The Good Doctor: New wine into old wineskin?

Can We Bring Back the Old-Fashioned GP?

Can a Man Pour New Wine Into Old Wineskin?

The NHS apparently thinks So.

According to Mr Hunt, secretary of State for Health, failure to care for the elderly in the community is responsible for the overuse of A&E by elderly patients. Who is failing? Social services, families, neighbours, the medical profession, all of the above, or just some?

A Named GP for Elderly People

This morning the BBC announced a major future change in the GP contract in order to address the said failure. The redress is to be achieved by reducing GPs’ paperwork. The time saved would enable GPs to act as “responsible named GPs” for the frail elderly, those over 75 years of age.

But often the elderly go to A&E without the GP’s knowledge of there being a problem. How can a GP care for a person without the person presenting to their GP?! We have had the alternative of routine elderly checks come and go, at the behest of the NHS, who deemed them to be unhelpful. Are GPs now expected to just go and visit every elderly patient in case they have a problem? For a GP to do 4 home visits, he or she would have to sacrifice a whole session, which means 15 less appointments on average. The details remain unclear for now.

A Scapegoat GP:

The idea of a named GP means that the buck stops with a particular GP, when things go wrong. However, what happens when a GP is off, such as at night? How can any human being have a 24/7 responsibility?! When other professionals are involved in their patient care, and these other professionals mess up, how is a GP to be held responsible?! In reality, every patient will be looked after by several professionals including, in large practices, several GPs. When these professionals, such as OOH GPs over whom GPs have no control, come short, why should the named GP be responsible?! This seems extremely unfair, but not unlike NHS thinking. Unfair is acceptable.

Another way of describing the new changes is that GPs are expected to co-ordinate care of the elderly in the community. How novel is this idea? When all the wrapping is removed, you will realise that all that is being proposed is a change of garment. We, GPs, have always co-ordinated our patients’ care. Whether a patient is registered with one GP, several GPs or the practice is an insignificant detail. Ultimately GPs have always looked after their patients and co-coordinated their care. Naming a GP will achieve nothing, other than provide a scapegoat when things go wrong. But it will not improve patient care.

Why Do Elderly People End Up In A&E?

The assumption that elderly frail people end up in A&E due to lack of GP appointments is essentially flawed.

We have had a review by the last PCT of elderly patients in A&E. Not a single case was deemed un-necessary.

A recent survey showed that patients registered in a Darzi centre which is open 12 hours a day every day of the year, were amongst the highest users of A&E.
By the end of this morning clinic, I have more than 30 appointments available and not used by patients.
For nine months, my wife and I opened on Saturday from 9am-3pm. In that period we created 998 new appointments, and we reduced A&E attendance by 68 patients, a tiny percentage of A&E attendance. The service was well advertised.

It may be true that not all patients can get an appointment with their GP on the day and hour of their choice. But whatever we offer has to be better than travelling to Basildon and waiting up to 8 hours to be seen. We often offer same day appointments only to be rejected because patients have more important engagements. On one day alone last week, we had 28 unused appointments, and 12 DNA’s ( did not attend), with our GPs.

Lack of GP appointments is a fallacy and an excuse for failing families, social services and the NHS, who would gladly waste money on fat severance payments for managers, only to rehire them again, than spend it on patient care. The above confirms that there are other reasons for patients choosing A&E, which are not related to availability of GP appointments.

Why Do Patients Choose to GO to A&E?

When we ask frequent attenders at A&E for explanations, the most frequent answer is that they like to have tests and results on the same day and quickly. A&E is mainly staffed by young inexperienced poorly supervised doctors, who over-investigate. Allied with the fact that any tests requested by A&E are treated as a priority, results are reported within hours. However, some patients think a doctor who requests lots of tests is a good doctor. Do we blame such patients, therefore for preferring A&E to general practice?

What Patients Want:

We offer blood tests by appointment, in the surgery and we request x-rays for which patients have to go to certain places such as Orsett or other places in Thurrock. But they all require separate appointments, and the results require further appointments a few days later. Patients want their test and result within an hour or two, as they do in A&E.

Some GP colleagues have shared this with a CCG in a meeting designed to answer the question of what GP’s can do as a clinical commissioning group to address the overuse of A&E. My contribution was: let us pilot a local diagnostic centre, where patients can be sent by their GP’s on the day for blood tests and x-rays and ultrasounds and ECG’s, and where they can be given their results on the same day. It could be an expansion of the Minor Injuries clinic which already exists. We are spending money on these tests anyway; for as little extra, we can have a local diagnostic centre. If this does not reduce the pressure on A&E, it can be scrapped. CCG’s are meant to save the NHS money, but the leadership of CCG’s is determined by elections, that is by a measure of popularity amongst GPs, not by competence. Therefore a GP may win a lot of crony votes, but lack aptitude. Do not, therefore, expect CCG’s to solve this problem.

The Old-fashioned GP:

Back to the “named GP” idea, the NHS is buttressing the idea with revival of the “old- fashioned GP”. They want the old-fashioned GP back, in modern England, because he or she knew their patient well. How realistic is this? Not very realistic in my opinion, and here is why:

The amount of data the average GP has to handle per patient has increased several times over my short professional career as a GP. No old-fashioned GP could keep such extensive data in their shrinking brain.

One of my retired colleagues used to boast that he knew his patients’ history inside out. He never kept any records. That was 20 years ago. He would not survive a day in the modern NHS. The amount of data stored by GP’s and demanded, by all sorts of agencies, is phenomenal and only increasing.

The UK population is the most mobile in Europe. We change address more than anyone in Europe, because we lack job-structures and because a house is a means to make money. So we buy mostly in order to sell. This means most GP’s never get a chance to get to know many of their patients.

GP’s who are part of the general population are less likely to stay in the same job for long. Most young GP’s will do locums for 2-3 years whilst they ponder over where they want to settle. They may get a salaried position for a few years and move on. The old-fashioned principal GP is a fast disappearing species, partly thanks to the constant meddling of the NHS in the GP contract.

There is a shortage of GP’s in this country, as the HS has made it an unpopular career option, by measures such as the latest subject change. The result is that we rely on overseas doctors, who may simply return to their country of origin or keep moving within Britain, in pursuit of a better job, a better school or a better property.

Most of the recent changes in the GP contract have moved GP’s from the old-fashioned GP model closer to a salaried 9-5 model. This is sheer folly by NHS civil servants and politicians. You cannot have your cake and eat it. One either wants an old-fashioned GP or a modern salaried GP.

The old-fashioned GP was a trusted, respected member of society, whose opinion mattered. He or she looked after people who had a sense of responsibility and pride. Even in my short career as a GP, twenty years now, and some of my colleagues have a 40 year experience, I have seen the patient-doctor relationship increasingly strained by:

The population is generally less respectful. GPs are regularly disrespected by those who demand respect more than any.

Patients are generally less trusting. Some would rather believe a newspaper article than their own doctor.

The rights culture: more than ever patients stand upon their perceived rights, and seem to forego any sense of responsibility.

More than ever patients demand what they want. In the old days they accepted care based on need. Now more than ever patients will demand what they deem to be necessary, against common sense, medical science, protocol or NHS regulations. Woe to those GPs who do not deliver!

More than ever patients are likely to complain and cause un-necessary stress to those who look after them. That is not to say there is no place for complaints.

The proposal to revive the old-fashioned GP would not win the vote of a famous physician, my most favoured countryman, Jesus of Nazareth who said:

“Neither do people pour new wine into old wineskins. If they do, the skins will burst; the wine will run out and the wineskins will be ruined. No, they pour new wine into new wineskins, and both are preserved.”

NHS leaders ought to kneel down and meditate on such wisdom.

Old-fashioned GP’s will not be able to cope with the new wine of modern Britain: with a plethora of data (often utterly useless), increasing demand at every front, a broken society, lack of funding, indeed reduced GP funding, a “gimme” generation who is unwilling to cope with simple problems and over-dependent, and a society that over-medicalises non-medical problems, and a political elite that manipulates GPs in order to win votes. If you want old-fashioned GPs, we must first restore and espouse old-fashioned values.

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