I heard on the BBC news last week that the emergency department of a hospital in Nottingham saw over 700 patients in one day. Now, in peacetime, and unless plague is sweeping across the land, that ought not to happen. What can it mean? The collapse of General Practice?
Right now, in British General Practice, professional morale is at rock bottom. GP training positions can’t be filled. GP partnerships are advertised and nobody applies. GP surgeries are either being placed into special measures or closed altogether. Medical School lecturers are hostile to general practice and put the students off. Junior doctors are heading for Australasia in droves. When you consider that most young people who enter medical school do so with a high sense of vocation and a genuine wish to serve the community and make the world a better place, this is bizarre. What task could be more rewarding than that of entering people’s lives in a unique way, using one’s knowledge and expertise to help and to be of use?
In my opinion, British General Practice has lost its way. It did so circa 2004-5, when a contract was negotiated whereby the responsibility for out-of-hours patient care was handed over from practices to trusts or health boards. That was a fatal error. The opportunity to stop being on call, to shut the surgery door at 6 pm and not look back, looked like a priceless gift but in fact it turned out to be a poisoned chalice. We should have known. After all, with power comes responsibility. If you abrogate the responsibility, you lose the power. Thereafter, it hardly mattered how well a GP was paid or how much free time he was given. He would be at somebody else’s beck and call, powerless, and miserable.
The new contract came into being at a time when information technology was taking off and paper records were being scanned into electronic systems. Sophisticated and expensive software packages were adopted by NHS Direct in England and Wales and NHS 24 in Scotland. There were frequent system crashes.
The new contract was target-driven and GPs were remunerated according to their attainment of set targets as delineated by the Quality Outcomes Framework (QOF). GPs, doctors generally, have been training to hit targets since long before they ever entered medical school, and it should have come as no surprise that most GPs would fulfil the requirements of the QOF and gain maximum points nearly 100% of the time. The QOF therefore evolved and became more complex, more IT-driven, and more time consuming. Computer systems were programmed to drive the QOF, so that GPs would be prompted by a series of alerts on the computer screen to ensure the QOF was adhered to.
The new contract also brought in a system of annual GP appraisal, whereby an appraiser, usually a GP colleague from a neighbouring practice, would spend a couple of hours with the appraisee reviewing his educational activities and monitoring his continuing professional development. Appraisal was developed shortly after the trial and conviction of a single-handed GP in the north of England who was found guilty of murdering fifteen of his patients, and who it was thought over his lifetime might well have murdered in excess of 300 people, making him the most prolific serial killer in the UK’s history. By a strange non-sequitur, this was depicted by the media as the event that kick-started appraisal. Read any newspaper article of the time about GP appraisal, and you could be sure the name Harold Shipman would appear in it. The purpose of appraisal therefore was to stop GPs from murdering their patients. Actually GPs knew perfectly well, and said often enough, that “appraisal won’t stop another Shipman.” I suspect Dr Shipman’s appraisal paperwork would have been quite up to the mark. As it turned out, appraisal wasn’t even that good at detecting GPs who were incompetent.
Meanwhile the ever exuberant, nay promiscuous QOF sired progeny such as “QIP” and “Whole Systems Working” by which GP practices were required to undertake ever more arcane and time-consuming pieces of paperwork (or electronic work). It was around this time that I myself decided to get out. I remember I attended a GP locality meeting at which GPs were being asked to undertake a particularly pointless piece of work. I stood up and made a short speech, subsequently referred to by my colleagues as “the speech”, rubbishing the whole enterprise. For a flavour of the occasion, I refer you to Chapter 17 of my novel Click, Double-Click. ACS’ rant was, essentially, my rant.
The QOF has been abolished, at least in Scotland. It is being replaced by another contract, to be “rolled out” (as they say) in 2018. Will it be better? I was about to write “I’m not holding my breath” but actually that’s not good enough. GPs need to take back control of the nature of the profession. The motto of the Royal College of General Practice is “Cum Scientia, Caritas.” It seems to me that science has been replaced by pseudo-science and care or compassion is in danger of being lost altogether. We need to come up with a plan.
Let’s draw up a model of care for a population of, say, 7000 people. I’m going to envisage it as being located in a Health Centre in a small town serving the population of the town itself, and a surrounding rural community, but it could as easily, with some modification, be an inner-city practice.
The practice needs seven GPs. If a GP has a “flock” of around 1000, he will seldom see more than 100 patients per week. That’s 20 patients a day, 25 if the GP wishes to devote one day a week to research, education, administration, or a special interest. Offer fifteen minute appointments. Patients will be able to be seen on the day they phone for the appointment. Believe me. I’ve done it.
The practice does its own out-of-hours work. This means being “on call” between 6 pm and 8 am once a week. Depending on the work load, consideration could be given to sharing “on call” with neighbouring practices so that the frequency is lessened. Schedule your night on call to be on the eve of your “off the floor” non-clinical day.
Next, the Health Centre has an in-patient unit. This is not as innovative as it sounds. Think of the traditional “cottage hospital”. There is much talk at the moment of “hospital in the home” particularly with regard to care of the elderly. But “hospital in the home” is very expensive. “Hospital in the GP surgery” is viable and still constitutes care in the community. Many elderly patients need to be admitted to hospital not because they need sophisticated tests or therapies, but simply because they need nursing care. This is the sort of patient who should be admitted to the GP unit.
GPs running such a unit would be required to cultivate and maintain skills that are chiefly learned in hospital emergency departments and in-patient units. They would have access to near-patient testing such as routine biochemical and haematological testing to allow for monitoring of intravenous therapy. There is no reason why there shouldn’t be on site plain radiography. Other lab facilities could be developed depending on the extent to which GPs were comfortable managing more serious conditions. The unit would be run by GPs and practice nurses. Allied health professionals such as physio, and OT would have input. The on-call doctor would be on site. Evening and overnight consultations would also be on site. Home visits might take place but the default position would be to consult on site. Transport, and a driver, would be available for both doctor and patient.
That strikes me as an attractive proposition for both patient and doctor. It’s real. It’s caring. It can’t be belittled. It’s pure medicine.