Leading the way

Q&A with respected US primary care expert Professor Gordon Moore

IT WAS more than 20 years ago that Professor Gordon Moore first visited the UK to study general practice as a Fellow with the Kings Fund in England. The Harvard Medical School graduate came to these shores in 1988 when, he says, his “admiration and envy of GPs and the NHS” began. In the years since, Professor Moore has built a reputation as something of an international expert in primary care with a knowledge and insight into the field that would no doubt be the envy of many in UK general practice today.

The 72-year-old Bostonian, who qualified in 1963, shared some of this insight with doctors at the recent RCGP annual conference in Glasgow. His speech highlighting the lessons the US could learn from UK general practice was widely applauded and considered a number of timely issues, from the emergence of Darzi centres to the increasing corporatisation of our healthcare system.

The professor’s first visit in 1988 was designed to build his knowledge of the UK healthcare system with a view to informing his work as director of teaching programmes at the Harvard Community Health Plan (HCHP). He followed it up with a second year-long visit with BUPA in 1995. Professor Moore practiced at the HCHP as a primary care internist (a GP for adults) for more than 30 years and helped create the Department of Ambulatory Care and Prevention – the country’s first academic department fully based in a managed care organisation. He remains a professor in the department, which is now the Department of Population Medicine.

From 1997 to 2008, Professor Moore ran a national programme for the Robert Wood Johnson Foundation called Partnerships for Quality Education, whose purpose was to help doctors and nurses in training to become competent in systems thinking, quality and practice improvement. A father of two grown-up daughters, his work in Harvard currently focuses on a number of areas including educational strategies in healthcare, teaching about population health approaches, international health services and effectiveness of primary care.

What do you regard as the key strengths of UK general practice?

When people talk about general practice in Britain, it’s really regarded as the jewel in the crown. There are a number of elements that I see as fundamental to its success. One would be its clear structure, the fact it is available everywhere and that the GP has the role of first access care and control over referrals into the acute sector. GPs in the UK also have a close relationship with their patients over many years, which is very important, as this continuity of care builds trust. GP training is very good in the UK and the general practice ‘brand’, or public image, is strong. Having one voice – in the form of the RCGP – is also crucial in conveying a single national message about general practice.

What are the main problems with general practice in the USA?

The biggest problem is that very few American graduates are choosing general practice as their field of career interest. So numbers are declining and waiting times have soared. Also, the structure is loose and fragmented, the system is very ill-defined and there is little continuity of care. Americans may see anyone they choose; there is no workforce planning, and there is no planning that assures that GPs practice where they are needed. Patients may self-refer to specialists and specialists are quite happy to poach patients who would be better served by GPs. Also, US GP incomes lag dramatically behind those of hospital specialists because of the compensation scheme in place to support GPs.

What lessons could the USA learn from UK general practice?

A great deal of the success of the UK system is the pride of place of general practitioners in the system. They have a sense of personal self-worth, of contributing and of doing good. Also, there is no structural support for GPs in the US and little continuity of care; trust from patients has diminished. We won’t be able to fix general practice in the US until we pay heed to the rules that our general practitioners would need to follow in order to give them authority, responsibility and accountability within the system.

What lessons could the UK learn from the USA?

The most important thing is that nothing is forever – your high regard from the public has to be constantly earned. You could easily miss important opportunities to make the system better or make mistakes which are driven by self-interest, ie: in out-of-hours cover. When I see things like out-of-hours provision, practices using more personnel who are not doctors, patients seeing their own doctors less, that has got to have an effect on continuity and trust. General practice should not make the same mistakes that have been made in the US that have led to a degradation in continuity of care.

Do you see any worrying trends in UK general practice?

The erosion of continuity and trust is a major issue. The enlarging size of practice groups that cross-cover and the increasing number of Darzi polyclinics are two examples of how that can happen. The rise in GP-run referral centres can also lead to deskilling on the part of GPs and the loss of effectiveness at the triage interface. And what I call corporatisation is coming to the UK, whether in the form of international healthcare insurers buying the right to provide general practice in your community or the increasing use of salaried GPs. The net effect is to diminish the number and salutary effects of owner-operator GPs. I have found that salaried doctors without a long-term stake in the practice do not typically show the same drive for excellence, commitment and accountability to their patients as those who own their own practices.

Is free-market competition in medicine a good idea?

Yes. I’ve found that if salary is not dependent on performance then you start managing your time instead of your performance because the money is guaranteed. Market forces and some degree of pay for performance, some degree of competition in which patients are free to choose doctors who are providing better care, should be built-in. But unregulated market forces can also lead to bad outcomes. The more you pay according to specific indicator conditions the more you worry that the things you are not incentivising will degrade. Market forces can assist in delivering better value for money and service but they can go too far and there need to be checks and balances on the raw impact of market forces.

Should private firms be allowed to run primary care services?

Yes, I believe the existence of private primary care services, on an even playing field, can make things better. If someone can get a service free from their GP yet they choose to pay for a private service then, if I were the free service, I would be concerned I wasn’t doing something right. It’s a strength of the English healthcare system that you have a core service that’s been improving over the last 10 or 15 years and also have a private opt-out. The presence of a free at the point of care public system which has to compete with patients who might choose to go outside puts pressure on that core public system to perform better and the public deserves that.

Interview by Joanne Curran, associate editor at MDDUS