation.
In the final chapter we are presented with the main challenges that general practice faces during industrialisation. However, the conclusion is optimistic suggesting that industrialisation can result in improved care whilst maintaining patients as individuals, though not without significant effort.
Dr Iliffe convincingly describes the process of industrialisation of family medicine through a highly researched book littered with interesting quotes and references. I would recommend this book to both new and experienced members of primary care who wish to understand more about this process of industrialisation and how we can best optimise the changes that it brings.
