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Rapid Responses: Rapid Responses published:
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GP is sexy
- Tiago Villanueva (27 July 2007)
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Blame the State Apparat, not Government ?
- L S Lewis (28 July 2007)
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Myths about markets and health...
- stephen black (30 July 2007)
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Yes but..
- Graeme Mackenzie (31 July 2007)
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Instincts for caution, doubt and frugality
- Kevin Barraclough (31 July 2007)
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General Practice can save the NHS but...will it?
- Robert Lewis Miller (31 July 2007)
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It is not enough to be right.
- Steven Ford (1 August 2007)
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General practice and the Darzi report
- Roger H Jones (21 August 2007)
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Tiago Villanueva, GP registrar Portugal
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Dr Heath's article is an inspiring account of the unlimited potential of General Practice, even though everyone seems to take the specialty and its doctors for granted starting with the patients themselves. Undergraduate medical training is also pretty much very hospital-centric, and graduates already start out their professional lives with a pure biomedical model embedded, rather than a broder bio-psycho-social one, that takes into account people's feelings, fears and emotions. Many patients often just turn to the GP when they need trivial things like the odd sick leave because of the common cold. GP's are often frowned upon by hospital specialists. GP is not as sexy as the fast paced, technological hospital medicine depicted in popular TV shows "Dr House", "Gray's Anatomy" or "ER". It would all be different if the public at large could somehow realize that GP is not only sexy, but also carries enormous potential to bring about better health to the community. GP's are far from being mere prescribers of pain medication... Ideally, good GP's embody the essence of the true "Renaissance man", but the challenge is how to generate well trained physicians with not only a vast knowledge of clinical medicine and a fat portfolio of clinical skills,, but also an in-depth sharpness and understanding for the human nature, with training in psychology, antrophology, sociology, etc... Perhaps we need a "make-over" of GP, so that it becomes more popular and better understood. How to do it, I don't know, but I reckon that if people start watching on TV good looking doctors racing to their house calls in stylish Audi's or conducting Advanced Life Suppport measures with telemetrics in the hallway of the surgery in order to save the life of a patient who just fainted while waiting for their routine consultation, then the reputation might start to change. General Practice is challenging. General Practice is deep. General Practice is rewarding. General Practice is also sexy. However, I feel it is the easiest job in medicine to do wrong, and the hardest one to do right. As such, it should have the best people drawn into it, who see it is worthwhile. But decision makers also need to create incentives to attract top talent to the specialty, and ensure GP candidates are properly trained. At their best, GP's will pretty much do anything, from minor surgery, to Advanced Life Support, to counselling, but creating true "Renaissance men and women" requires a lot of resources, which may not be available. I will be expecting the worse, and hoping for the best. Competing interests: Tiago Villanueva is a GP registrar. |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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Heath's defends an idealisation of a general practice form already passed. Is this a pathological grief reaction ? Or is it simply that ideology brings selective blindness ? Firstly, she declares that "UK National Health Service is designed as an expression of social solidarity " , neglecting the fact that it was British GPs , through the BMA, who stuck out against it - declaring it to be a socialist evil.. I quote Nye Bevan:- "the hardest task for any public representative charged with the duty of making a free Health Service available to the community is overcoming the fears, real and imaginary, of the medical profession. His task is to reconcile the general public interest with their sectional claims. No pressure groups are more highly organized in Britain than the professions, and among these the medical professions are the strongest." Heath believes it is governments which are sapping the morale of GPs, by introducing the twin evil of markets and private profit. She forgets that it was the GPs themselves who agreed a new contract that abolished their commitment to 24-hour 'social solidarity', whilst giving them better rewards. She further neglects the fact that Specialists cling on to their private practice - whilst many suspect this has a direct effect upon waiting-lists , the quintessential expression of British 'social solidarity'. She should read the "Liste d'attente" article in BMA News, and perhaps reflect on the absence of waiting lists in France. In principle I applaud phrases such as 'money-following-patients', 'payment-by-results' and 'contestibility'. They at least offer some hope of focussing an otherwise burgeoning and ineffective Stalinist state industry upon real outcomes for people, rather than the tractor-factory annual returns. The special role of Primary Care Physicians in the UK is already sullied. The possiblity of their recovery to a central 'gatekeeping' role is offered by Primary care Commissioning. But the IT and Management add- ons make this peculiarly unattractive... Could it be the Health Service Managers who are determinedly undermining the GP morale and esteem ? The one continuous thread that I see throughout the last 50 years of the NHS has been the Apparat's desire to 'break the power' of doctors, and bring them to heel... whilst securing their own continued expansion of power and inefficiency. Competing interests: I am an NHS GP and a Socialist |
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stephen black, management consultant london sw1w 9sr
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Iona Heath makes some useful points about the role of GPs in the NHS, but also peppers her argument with some poorly supported but widely held cliches. These really need to be challenged for the sake of honesty and proper debate. She claims that the cost of healthcare is increasing exponentially due to new technology. This is a widely held myth but, at least by comparison to other industries, nonesense. The car, computer and telecom industries, for example, adopt new tehncology at a far faster pace then Medicine and they are all seing dramatic reductions in the cost of the goods and services they provide. If anything it is the reluctance of health to adopt new technology or improve the efficiency of working practices that keeps costs rising. Heath also doesn't understand markets, or rather believes in a socialist parody of how real markets function. Markets don't need increasing demand to thrive, nor are they motivated only by the pursuit of private profit. The public gain from markets is enormous as they incentivise the pursuit of efficiency. And they don't have to involve profit, just some objective measure of success (the key is reliable information about what works and what doesn't). She poses the question "how can unprofitable need be given priority" as if it is a failure of markets. But this assumes that some things are inherently unprofitable. The English system of Payment By Results makes this easy to deal with as the prices of services are set centrally. The centre is free to pay more for priority areas and so can avoid inherently unprofitable services. Markets are probably the best hope we have of improving the rate of quality and efficiency improvement in the NHS. If anybody knows the magic ingredient that needs to be added to central planning that would suddenly help it achieve those improvements, I'd love to hear it. Competing interests: None declared |
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Graeme Mackenzie, OUT OF HOURS GP North Cumbria
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As a GP who left full time partnership for out of hours (more for personal family reasons than professional)I found this article brought many possible responses into my head. It is easy to write idealistically about one's job because when you are wrting it you are generally not doing it at that point in time. That immediately changes what you write. In principal, I agree with the article but the reality of being a GP can quickly erode the noble sentiments being expressed. In my 20 years as a full time GP I very much wanted to work by the tenets in this article. The reality was much harder. Being a full time GP with an average list is hard, hard work. It is not just easy to get it wrong: getting it wrong, very wrong, is part of the process. The work rate of most GPs is damaging to both patients and doctors. That work rate or "busyness" is often used as an excuse for "getting it wrong". However it is that work rate which makes GP so economical. To complete that argument, GP is efficient and cheap because it half does things. Usually we get off with that and we will use our "luck" to rationalise our failures. However that is changing and in my latter years I saw standards rising and GPs trying much harder to do a better job. However the current system is not designed to deliver that service. Add in the internet and rising patient expectations and the current system will probably fail. Yes we can do more in practice, yes we can keep people out of hospital, yes we can really be that holistic ideal but only with lots of more time per patient, That of course means much lower lists, lots more doctors and in time perhaps less pay. At the moment it pays doctors to work too hard. That incentive may need to be removed. This is complex stuff because if doctors work less hard they risk being less experienced and less effective at each contact. The conundrum is we need experienced doctors working less hard They also need to be well remunerated but not be attracted to work too hard (for their sakes as well as the patients) just for more money. Competing interests: None declared |
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Kevin Barraclough, GP Painswick Surgery, Gloucestershire
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Iona Heath has (again) nailed the central role of general practice in maintaining a publicly health service and in protecting all of us from the risks of the 'medicalisation of normal life'. There are huge upward pressures on health expenditure. Some are justified (many anti cancer drugs are simply better than the old ones). But many are not. Almost every patient I see who is concerned about a particular symptom could have serious underlying disease. But, despite what the lay media portray, the risk is usually low. The media, the private healthcare industry, over inclusive guidance statements and sometimes, potentially, the Courts all generate anxiety and increase demand. There are few counter balancing downward pressures on this process. My patient's anxiety will be relieved, and he/she will think I am a good doctor, if I refer them privately for expensive and invasive investigations. I may suffer censure if, once in 250 times, the patient does indeed have significant disease and I have failed to investigate. But over investigation or over treatment of minor 'risk factors' for disease, though often popular with patients, not only wastes resources but erodes people's confidence in their own health. And, as James McCormick succinctly put it: "since death is an inevitable consequence of conception, a morbid preoccupation with its avoidance, and the state of Holy Dread which such a fear engenders, may diminish the quality of life." General Practice in the UK has allowed the continued existence of a publicly funded heathcare system. As Dr Heath states, it has done this through the NHS tradition of 'caution, doubt and frugality'. Often (but not always) nihilistic medicine is good medicine. It is necessary to recognise that models of 'market forces' that may have generated efficiencies in IBM in the 1980's may not be the appropriate models for Healthcare. This is mainly because there is little to counter balance the enormous pressures that lead to the 'medicalisation of life' Competing interests: I have never met the woman but I consider her article 'Medical Generalists' (BMJ 2005:331;1462-4) the best article defining general practice in print |
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Robert Lewis Miller, General Practitioner Woodstock Medical Centre, BT6 9DL
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Iona Heath is a dedicated GP committed to the welfare of her patients and the reputation of her profession. One cannot disagree with her article although it does rather imply that general practitioners are saints or as near as dammit which is one of the things which gets up the noses of politicans and those of other professionals. Others work long hours in difficult conditions. Since the introduction of the European Working Time Directive junior doctors no longer work the kinds of hours they used to, thank God. My children in Banking, Business and the Law as well as in Medicine have told me this. Many patients value a potent continuing relationship with their GP but many others just want competent, decent and timely attention similar to the service they get from their Accountants or Lawyers. And this second type of patient tends to be the sort who sit in Parliament or make donations to Political Parties. Patients are not perfect either and one major factor which currently influences medical practice, which she did not mention, is awareness not to say fear of litigation. This is a potent reason to practice guideline medicine. This of course tends to be slow and expensive. However,"the protocol will keep us free". To err is as human as the desire to protect one's tail! Politicians conciously or unconciously denigrate doctors as their prime objective is to get re-elected and so they may at times behave like a junkie who will do anything to get a fix. All things are relative. If doctors are more popular with the voters then pulling them down will improve the standing of everyone else including politicians. After all, if doctors really are as holy as they make out, they will bite the bullet and go on serving the needy. And if they protest this shows that they are just as venal as the rest of society As the NHS is so closely identified with the political party in power, so called Health Improvements are designed to improve the political kudos of those politicians and their party. Any health improvement is therefore a serendipitous side effect! I believe that The NHS must become semi-detached from the Govermnent if it is to function efectively for all. Most general practitioners work hard and deserve their NHS income. Any GP seeking to take vows of poverty, chastity and obedience is clearly in the wrong profession. General Practice can save the NHS but will it be allowed to? Lewis Miller Competing interests: Ex chair of Eastern Local Medical Committee. |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice
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Sir Iona Heath and many of your other contributors share a broad antipathy to the current NHS market reforms. They are entirely right in their views and deserve the widest possible audience. Being right and being read is not enough however. Can someone please explain to me why doctors and other health workers are not more overtly politically engaged? If a credible Independent candidate - not necessarily a doctor - were to stand in every UK constituency at the next general election, on a platform at least substantially devoted to the NHS, there is, in my view, a realistic prospect of a number being elected. There is a precedent in Dr. Richard Taylor who has now been elected twice. Though improbable, but not impossible, a majority might be attained and can anyone adduce convincing evidence that that would be a bad thing? Yours sincerely Steven Ford Competing interests: I aspire to be an Independent MP |
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Roger H Jones, Wolfson Professor of General Practice King's College London, Department of General Practice & Primary Care, London, SE11 6SP
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Iona Heath’s excellent recent article on the relationship between general practice and the future of the NHS (BMJ 28 July 2007, p. 183) identifies the cardinal features of good general practice and emphasises the ways in which a strong primary care sector contributes not only to the health of populations but also to the provision of cost-effective health systems. Her comments on the continuing need for a properly-trained, highly-skilled primary care workforce are of particular relevance in the light of Sir Ara Darzi’s recent report on the provision of health care in London.1 Darzi provides an overview of healthcare in London, in which I believe he underestimates the quality of general practice care. Some of his statements about the way in which general practice is provided (eg. p.10, para 16) verge on caricatures, and he does not acknowledge that high quality care is being delivered all over the capital from well equipped group practices by multi-disciplinary primary care teams offering a wide range of services. Of course the quality of care across London is patchy, as is everything else, and of course there are ‘black holes’ where something clearly needs to be done. However, the prescription for this insecure diagnosis, the setting up of polyclinics, whose precise structure and role are not well-described in the report, raises concerns about the impact that this development could have on general practice. General practitioners provide continuing, personal, comprehensive and co-ordinated care to their registered populations, and in doing so exercise a benign gatekeeping role which protects individuals from high- techology medicine and avoids the unnecessary use of resources. The parsimonious approach taken to patient management by general practitioners is well exemplified in the successful experiment of placing GPs in accident and emergency departments, where they perform less investigations and admit fewer patients than comparable hospital doctors.2 Up to 40% of patients consulting in general practice do not have a condition to which a precise diagnosis can be given, and most of these patients recover spontaneously. Such patients, often with background social and personal difficulties, do not need instant access to specialoid medicine, to ultrasonography or to other technological investigations or hospital specialists. Over-investigation and over-referral will threaten the delicate balance between primary and secondary care. It is also possible, unless great care is taken, that setting up polyclinics would damage existing group practices. Successful practices have generally been built up by committed GPs working hard over a long period to form a strong primary care team which also has strong links with its local community. Changing these arrangements, and distorting the scale of primary care provision, is likely to have unintended, adverse consequences, in which increasingly impersonal care will lead to increasingly inappropriate patient management. Whilst we should be in no doubt of the need to continue to develop high quality general practitioner services in London it isn’t clear that the polyclinic model is an appropriate remedy, even where one is required, and there is a real possibility that this development will damage existing structures. Getting this right in London is important, particularly since Darzi is now embarking on a review of the whole NHS. References 1. Healthcare for London: A Framework for Action. Department of Health: NHS London, July 2007 2. Dale J, Green J, Reid F, Glucksman E, Higgs R. Primary care in the accident and emergency department: comparison of general practitioners and hospital doctors. Brit Med J 1995; 311; 427-430 Competing interests: None declared |
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