It’s conference season and, after the warm up acts of the political parties, we have now had the big one, the main event – the conference of the Royal College of General Practitioners. I know you’ve been excited – it’s always good to hear GPs bemoaning their lot and calling the government to account. But the problems are genuine and GP practices really are closing at an alarming rate with more and more GPs abandoning the profession as workload rises exponentially and recruitment continues to struggle to keep up with the number of doctors leaving.
Reflecting on the assertion, given some support at the conference by RCGP chair Dr Helen Stokes-Lampard, that the causes of ill health are largely social, Dr Phil Hammond has said: ‘For 90% of symptoms you’re better of with a dog than a doctor’. He points out that ‘Dogs are an antidote to loneliness and a lack of exercise. And they give encouraging licks, which generally GPs are reluctant to do’. He’s probably right but life as a GP does feel more challenging than a job that can be discharged with a pair of appealing eyes, a shiny coat and a tail that wags. The reason for this is, in part, that medicine continues to be asked questions to which, largely, it doesn’t have the answers. That’s why we need GPs and, especially, GPs with a special interest in being a generalist. We need super generalists every bit as much as we need super specialists. If GPs are ‘ideally positioned’ to do anything, then it is to navigate the uncertain waters of discerning the cause of a patient’s symptom and distinguishing the minority which are medically important and warrant hospital attention from the rest that are medically less worrying and can be safely managed, medically or otherwise, in primary care. GPs have long been considered to be the gate keepers to secondary care who, by assessing and managing risk, protect hospitals from unnecessary patient attendance even as they protect patients form unnecessary, and potentially harmful, hospital intervention. It is a key role within the NHS, one which, with all due respect to our canine friends, is beyond the ability of even the most diligent of hounds. Primary and secondary care compliment each other – both are vital and each need the other.
Though, like a tickle on the tummy, offering money for a state-backed indemnity scheme for general practice is welcome, something more has to happen if things are going to improve. Insisting on the continuation of such harmful activities as over regulation and the slavish pursuit of all that can be measured won’t solve the problems the profession faces. Neither will having yet another tick box to complete as has been suggested this last week with the proposal that we now ask every patient the nature of their sexuality. It’ll take more than a doggie choc to get me to do that! As, perhaps, in much of life, we would do well to listen to Pete Doherty singing ‘You’ll never fumigate the demons, no matter how much you smoke’.
So what needs to change? Much has been suggested previously but not least is a need to realise that doctors, like patients, are people, They are not robots, programmed to infallibly do the right thing. Like patients they need to be allowed to acknowledge their limitations and work within them. It is simply unrealistic to expect GPs to comprehend the intricacies of, for example, cardiological problems at the level of a cardiologist. Furthermore, an expert, judging, from a distance, that a particular referral isn’t warranted doesn’t mean that it was inappropriate from the point of view of the GP. Far less when the inappropriateness of that referral is the opinion of a medically untrained person following a protocol. Despite having less specialist expertise in a particular field, GPs have a good deal more understanding of the patient sat in front of them. Quite apart from the obvious negative impact on patient care, demanding GP’s function at levels higher than they feel competent, and dismissing their genuine concerns, will increase levels of stress within the workforce still more significantly and consequently accelerate the exodus from the profession. General Practice continues to deal with the overwhelming majority of medical concerns presented across the country each day – remarkably few are beyond the competency of GPs. This should be appreciated more highly and the fact accepted that a small proportion of those concerns, as deemed appropriate by the, on ground and in the firing line GP, will need to be passed on to those with the requisite additional knowledge and skill.
Equally doctors need to be given time to grow into their roles. All good things take time to mature – it’s not just fine wines that get better with a few years behind them. The government have pledged more GPs. This is good but, even if these doctors can be found and this promise can be kept, it will take a long time for it to make a real difference – longer even than the 10 years or so that it requires to train a GP since it takes more than just having the letters after your name to be a family doctor. As a young GP I was fortunate to work in a supportive practice that was nurturing rather than critical of what I did. Without question I sometimes referred what I need not have, investigated more than was strictly necessary and admitted patients who more experienced eyes may have managed at home. No doubt sometimes I still do. But this is, in part, how one learns. If I am any better now than I was then it will be because I have been allowed to mature over the subsequent twenty years in a practice whose more experienced doctors were wise enough and kind enough to consistently encourage and support me rather than question me on every decision I made and criticise me for every less than perfect action I took. We must not insist that less experienced doctors behave in the same way as those who have years of on the job learning behind them anymore than we should expect GPs to manage specific conditions at the level of those with specialist knowledge. I am fortunate to work with a bunch of young GPs who are, not that it’s a competition, far better doctors than me. And without a doubt, in 20 years time, if they are allowed to grow into their roles, they will be better doctors still. We all need that time to develop. My progress may not have been as great as I would have liked but demanding perfection, at any point in ones career, is both unrealistic and damaging.
But despite all this I am not planning on leaving General Practice anytime soon – and no, I’m not barking! I’ll stick with it a while longer because, quite simply, despite everything, being a GP is one of the best jobs in the world. Each week I have the very great pleasure of being consulted by patients who are people of whom I am genuinely fond and who I find it an absolute privilege to see. We often laugh together – and occasionally cry. Daily I share in the joy of patents who are pregnant or who are venturing out on the adventure of parenthood; I try to offer reassurance and help to those who are unwell and to those who, in innumerable ways, are struggling; and I share in the sadness of terminal illness and bereavement. And occasionally maybe I may make some small difference. It is an inherently rewarding way to spend ones working hours. Perhaps on occasions, patients feel they need to see me – but what is more certain is that my day is enriched for seeing them.
And its not just the patients who make each day worth getting out of bed for. What also makes the job so good, despite the difficulties, is the people I work with, who allow me to be the doctor I am rather than insist I am the doctor some faceless authority demands me to be. The flexible and supportive nature of the team in which I work is fundamental to what makes our practice, and the NHS as a whole, work so remarkably well. And I’m not just referring to my partners who notice when I’m running behind and help out by seeing a patient of two. In addition, there are nurses (both practice and district) who, on top of their already busy workload, are always happy to help with one more dressing and HCAs who don’t complain when I ask them to squeeze in an extra ECG; there are reception staff, manning the front line with good humour and still managing a smile when they bring round coffee and cleaners who stop for a chat at either end of the day; there are admin staff, who cope with my garbled dictations and smooth my way through the machinations of the NHS with good grace, and pharmacy staff who are ready with advice on prescribing issues and information on the availability of yet another difficult to source drug. And there is a manager who manages with the understanding that General Practice is a team effort that works for the benefit, not only of those who rely on the practice for medical help, but also for those who work within it, a manager who realises, as does everybody else who makes up the team, that the bottom line is not the bottom line, that people matter more than targets and financial reward.
Primary care needs to remain locally responsive to individuals – both its patients and staff. General Practice needs to remain small enough to see the big picture. Larger, regional primary care centres, obsessed with chasing targets, ticking boxes, and slavishly adhering to protocols, may appeal to those holding the purse strings but there will be a high price to pay for such economies of scale,
General Practice can sometimes feel like a battleground – like the NHS as a whole, it certainly has a fight on its hands. But it a fight that is overwhelming worth fighting.
Now who’ll take me for a walk?