Advanced Access – a step in the wrong direction

So Gary Oldman looks set to win the Oscar for best actor for his starring role in ‘The Darkest Hour’.
If that film is anything to go by, Winston Churchill would have liked what I had my eye on as 2017 drew to an end – that is a ‘Drinks by the Dram’ Advent Calendar available last December on Amazon for a shilling short of £10,000. But then who wouldn’t want to start the day with a 60 year old Glenfarclas or a shot of Pappy Van Winkle’s 23 Year Old Family Reserve to accompany their coco pops? Churchill’s penchant for starting the day in the manner he intended to continue may have had us reaching for our CAGE questionnaires and dolling out the health advice but one can’t help admire the man for his leadership. He was a man willing to take a stand.

Locally, advanced access [AA] is up for discussion again. A year ago we extended opening hours until 8pm on two nights a week as a tentative step towards the government’s wish that GP surgeries open 8 till 8, seven days a week. It’s not been a great success. Ours is not a commuter town and, for the most part, patients who have taken the late appointments would have preferred appointments in normal working hours. After all, late appointments are hardly the natural habitat of babes in arms and the frail elderly. So should we continue AA as we are being pressured to – or say enough.

Most fundamentally I think we need to be clear that the problem with the NHS is not the failure of GPs to be open for longer. The suggestion, therefore, that such would solve the problems the NHS is facing is disingenuous. The problems are far greater than that and, I suspect, largely reflect the broken society in which we live. Going along with AA only serves as one small further encouragement to the continued overlooking of the real issues.

I believe that Advanced Access is a step in the wrong direction – I think it is bad for us, bad for our patients, and bad for society as a whole.

Despite being a strong partnership, over the last year AA has fragmented the practice by making us more disconnected – we have seen less of each other and, outside of work, it has impinged negatively on our personal lives. Continuing with AA will perpetuate this still further and all the more if it’s extended as planned. The only real benefit to us personally is a little extra money – money the NHS can ill afford to spend on dubious initiatives like AA. The world tells us that money is the route to greater happiness, and makes the extra work worth while. But if we were to ask ourselves what our intrinsic values are, what it is that is really important to us, few of us would say money. For sure we need enough but AA takes us away from what is really important to us and thus has us being paid to be less happy. This will inevitably increase the risk of burn out, worsen GP recruitment and hasten the exodus of GPs leaving the profession early. Each of these will impinge negatively on patient care.

So what of the patients? More altruistically we might say that one of our intrinsic values is the provision of good quality care to our patients. But I don’t believe AA offers this. Your practice may be different but we have shown from experience that locally there is little call for extended opening. Seeing people late is a less good service for those patients who are being forced into taking less convenient appointments. And even for our working patients AA comes up short since it reduces still further the little leisure time workers can enjoy. AA actually forces those who do work to work longer and harder and denies them the right to take time out of work for genuine health concerns. It’s not our working patients who benefit from AA, rather it’s their employers – employers who, all too often, demand more than their pound of flesh from their staff and who far, too readily it seems, discipline them for even the most legitimate time off work due to ill health. This isn’t good.

AA demands both we and the workforce in general work longer and harder with the promise that that will make you happier due to some scant financial reward. It’s not true. As Lily Tomlin once said, ‘The trouble with the rat race is that, even if you win, you’re still a rat.’ And nobody on their death bed ever said ‘I wish I’d spent more time at the office.’

Neither is AA safe. We already work long, intense hours. Working longer will lead to errors – patients will be harmed. The GMC has advised that we should speak out if we are being asked to do more than we can reasonably be expected. Regardless of what we may currently feel about the GMC, we simply can’t just roll over and do more.

AA is, therefore, bad for us and our patients but it is, I think, another small nail in society’s coffin. The problem the NHS has is that it is being asked to solve the problems of a broken society. But it can’t because society’s problems simply aren’t predominately medical. This needs to be shouted from the roof tops if anything is going to change. Simply capitulating to the notion that ‘improved’ access to health will solve everything is to perpetuate the myth. Of course the powers will be will try to make life difficult for us if we say this (indeed they have, for us, already) but we won’t be wrong just because they don’t like what we say. It is, after all, in their interests to make us out to be the villains since doing so lets them off the hook of really addressing the problem. I’m no conspiracy theorist but isolating individuals and making them the problem rather than acknowledging the system itself is broken seems to be a trend. Blame Hadiza Bara-Garba for the death of a child, blame GPs for the failure of the NHS – it’s all much the same. We need to come together and standup for what we know to be true if we’re not going to be complicit with what is making society worse.

Some seem to think that Advanced Access will just go away if we tow the line for the time being but if we do we may risk it gradually establishing itself as the norm and remaining with us for ever. If we’re happy with that then fine but, if not, shouldn’t we be at least saying so now. I know it’s only a tiny little stand – hardly on a par with Churchill’s – but could we not take some professional satisfaction in coming together and making it our stand?

These are my thoughts but perhaps they are the ramblings of grumpy old man who is trying to justify his selfish desire to lie in at the weekend with some wordy pronouncements which, despite his protestations, have no merit. Or perhaps they are the ramblings of a grumpy old man who selfishly wants to lie in at the weekend but, fortuitously for him, on this occasion at least has a point. Is this a battle worth fighting and if so what price – financial or otherwise – should we be prepared to pay? Or should we save ourselves for bigger battles ahead and hope that it does indeed just go away soon? I’d be genuinely interested to hear your thoughts.

So the motion is: ‘Advance Access should be abandoned and GP practices trusted to be run professional enough to determine opening times according to individual local need and individual practice capacity.’

Do I hear ‘Aye’?

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