The writer, a former head of the Number 10 Policy Unit, is a Harvard senior fellow
Long before the pandemic struck, one of my favourite GPs told me he was getting out. The nine-minute appointment, the paperwork and rarely seeing the same patient twice, had destroyed the enjoyment he used to get from building trusted relationships. It wasn’t the job he’d signed up for any more.
GPs like my father-in-law, who knew the medical history of entire families, have been replaced by a stranger on zoom. That’s if you’re lucky. If you’re repeatedly fobbed off, as one of my friends was this summer, you might end up in hospital with cancer — which is where she is now. I can’t help thinking that she’d have got better treatment if she’d cut out the middle man.
We patients feel jilted by the doctors we used to regard as our local heroes. But GPs are equally angry, complaining of exhaustion as they are consumed by the NHS’ backlog. Money alone can’t solve this problem: the government is training more GPs, but the numbers don’t go up, because so many are retiring or reducing their hours. Something fundamental has to change.
The stand-off between government and unions isn’t helping. When the BMA describes our precious face-to-face appointments as a “treadmill”, our respect for GPs takes another hit. The BMA turned family doctoring from a vocation into a job in 2004, when it persuaded the government to let GPs give up out-of-hours care with no reduction in pay. Now, it’s encouraging them to go on strike — prompting one hospital consultant I know to ask bitterly whether anyone would notice.
It’s time to stand back and ask what GPs are for. Historically they have had two roles: as a trusted face for patients, and as gatekeepers to a rationed system. Both have eroded. Continuity of care waned after the 2004 decision, even though a recent Norwegian study shows that face-to-face appointments and continuity of care are better for health — and most GPs agree that remote consultations are leading to misdiagnoses.
The gatekeeper role has also changed. When one son emerged from a playground clutching his wrist a few years ago, the GP receptionist sensibly told me to go straight to A&E. When another son hurt his back badly in the first lockdown, I called the three nearest surgeries in a panic. Two didn’t answer. At the third, the GP sounded terrified, and told me to call 999. When I suggested that we were trying not to burden hospitals in the pandemic, she put the phone down.
Some argue GPs are redundant in a world that is increasingly specialised. But those I most respect are the ones who will sometimes admit they don’t know the answer — and openly consult a textbook. Generalists can’t be expected to know everything. But they are still hugely valuable if they can look at the whole person. Elderly bodies often suffer from multiple issues. Afflictions can be both mental and physical. In an ageing, lonely, difficult world, GPs can provide reassurance and treatment. But this kind of conversation doesn’t fit into nine minutes.
This sounds like a recipe for even more work. But not if we stop GPs spending time on the wrong things. Analysis by Becky Malby at South Bank University suggests that 40 per cent of GP appointments pre-Covid were unnecessary, avoidable or could have been done by other staff. These include monitoring test results, writing sick notes and much prescribing. In the London borough of Tower Hamlets, GP and professor Sam Everington says that he relies on the pharmacist to do repeat prescriptions and complex drug reviews, and a practice nurse to lead the management of patients with multiple long-term conditions. This enables him to focus on complex cases — the bit he was really trained for.
Malby has also found that around 5 per cent of patients are “super-attenders”, who use up about 20 per cent of all GP resources. This group includes, as you would expect, the elderly and those suffering from chronic disease. But around half are, in Malby’s words, “struggling with life”. Loneliness, domestic violence and unemployment all trap people into misery, which can spill over into depression. The tragedy is that too many have nowhere else to go.
Suzanne Koven, an American family doctor and author of Letter To A Young Female Physician tells how she changed her approach when she was injured, and her office temporarily doubled the length of her appointments. With more time to chat, she discovered that a patient who had been a repeat attender for many years, had a desperate family history she’d known nothing about. After the woman confided in her, Koven was able to stop prescribing pills and help.
Amid all the heartache and exhaustion, there is perhaps a way out. Good GPs want to treat the whole person, and provide the continuity of care we have lost. That could be restored if they could delegate to a wider team, and we patients came to trust that team as a whole. If the future is going to be monitoring our own blood pressure, and going direct for scans, we will be dealing with a nurse and a physician associate, not a GP. Some practices are already doing this — others have no strategic approach at all. That’s an argument for ending the self-employment status of GPs and making them salaried NHS employees, with clearer hours and job descriptions.
The more that GPs insist they cannot see people face to face, the more they are talking themselves out of a job. But we need them. We spent the past 18 months trying to help “protect the NHS”: now we’d like it to reform, to protect us.
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