Monthly Archives: March 2015

See no evil, hear no evil, speak no evil – of patients

If I am unhappy with my own GP I can take a number of actions. I can complain to the practice manager of my surgery, I can complete a friends and family test, anonymously as well as leaving messages on the NHS Choices website, again anonymously. I can also use social media to talk about my GP, call a newspaper or even lodge a complaint with General Medical Council. One of my own patients has written directly to the Parliamentary Ombudsmen and brings in the acknowledgement slip with her each time she comes in.

That I can’t reveal anything more about her, in an effort to protect her confidentiality illustrates the issues that doctors, including GPs, have in talking about the minority of patients that make their life and work a struggle at times. Reported case studies need patient permission and many bloggers who write in the medical press change the details of patients that are rude, inappropriate or simply daft, in order to protect their identity.

When it comes to the issue of trying to provoke debate about what some patients actually come to the GP about, this issue makes it very hard to know what to do. It seems that GPs are to “See no evil, hear no evil and speak no evil (of)” their patients. The customer, sorry patient, is always right and according to the health secretary knows better than the doctor. How can you compile a record of how the GP system in the UK is, albeit in some cases inadvertently, abused by patients.

Resilent GP debated the posting of the “inappropriate use of GP appointments” survey report. After being posted on the website, it was withdrawn after concerns about whether patients’ confidentiality was being breached. Careful reading of the report will show that this is not the case. It was restored so that healthy debate can continue. The Resilient GP partners have stated publicly that they feel that it is not unethical to raise real life examples of inappropriate appointment use. This is done by the ambulance service..

Although there are concerns that there is no fixed definition of an inappropriate consultation and that “naming and shaming” such inappropriate uses will discourage patients from attending their GP with vague symptoms that could belie some serious cause, I would argue that we don’t seriously think that speaking to your GP about the colour of the fluff you find in your belly button (true story) or any of the “symptoms” listed in the survey could result in a medical diagnosis other than health anxiety. Furthermore, by educating patients not to use up appointments with such things we may actually improve access for those that actually need it, for their serious, even life threatening conditions. Therefore, in order to improve access for patients in need, we need to first identify and discuss the problem of inappropriate GP appointment use, then decide how this problem should be tackled by the general practice, public health authorities and society as a whole.

Ethical considerations

We feel that is is not unethical to raise real life examples of inappropriate appointment use. No one has identified any patient and sharing information on the misuse of resources and opportunity cost involved denying someone else more in need of an appointment is both worthy, ethical and necessary. The ethics of utilitarianism are equally important here and it is a duty of doctors to challenge inappropriate use of resources. It is, to us, highly unethical that the leaders of the profession have done nothing to challenge this elephant in the room.

We understand some might feel uncomfortable, but these are examples happening every day in the NHS, which occur solely because we are free at the point of use. The public have a duty to use services responsibly, or be educated in where they are not. The problem is now we are so overregulated and time stretched that for a doctor to challenge such use simply invites a complaint which then takes hours to respond to, so many NHS staff lack the courage or resilience to challenge. So we have to be brave, as a group of healthcare workers desperate to improve access for patients in need, and stand up to defend the NHS, profession and other patients who cannot access healthcare by raising this vitally important issue.

Inappropriate demands to GPs

Introduction

General Practitioners in the UK (GPs) have been contracted since 1948 by the National Health Service (NHS) to meet the reasonable healthcare needs of their patients. Each GP has registered with them on average 1,700 patients, any one of whom can request an appointment to be seen by the GP, giving no information in advance other than whether they need to be seen routinely or as an emergency.

To become a GP, one must study for a minimum of 4-6 years at University, work for 3½ years in hospital and then spend 1½ years training in General Practice before being allowed to practise independently – a total of 9-11 years of training and significant personal and taxpayer investment.

Every effort is made to encourage the ill to consult their GP in a timely fashion to receive whatever treatment or reassurance they need. Indeed, no GP ever minds reassuring someone worried they might be unwell.

Increasingly, however, many GPs feel that what is expected of them exceeds what might reasonably be considered fulfilment of healthcare need, or that it might reasonably be expected to be met by friends, family or other trusted sources of advice.

The real danger is that if NHS time is taken up dealing with matters that could be dealt with by someone else, the ill will find it harder to access the medical treatment they need that only doctors can provide. This important concept is known as “opportunity cost”.

We have latterly been raising this issue in public and been met with bemusement by those who never face (or acknowledge) the demands that are presented to GPs on a daily basis.

The conventional response by GPs to such requests is to seek to understand and even sometimes address what lies behind such enquiries, whether it be inadequate education or family support, concealed anxiety about a possibly underlying health condition, poverty or simply the need for an advocate.

In the face of unprecedented demand for NHS services in general and the skills of GPs in particular, it is now time to ask whether General Practice is being used appropriately, or whether society could meet some of the needs a GP routinely encounters without recourse to the NHS.

Survey Method

We conducted a survey on a large, private online discussion group composed entirely of GPs. We asked for examples that were considered by that GP to be an inappropriate use of their time and skills. We received over 200 unique responses. We excluded very similar responses or those we considered might have conceivably have been a presentation of underlying illness.

Another large closed group was consulted about how best to present the findings, which were then published on our website in the prior to a general election.

All responses have been anonymised.

Survey Responses

For ease of reference, and to help stimulate ideas for alternative solutions, we have divided these into six categories: cosmetic, normality, trivia, requests for prescriptions for everyday items, administrative and miscellaneous.

  1. Cosmetic

    – Concerns apparently relating entirely to cosmetic issues

    1. “I have stretch marks on my thighs”
    2. Cream to make breasts bigger
    3. Anti-ageing cream
    4. “Is my nipple too hairy?”
    5. “Is there a pill so I can have a baby boy?”
    6. “I have ugly feet”
    7. “Do you have something to make my nails stronger & hair shinier before my holiday tomorrow?”
    8. 19 yr old girl: “My chin looks too fat in photos on Facebook – I need an operation”
    9. “My iPhone camera makes my face look wonky”
  2. Normality

    – Concerns that in the opinion of the doctor are closely related to normality

    1. 6 week pregnant woman attended out of hours because she felt her tummy was “too flat”
    2. “My cat scratches my furniture and it upsets me because I love him”
    3. “I went to the gym yesterday and now my arms are hurting”
    4. I want to find out about my son’s ying and yang”
    5. “I have cockroaches in my house”
    6. “Doctor, please tell my son to study harder so he can get into Eton.” The child was 6
    7. Mum booked an appointment to ask the doctor whether she thought it was Ok if an 11 year old daughter went on a planned, overnight school trip that all the other children are going on
    8. “My sleepy baby keeps rubbing her eyes”
    9. “I seem to urinate for ages after drinking X pints of beers with mates”
    10. “A bird pooped on me”
    11. “My skin is too soft”
    12. “Can my child get red eyes from chlorine in the swimming pool”
    13. “What normal 15 year old boy doesn’t have porn on their computer?! I’ve looked and looked but he really doesn’t! That’s not normal!”
    14. “My daughter has a brown rash on her leg”. (felt tip pen ink which was rubbed off with an alcowipe pad)
    15. “My son has a rash on his ankles every night” (sock marks)
    16. “How do I get an eyelash out of my baby’s eye”
    17. “Can you stop my 11 year old daughter from only eating pizza and chips for dinner.”
    18. “I’ve bought these fancy anti ageing face creams. Can you look at the ingredients and tell me which order I should use them in?”
    19. “My son’s shoes are rubbing him”
    20. “I dreamt a few times my 12-yr-old daughter had stopped breathing. I was terrified I couldn’t help her”
    21. “Doctor – my stomach makes this weird rumbling/gurgling noise whenever I haven’t eaten. Its starting to affect my work!”
    22. “Hi Doctor. I booked this appointment 2 weeks ago but the problem has gone now. I didn’t want to waste the appointment so I thought it best to come anyway.”
    23. “I have grey hairs….I’m nearly 40….have I got a medical condition?”
    24. “I’m worried about a white lump in my baby’s gum.” The receptionist suggested it was a tooth. The irate mother suggested only a medically qualified person should judge that diagnosis. She demanded urgent appointment. It was indeed a tooth.
    25. “I get a static shock when touching the banister.”
    26. “Drinking coffee makes me urinate more & it’s affecting my quality of life.” Patient drank 5-6 cups a day.
    27. “I need some advice as I want to break up with my boyfriend and I don’t know what to say”
    28. “I have had a mouth ulcer for 2 days”
    29. Man in mid 20s “why when I drink certain types of beer I vomit and have a headache the next morning”
    30. “My child has something dangling at the back of his throat” (This is called a uvula and almost all people have one).
    31. “I get sore feet when I dance in high heels”
    32. “I can’t stop eating sweets and chocolate – I think I must have diabetes.”
    33. “I would like to undergo fertility testing as I have not become pregnant for 2 years now”. The husband had been away for 18 months.
    34. The other Dr told me I’m overweight but I really think it’s fluid and a water tablet would help don’t you Dr?” The patient had a BMI of 49 (morbid obesity).
    35. “I’ve lost my spidey-sense and need a test to find out why”
    36. “I had an insect bite last week and it itched like hell. It’s gone now, but wondered if it will itch if I get another one?”
    37. “If my body gets cold, I sneeze. This doesn’t occur if back in my hot home country.”
    38. “How do I guarantee a boy baby?”
    39. “I’m addicted to crisps “
    40. A man drags his partner in to surgery “He’s been talking to other men on the internet!”
    41. “What is the best way to cut my baby’s fingernails”
    42. “My wife is 30 , I am 50. I can manage sexual intimacy only 2 times a week. Do you have a pill to reduce her libido?”
    43. “My penis gets cold when I go outside.”
    44. “My 10 yr old daughter won’t eat vegetables. Can you refer her to a hypnotherapist?”
    45. A man presents with a yellow lump on his leg which had come up suddenly. This was triaged from a phone consultation to be an appropriate GP consultation. When the man attended, the GP pulled a gummy bear from the patients leg.
    46. “I’m allergic to avocados, if I eat 8 I’m sick.”
    47. “Doctor, my skin went a little red in the sun this past weekend”. “Did you use sun screen?”. “No”.
    48. “My testicles swing too much.”
    49. “I am allergic to cats. I am getting a cat. Can I get a vaccination”.
    50. “What do these grey hairs on my head mean? Is it normal?”
    51. A 24-yr-old lady attended GP worried as she got butterflies in her tummy when she was around a man she liked.
    52. “I have had a runny nose for the last half hour”
    53. Patient attends after a heavy night drinking with a headache.
    54. A middle aged man attended clinic wanting to know if it’s normal to have to blow his nose after washing his face.
    55. A patient with no symptoms attends to demand the doctor sends her for an X-ray “to make sure I am OK”
    56. “My pubic hair is too curly”
    57. “Please can you remove this pubic hair from between my teeth”
    58. “Doctor, please help. My partner has a fetish for silk scarves”
    59. “Doctor, I cannot fart without making a noise”
    60. “Doctor, I can’t face a bikini wax while I’m pregnant (it’s more painful than usual) so can you advise me how to tell my husband that I don’t feel sexy at the moment.”
    61. A patient consulted as they were concerned their feet sweated when they wore trainers.

3. Trivial

  • Concerns that the doctor felt could have been addressed by any sensible adult
    1. “Can you settle a marital dispute? My wife thinks paracetamol is better, I think ibuprofen is. Who’s right?”
    2. “I have sneezed twice in the last hour”
    3. “I have a scratch on my arm” (tiny 2 millimetre scratch. No infection).
    4. “My child has turned blue” -the child had blue dye on him from a duvet cover which had not yet been washed.
    5. Two emergency appointments for a cold sore. The first to tell the patient the diagnosis, the second (later that morning) because the grandmother (a nurse) disagreed with the original diagnosis.
    6. Out of hours prescription request for skin emollient (like a moisturiser).
    7. Patient called 999 and attended A&E because they had broken a FALSE fingernail.
    8. Man requesting a contraceptive pill
    9. “My child smells like yeast….”
    10. “My poo smells this morning and it doesn’t normally” with said excrement wrapped in tinfoil in a carrier bag.
    11. “I burnt the top of my mouth on pizza 5 days ago…”
    12. “I have blisters on my hands since I started in the rowing club”
    13. “I had a rash last week…it’s gone now. But seeing as I had an appointment I thought I’d come anyway!”
    14. “Tap water makes me ill. I can only drink mineral water but my decreasing benefits mean I can’t afford it anymore. What should I do?”
    15. “My cat has IBS – I just wondered if I could catch it from him?”
    16. “My lodger is annoying me because he’s spending too much time in his room.”
    17. “Can you fix my sprained ankle before I go out tonight as I want to wear heels.”
    18. “My 3 year old daughter’s poo is bright blue! Look!!”
      (Mum takes out a sample of excrement in the surgery in a Tupperware container).
      “Has she been doing any drawing with crayons lately?”
      “Yes? I suspect the blue one is missing!”
    19. “I’m really worried my daughter has a splinter… can you get it out? We haven’t tried by the way, because we were so worried”
    20. “I broke my nail”
    21. A patient brought in divining rods connected to a computer. The computer concluded the patient was allergic to eggs. The patient then requested an allergy test to eggs.
    22. “I sucked a bit of old baler twine a week ago and still have a funny taste in my mouth.”
    23. “My husband was snoring last night – I recorded it so you could hear”
    24. “Please can I have sleeping tablets as I live on a noisy street?”
    25. “My child vomited once this morning” – but was otherwise entirely well
    26. “I have had a sore throat since this morning” (30 year old man)
    27. “I have had a runny nose”. “for how long”, “the last 30 minutes”. (No other symptoms).
    28. “My baby’s poo is a funny colour and smells offensive”
    29. “My wife isn’t interested in having sex with me. Please can I send her to you so you can give her something for that.”
    30. “I’ve tinted my eyelashes but now there is pus everywhere and I can’t see. This has happened before when I had an allergic reaction when I dyed my eyelashes and I had to go to hospital. Can you stop it happening again?
    31. A man presents to the GP on Friday and voices his anger about not being able to get an appointment until then despite the fact he had a sore throat 4 days earlier. His throat was now better. He continued to moan to the GP about the system, despite the fact the GP attempted to reassure the patient he had had a self-limiting illness as was evidenced by the fact he was now better. The patient left unable to appreciate he had not only wasted an appointment, but that he would have never needed to attend in the first place.
    32. “I’ve just run my first marathon. My knee now hurts. I have not taken any pain killers but would like an urgent referral to physiotherapy.”
    33. “When I clean my ears with cotton buds, it makes me cough. Why is that doctor?
    34. A patient attended an appointment to tell the GP they had had diarrhoea in the last week which had now resolved. They felt it was important to let the GP know their self-limiting illness had settled.
    35. “Doctor, my farts smell very bad”.
    36. “I get indigestion when it’s cloudy and my child has ear discharge when there is a full moon”
    37. A male patient who had been diagnosed with irritable bowel syndrome reattended the GP concerned his symptoms might actually be due to ovarian cancer.
    38. “My baby’s snot is just too green”.
    39. A patient attended as they had stepped on a “slimy creature” the night before. This turned out to have been a slug.
    40. A patient attended with symptoms of a blocked nose for 12 hours. The doctor advised some saline spray as a decongestant. The patient then angrily said to the GP “You are useless” and waved a hand in the GP’s face patronizingly saying “bye bye”.
    41. “Doctor I have a cold, and I want to get well before marathon in 4 days. What can you do”

3. Requests for prescriptions of everyday items

  • Another very common experience for GPs, borne largely of the fact that those on low incomes pay nothing for items which are prescribed for them
    1. Paracetamol or ibuprofen (extraordinarily common request, especially for children)
    2. Sunscreen
    3. Toothpaste
    4. Anti-aging cream
    5. Sudocrem
    6. Shampoo (“to make my hair shiny”)
    7. Chapstick (“because my lips are chapped”)
    8. Bra (because of breast pain)
    9. Multivitamins
    10. Talcum powder (for sweating)
    11. “Everything I need from the chemist: nappies, toothpaste, toilet roll and my shampoo”
    12. “We are going on holiday so I would like a (free NHS) prescription for paracetamol, dioralyte, emollient and antibiotics just in case”.
    13. Fortisip drinks (because “I don’t like cooking”)
      • these are fortified drinks for patients who are deficient in nutrition. They are often given to chronically unwell patients such as cancer sufferers who cannot eat properly. They are very expensive to the NHS. They are also frequently demanded by intravenous drug addicts who will not pay for food over drugs. They are often traded by drug users for drugs because of their value.

4. Administrative

  • A longstanding burden for GPs (see the 2001 Cabinet Office paper Making a Difference: Reducing GP workload). This work falls outside a GP’s NHS contract. Many GPs apply charges for this work, as they are entitled to, to attempt to recoup some of the costs relating to their own time and that of their staff in meeting these requests.
    1. “Please sign my passport form”
    2. “Please sign my form so I can do my parachute jump”
    3. “Can I have a Letter for housing” “But you received one just last week”. “Yes but that was from another doctor, if I get two letters I think it’s a more convincing argument. Can you say the corridor is too narrow for 2 people to walk through at once? I will wait while you write it, I don’t mind”
    4. “Please fill in my (medically unrelated) work forms”
    5. Patient brought in a picture of mould in a teacup for a letter to be written to the council in order that she be rehoused into a bigger bedroom flat with more windows.
    6. “I would like a referral for my daughter to become a doctor”
    7. “I need a sick note because I don’t speak English well enough”
    8. “The school require the GP to write a note to allow a child to wear swimming goggles for swimming lessons”
    9. “Doctor, I was in France last week. Could you give me a sick note to cover please”
    10. “Can I have a note to say it’s ok for my child to eat food on a TV show”
    11. “Do you know how I can get into the furniture design business?”
    12. “If you’re giving me a sick note for 1 week, you might as well extend it for 3 weeks since I’m going on holiday and then I claim back the annual leave.”
    13. “We don’t have the same travel channel on our cable TV as our neighbour. What are you going to do about it?”
    14. “My 9 year old daughter cries and cries because we can’t get a dog” (pets not allowed in block of flats). “Please write a letter saying she’s depressed so we can get her one”.
    15. “Can you write a letter to get me a new flat. Mine is really dirty.”
    16. Patient who was pregnant for 10 weeks and otherwise well. “I can’t work anymore, could I have a sick note to last till end of pregnancy.”
    17. “Can I have a sick note for 6 months because I am nearly at retirement age”
    18. “I need a GP referral to get a free eye test”
    19. “Which college should I enrol in?”
    20. “Please can you help me write my CV”
    21. “Please can you fill out my driving licence application as I’m not sure how to”.
    22. Can’t decide whether to emigrate to Australia or not. The doctor in question received a complaint relating to this consultation. Apparently the doctors was: “bloody useless GP, no help whatsoever”.
    23. “I need the bus stop to be closer to my house”. “I have to walk past too many homeless people on the way to the station”
    24. “I need a letter for the council so they will box in my pipes”
    25. ”I need a letter to get reconnected to the electricity.” Apparently the patient had allegedly “fiddled” the meter and had not paid the fines.
    26. “Can my 12 year old (perfectly healthy) daughter have a note to say she can go horse-riding?”
    27. “Can I have a letter to get a better mattress from a charity”
    28. “Can you write a letter for the nursery to say my son can go outside with a coat off.”
    29. “Can you write a letter today to say you think I should go to beauty school. In Costa Rica.”
    30. “I’ve just been on holiday with my mistress. I’ve just got back and work want to know where I’ve been. I’d like a sick note to cover me.”
    31. Appointment for a lady requesting a letter from the GP for a washing machine as the communal one in the flat was not convenient.
    32. Letter stating patient is unable to attend their tribunal or ATOS assessment (a very common request)
    33. “Doctor, I need a new referral for my hospital appointment”
      “I thought I had already referred you for this and you had an appointment”
      “Yes, I forgot about it”.
    34. Letter request from a patient to verify that they are now vegan so a study bursary could be claimed.
    35. A patient requested a letter of good standing for her dog because a neighbour had complained about said dog to the council.
    36. “Doctor, I’m very stressed. I work hard and have to pay my rent weekly, pay for my food and I am left with no money at the end of the week”
    37. A patient attended for a letter for her travel insurance as she wanted to cancel her holiday to Spain in December. She was worried she will catch Ebola.
    38. “Doctor, please can you write a letter to my daughter’s school to say I’m finding the school run tiring and can they arrange transport to and from my house?”

5. Miscellaneous

  • ranging from the treatment of pets to the downright fraudulent
    1. “I would like an ECG, so that I’m medically cleared to go and take hallucinogens for a week in a Spanish private clinic to treat my depression” (Patient had never presented with symptoms and never been diagnosed with depression).
    2. Home visit to an elderly lady who “could not get warm and was shaking”. (Requested by her daughter). When the doctor arrived, there was no medical problem with the patient. It transpired the pilot light had gone out on her boiler. The doctor attempted, but was unable to relight this.
    3. Home visit request – turned out to be a request to change batteries in a satellite television remote control and advice on how to use it.
    4. “Can you cut my sons toenails as he doesn’t like it.” (He was 17 years old).
    5. (Phone consultation) “Dr my baby has just woken up and is crying. I’ve run out of milk. Can you pop over and bring me some.”
    6. “Doctor, I have toothache”. “Have you seen a dentist”. “No”.
    7. Patient attends for a repeat alcohol blood test after the one done by the police following a drink driving test (to try and cheat the DVLA).
    8. “Doctor, I have cheated on my partner and now I don’t know who to choose”.
    9. A heavily pregnant woman attended the GP and asked that GP to phone her husband to remind him of his “responsibilities”.
    10. A lady attended to ask the GP why there was one viagra tablet missing from her husbands packet.
    11. GP called to a home visit because the patient couldn’t open her tablets.
    12. Young lady attends and shows the GP pictures of herself and her sister asking the GP who they think is more beautiful. The GP told the patient this was an inappropriate request for a GP. The patient was shocked and upset by this.
    13. “Doctor, can you ‘make’ me diabetic (ie. on the records), so that I can qualify for free viagra”
    14. “Doctor, can you tell my husband to stop buying food that’s near it’s ‘sell by’ date as he’s wasting money.”
    15. A patient attended wanting to discuss her guinea pig’s health and whether the GP could prescribe medication on the NHS as she doesn’t want to pay the vets bills.
    16. A patient attends as they want to stay on sickness benefits longer and is worried that the doctors are making him better too soon.
    17. “Doctor I took some of my epileptic dog’s diazepam to help me sleep but now she has run out. Can you prescribe us BOTH some more?”
    18. “I am pregnant, and want an early scan because if the baby is a girl I want an abortion”
    19. “I don’t know why I’m here doctor, my wife made the appointment.” “Well shall we bring your wife in or telephone her perhaps?”
      “We can’t. She’s in Portugal.”
    20. “I have a broken tooth”

Footnote

These may sound like extreme examples, but they are all genuine events. GPs report that whilst such requests are not new, they now occur far more frequently. At a time when there are more patients with long-term conditions requiring care from their GPs, and when the population is ageing, it is increasingly difficult to justify spending so much time dealing with matters such as those listed above.

Resilient GP Facebook Group

“Why should I join the Resilient GP Facebook group?” This is what one of our 1,000 members said:

I feel like you are all so knowledgeable and I have lots to learn about how things ‘really work’ as I’ve just been a salaried GP for a few years and never really had much to do with the ‘inner workings’ so therefore it was easy to just ‘leave it to the others’ in a way. But I now feel more understanding and empowered and am grateful to Resilient GP for opening my eyes and encouraging me to look at the bigger picture and support each other in this fight against the powers-that-be. So thank you all!

Pulse Live London 2015

Many thanks to Pulse for inviting Resilient GP Stephanie De Giorgio to join the panel with Clare Gerada and Peter Swinyard for the debate at Pulse Live on 17 March. Watch her in full flow in this video clip.

One of the biggest things that’s going to kill General Practice is GPs

At the moment, patient demand is just utterly extraordinary

Until we get rid of the “I couldn’t possibly say no in case we get a complaint” attitude, GP is doomed

Until we deal with the “[not] patient blaming attitude” we cannot have a proper debate

Consternation that Stephanie was not mentioned in an article reporting comments made by Clare Gerada gave way to delight when a link to this video appeared prominently on the home page of the Pulse website as “Editor’s Pick”. Thanks, Nigel!

A Manifesto For General Practice

We recognise that general practice’s share of NHS spending has fallen hugely in the past few years, and workload has soared. Both sides of this have to be addressed.

Therefore, we seek:

1. A commitment to reverse the disinvestment in general practice, so that by the end of the next parliament, the proportion of NHS funding spent in general practice has increased to reflect the large amount of work that has moved into general practice in recent years without any funding.

2. A commitment not to put more work into general practice without adequate funding – and explicitly, acceptance that the dishonest habit of rebadging existing money, or taking away money and offering it back for more work, does not constitute new money.

3. Agreement that whilst convenience of care for the more able is an acceptable aim, this must never be at the expense of access and continuity for the less able, and those who require care most.

4. Recognition that the unlimited growth of demand makes it almost impossible for general practice to contribute fully to the needs of a population that has growing numbers of elderly patients and those with long-term illnesses. To address this, there must be a concerted campaign to encourage self-care of minor illnesses. GPs must stop being the default solution for all manner of problems – medical, social or administrative.

5. Recognition of the impossibility of continuing with growing expectations of, and demand on the health service as a whole. We call upon all parts of society to engage in a rational debate about what we want from healthcare and what we can realistically afford as a nation.

6. Recognition that diagnosis of serious illness takes time and may not be possible early.

The demise of NHS General Practice?

I can support the aim of the NHS as it was initially envisaged. Pretty much as I can (in theory) support the aim of almost any socialised system. We ALL pay to keep the system running, and we USE it according to NEED (not WANT – but that’s another story). And it SHOULD function as long as costs are spread and the work is spread and the use is spread.

If any one part of the system becomes overloaded (or more than one part) then the system will start to FAIL. Unless the load is spread more evenly then the system will BREAK.

NHS general practice is failing. The breaking point cannot be that far off. Some believe this might be a good thing, so that something better (idealists) or cheaper (Tories) can be erected in its place.

Derelict hospital
Photograph by Chris Lloyd (CC BY-NC-SA 4.0 licence).

Why is this?

My opinion is that the failure can be traced back to the introduction of the “purchaser provider split”. Here’s the definition of this from the parliament.uk website:

“The purchaser-provider split in the NHS in England is intended to enable competition between providers, decreasing costs and increasing quality and innovation.”

Instead of the NHS (GPs, hospitals, community services, etc) all being one big ‘thing’, everything was divided up, parcelled out, costed (ho, ho!), and so on. Services were “commissioned”.

Different “providers” were encouraged. “Commissioners” could look at all the providers and choose the “best”. In practice this would either be the cheapest or the most politically desirable, rarely the “best”.

Once the NHS had been divided up into countless different parts, and the bottom line became cost, it soon became apparent to those with their eye on this bottom line that they had a golden goose right in front of them.

The GP contract

Nearly everyone in work is paid to perform a certain function. This might be folding tab A into slot B 100 times an hour. It might be seeing 15 patients in a clinic and operating for up to 5 hours per session. Or waiting on the 8 tables in your section of the restaurant.

The essence of paid work is that you’re paid to do a job.

The GP contract is not like this. A GP practice gets a set fee (usually between £80 and £100) per patient per year and for this they have to do pretty much ANYTHING ANYONE wants them to do.

They have to see patients when they’re ill (or when they BELIEVE themselves to be ill).

(And not just ill, but if they want to discuss an article they read about ME or total body candida, if they want a form signed for jumping out of a runaway train, or to get their anti-malaria tablets for their trip to Laos, etc etc etc)

They have to respond to calls and letters and emails and faxes from midwives, district nurses, counsellors (who’ve done the course), podiatrists and basically any one of 100 different types of “healthcare professionals” now populating the NHS who’ve all been taught that EVERYTHING now goes through the GP.

I could go on, but I won’t. The point is that GPs are not paid per episode, or per letter, or per phone call, or per illness, or per anything other than than set-fee, all-you-can-eat fee.

And this did not go unnoticed.

Hence the massive movement of patient care AWAY from almost everyone else TO the GP.

Which makes sense if all you care about is the bottom line (which, in the case of the NHS, is not high quality patient care but CASH) but it makes no sense at all if you’re a GP.

Why? It isn’t what you trained for. It isn’t why you became a GP. It isn’t what you’re good at. It isn’t in the best interests of your patients, your bank balance, or your health (mental and physical).

I could provide a dozen examples but that would be labouring the point. Suffice it to say that in nearly every hospital specialty, patients who were once followed up (if not long-term, then certainly for half a dozen clinic visits or so) are seen once and kicked out back to the GP.

And this is not a good idea.

Why? The clue is in the name. GPs are “generalists”. I know a little about a lot but I know a lot about very little. (I know a lot about the Gabriel-era of the progressive rock band Genesis but that’s of little use to my patients)

Ten years ago, you could see that hospital doctors often were not comfortable with this “new” way of working but this is not the case in 2015. It’s been accepted by everyone that this is the way to provide secondary care.

If – heaven forbid – a patient is admitted, they must be discharged as fast as possible, with no follow-up, with the GP to “chase” all outstanding tests, and to manage the patient, whatever their condition, whatever the number of their chronic conditions, however many drugs they’re on, however serious their status is.

If (oh, and this is SUCH a signifier of poor performance these days) a GP refers a patient to a specialist, they must be seen ONCE only and discharged with no follow-up.

Only GPs can prescribe anything. Only GPs can issue sick notes. etc etc etc

This is NOT the fault of hospital doctors. It is the “fault” of politicians, NHS managers, think tanks, the BMA, the RCGP and CCGs.

The GP contract is unilateral. GPs cannot change it. Only the government can change it.

Thus GPs are doing the only thing they can: voting with their feet. Older GPs are retiring as soon as it’s financially viable. Younger GPs are emigrating, or reducing their hours to the point where their sanity can be preserved.

So, what’s the solution?

I don’t think there’s ONE solution.

Some redressing of the balance would help. But the only way I can see that happening is a new conract for GPs and that would have to entail a much greater emphasis on item of service payments.

Co-payment is a political non-starter. That’s just a fact.

I would favour a radical overhaul, bringing primary, secondary and community care all under the same umbrella, and getting rid of (for-profit) private providers. But I’m aware this isn’t a popular option.

If SOMETHING isn’t done SOON, UK general practice WILL FAIL.

Should GPs prescribe damp proof coursing?

Health Secretary Jeremy Hunt recently came out in support of GPs prescribing treatment for damp in patient’s homes. According to Pulse Magazine, Hunt said that some CCGs are already going in to fix damp problems and stated that he did not want to stand in the way of more holistic approaches to health such as addressing housing problems, loneliness and isolation.

Site Manager

Housing improvement is becoming part of new initiatives in social prescribing, designed to address the wider reasons why patients attend. Social prescribing already exists in my area, where isolation is common and communities are increasingly fragmented. The scheme includes lunch clubs for the lonely and fitness groups but there are also wider opportunities such as ballroom dancing classes. While I can see the benefits of the project, particularly for lonely frequent attenders or those with mental health problems, I sometimes have an odd moment wondering what my role has come to when my pen hovers over the tick-boxes on the referral form.

My friends from medical school have followed careers like cardiac surgery. They get to burst through the operating theatre doors after performing a transplant, ripping off their mask to reveal their chiselled jaw and say to the relatives, “It’s been tough but he’s gonna make it”, while I am spotting who might benefit from a knitting club. How did my career come down to this? And how do we know if patients are complying? Do we need computerised records of dance class attendance or reviewing a satisfactory improvement in their tango or quickstep? What are the measurable outcomes of these schemes?

I have no problem with improving patients lives it it means reducing unnecessary appointments or the need for medication or else better mental health all round (I include myself in that list). But sorting out structural building work seems one step too far. Soon we will be prescribing popular home improvement brands such as Dulux or Ronseal along with all those billions of statins we are supposed to be handing out. Problem with damp in your home? Always check with your GP. And why not get the house ready for Christmas and have your three piece re-upholstered as well? Now that would be in line with the vision of a one-stop shop for health.

Dr Claire Davies, Network Locum Columnist

First published on Network Locum’s Blog on 22 January 2015. Reproduced by kind permission of Network Locum.