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EDITORIALS: Jan De Maeseneer, Per Hjortdahl, and Barbara Starfield Fix what's wrong, not what's right, with general practice in Britain BMJ 2000; 320: 1616-1617 [Full text]

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Only in some parts of the Country

Colin Mackenzie   (16 June 2000)

Babies and bathwater

Chris Manning   (18 June 2000)

Does it have to be one or the other?

Dilip DaCruz   (20 June 2000)

If it ain't broke don't fix it - use it

Gillian R Cooper   (21 June 2000)

Re: Does it have to be one or the other?

Chris Manning   (22 June 2000)

Continuity of care in modern general practice

Maureen Baker   (28 June 2000)

There's a lot wrong now

Malcolm Aylett   (22 July 2000)

Re: There's a lot wrong now

Arun N Patel   (8 May 2002)

Only in some parts of the Country 16 June 2000
Colin Mackenzie, Retired family physician Santa Cruz, California Send response to journal: Re: Only in some parts of the Country	"British primary care is said to be the envy of the world." I see this theme re-occuring in the media of the U.K. Having a sister who lives in a suburb of London gives me a keyhole-view of her primary care. The care she and her peers receive in her locality do not bear out the opening statement. The care of patients in any place will always depend on where a patient lives and on their financial circumstances. Nowhere is this more true than in the U.K. with its unfair private and government medicine. "British premier league football is said to be the envy of the world." Who are these people who say these things? I suggest that they are invented slogans that often bear little resemblance to the true state of affairs. Primary care needs fixing everywhere, let's do it everywhere and stop clouding the issue with patriotic drum-beating.
Babies and bathwater 18 June 2000
Chris Manning, Co Chair PriMHE (Primary care Mental Health Education) Hampton Wick Send response to journal: Re: Babies and bathwater	Dear Sir, I am hungry, so I stop off at a pleasant local cafe where the lively Italian owner knows me, energises me with conversation and takes my order. It so happens that morning I have read the results of a double-blind RCT that shows that two slices of bread will satisfy my hunger as completely as an almond croissant, so I order a slice of bread to go with the glass of water that I know will quench my thirst as adequately as his delicious coffee (having the previous week read the results of another RCT on that particular subject). To my complete surprise, I find that the entire experience is nowhere near so fulfilling as previously and I stop visiting the cafe. Others start doing the same for similar reasons, realising that the outcome, in terms of satisfying their need for food and fluids, can be adequately dealt with by eating whilst working. I later hear that the owner has become so dissatisfied and vexed that he no longer runs the cafe personally and has hired a call centre to take any orders over the phone. People who still drop into the cafe are dealt with by a minimally waged 17 year old who sits out the back and takes the food order over an intercom. The owner later relents and opens up another cafe to the delight of many of his original clientelle. The prices are admittedly more expensive than his original cafe, which is frequented almost exclusively by those in receipt of state benefit and people who prefer to follow the evidence or enjoy telling everyone how important it is to be abstemious. "Primary care was never meant to be sporadic care: it requires care to be focused on a person over time. The health benefits of delivering primary care through a long term relationship with a single practitioner or small team at a local "single point of access" are clear". If ever we needed continuity of care(r) it is now, if ever we needed to hold on to process as well as outcome it is now. So many of life's quality measures are stacked within our own minds and perceptions - the difference between your name and address and what you like to be called or your formal religion of origin and your own personal beliefs. It is not about more money. There are some really good ideas coming out of this Government - it is their implementational style and accompanying haste that are truly so appalling. There is now a real danger that we will witness a huge fragmentation of personal care, vocational intent and professional artistry if everything is reduced to the lowest common denominators rather than levelled upwards to the highest common factors. If others really do envy this system of ours as much as they say, whilst backing it up with the evidence for so saying - then why the devil can't we? Yours Faithfully Dr Chris Manning MRCGP This is my personal view and does not necessarily represent the view of any organisation with which I am associated.
Does it have to be one or the other? 20 June 2000
Dilip DaCruz, consultant in emergency medicine, Al Ain Tawam Hospital, Al Ain UAE Send response to journal: Re: Does it have to be one or the other?	I have little doubt that continuity of care as practised in Primary Healthcare in the UK is a pearl glistening in the murky waters of the NHS. It must not be sacrificed. But there are tens of thousands of patients who elect to visit their current centres for 'sporadic' care (A&E departments), and any serious analysis of policy must therefore take this phenomenon into account. As one would expect, these patients haven't all got it wrong. They know what they want, and it is a doctor - any doctor - to see them on the spot, continuity be damned! Primary Care is not only about continuity. It is also about accessibility. Some problems, a child with earache for instance, do need a 'doc-in-the-box'. The pearl can follow later.
If it ain't broke don't fix it - use it 21 June 2000
Gillian R Cooper, GP Elgar House, Church Road, Redditch Send response to journal: Re: If it ain't broke don't fix it - use it	At last someone is commenting with sense on the value of general practice in the UK, and they are practitioners from different countries with good health services of their own. I believe that this article supports my belief that the most important contact between the patient and the NHS is that person's GP. We are the patient's adviser, advocate and friend as well as being uniquely trained to save the NHS millions by having the confidence not to refer the majority of patients to secondary care. With the introduction of NHS Direct, walk-in centres and the possiblity of dual registration and longer opening hours, the liklihood of establishing that unique relationship between patient and their "own" doctor is significantly diluted. This is too high a price to pay for the greater ease of access which would mean second rate medicine at high cost. Please, it is about time common sense prevailed and we started to value what's right in general practice. By all means concentrate on what's done badly but these changes are a very blunt instrument. If it ain't broke don't fix it
Re: Does it have to be one or the other? 22 June 2000
Chris Manning, Co-Chair PriMHE Hampton Wick Send response to journal: Re: Re: Does it have to be one or the other?	Dear Sir The doctors in Israel are on strike for the second time in twenty years the death rates have fallen (except in the one hospital where they are working as normal). The WHO has today announced that France has the best health care system in the world, but as deeper analysis shows, this involves huge levels of prescribing and secondary care referral with no downward pressure on that most insatiable commodity - a personal belief that medicine has all the solutions to life's woes and difficulties. Populist policies are acceptable if they are part of a thought- through medium to long-term strategy. There is no evidence that this is the case in the UK, where demand, which can so easily replace need, is now outstripping supply. Nature abhors a vacuum and stressed up, needy people will act up in every conceivable forum they are offered (just consider how the NHS has revealed unmet need whilst actively fostering illness behaviours). This is not however necessarily the best way to deal with the problem. The emphasis needs to shift towards producing a twin culture of responsibility and duty of care in all individuals and organisations responsible for health, unplugged from short termist political diatribe. The child with earache can be dealt with initially with paracetamol and advice given by anyone with the skill and knowledge appropriate to that problem. A 'doc-in-a-box' is not necessary at all. We have books, websites and grannies to complement this facility. If people are turning up in their droves at A and E departments inappropriately then of course we must seek reasons for that behaviour. However, I would bet my last Prozac that surgeries which give good care (however so provided)and where the staff know their punters can deal with this sort of problem over the phone and a minimum of fuss. The continuity is not just important for the medical care either- it is about how you educate and train up your patient population to the best level of understanding achievable so that they become as independent as possible from this whole sagging edifice and its tendency to produce learned helplessness and enfeeblement. Yours faithfully Dr. Chris Manning
Continuity of care in modern general practice 28 June 2000
Maureen Baker, Honorary Secretary RCGP Send response to journal: Re: Continuity of care in modern general practice	Response to BMJ article Fix what's wrong, not what's right, with general practice in Britain - Jan De Maeseneer, Peter Hjortdahl, Barbara Starfield The authors' recognition of the strengths of British general practice (1) is welcome, especially in this time of evolution within the National Health Service. The Royal College of General Practitioners (RCGP) believes that those patients with low continuity of care are more vulnerable than others. However, continuity is evolving and in many general practices today it means co-ordinated, integrated, team based- care. The patient's record is shared among team members who can all work to the same protocols and guidelines, offering consistent advice and decisions. As prevention; the care of chronic diseases; and the monitoring of therapy become nurse-dominated tasks, general practice patients will increasingly perceive continuity as a team concept. Even so, we accept that team based continuity is not the gold standard for many patients. They look for their care to be predominantly delivered by the same person, usually their own general practitioner who knows and understands them, and has a personal relationship with them, often over many years. Whether team based or not, attitudes to access are changing. Easier access increases demand and this increases the responsibility of general practitioners. If the opening hours of general practices are to be extended to meet demand, we will enter the world of shift working and doctors will start to see routine patients during anti-social hours. While this may improve access, it may cause problems with stress and job satisfaction for doctors, with consequent effects on retention of doctors within general practice. However, some doctors, nurses and receptionists may welcome more opportunities for flexible working hours. Whether it suits workers or not the implications of greater access to GP care need to be carefully considered, especially given the current workforce restraints within general practice. (2) We also welcome the authors' conclusion that "the current registered list and payment systems for general practitioners have served the health of Britain well." In an RCGP publication about Independent Contractor Status, out last week, we acknowledge that the different requirements of patients, doctors and society can be well served by independent contractor status. (3) Our analysis does not invalidate other models of delivery of primary health care, but recognises the particular strengths of independent contractor status in the delivery of care which is first contact; longitudinal; and comprehensive. (4) Dr. Maureen Baker, Honorary Secretary of Council, Royal College of General Practitioners, 14 Princes Gate, Hyde Park, London, SW7 1PU 1. De Maeseneer, J., Hjortdahl, P., and Starfield, B. Fix what's wrong, not what's right, with general practice in Britain. BMJ 2000; 320: 1616-1617. 2. Mathie, A.G. The primary care workforce - an update. London: RCGP, 2000. 3. Baker, M. and Pringle, M. Is there a future for independent contractor status in UK general practice? London: RCGP, 2000. 4. Starfield, B. Primary care. Concepts, evaluation and policy. New York. Oxford University Press, 1992.
There's a lot wrong now 22 July 2000
Malcolm Aylett Send response to journal: Re: There's a lot wrong now	Editor - The continuity of care with which our colleagues on mainland Europe and the United States credit British Primary Care[1] hardly now exists. Indeed, a survey of all Wiltshire practices in 1976 found that, even during normal working hours, only 26% of practices expected patients to see the same doctor.[2] By 1990, I could find only four practices of the 51 in Northumberland who had such a policy. Outside working hours, of course, there is now almost no contact between the patient and his or her practice. Despite the purported high degree of satisfaction with out of hours co- operatives,[3] anyone who talks to friends and patients on the street knows that the quality of care has fallen precipitously. Take some recent examples in my own community. A man developed heart failure over night and his dyspnoea led to a request for help at three in the morning. Five years ago his symptoms would have been relieved within minutes but now he had to wait for hospital care an hour an a half later. A woman on chemotherapy for breast cancer knew that her white cell count was low, but because of course no details were available to them, NHS Direct advised her to try and contact her practice, despite the fact that they were off duty. After many phone calls, she was advised to go to hospital. The blocked catheter of a house bound elderly man used to be changed at any time by his general practitioner, but now, out of hours, a long and arduous journey to hospital seems to be the only option. The "profound sense of unease abroad in the profession"[4] has been attributed to the loss of our core values and real personal continuity of care was, I believe, the key to these. Your authors' plea to not fix what's right with the NHS comes several decades too late. Malcolm Aylett general practitioner Stone Martin, Wooler, Northumberland NE71 6QL 1. De Maeseneer J, Hjortdahl P, Starfield B. Fis what's wrong, not what's right, with general practice in Britain. BMJ 2000; 320: 1616-7. 2. Aylett M. Continuity of care - seeing the same doctor. J Roy Coll Gen Pract 1976;26:47-52 3. Salisbury C. Br J Gen Pract 2000;50:443-4. 4. Hodgkin P. Postcards from a New Century. Br J Gen Pract 2000;50:516-7.
Re: There's a lot wrong now 8 May 2002
Arun N Patel, Specialist Registrar in Public Health Medicine North Nottinghamshire HA, NG21 0ER Send response to journal: Re: Re: There's a lot wrong now	I am in full agreement with Malcolm A. The "so called" continuety of care - a centre piece of pride of British health service no longer exists. This is especially clear in big cities (London) where patients go through delays in receiving treatment as the GPs, Out of hour service duty doctors and A & E departments toss them endlessly, unless he/she is on the verge of dying. The failure to provide our elderly and chronically ill patients with a comprehensive care can squarely and without hesitation be put at the door step of "indifferent and inconsistant primary care offered by failing GPs".