Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The State of General Practice
- Trevor JD Jones (7 June 2008)
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The state of general practice: not all for the worse
- Ghislaine C Young (7 June 2008)
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The destruction of patient- centred general practice
- Charles B Fearn (9 June 2008)
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Is it the beginning of the demise ?
- kamal Sidhu (10 June 2008)
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Embracing an Interdisciplinary Team Approach
- Lee Mantini RN, MHScN (10 June 2008)
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Wise advice.
- Edoardo Cervoni (10 June 2008)
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Re: Wise advice.
- Stephen A Rousseau (18 June 2008)
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Trevor JD Jones, GP St Johns House Surgery Worcester WR2 5BU
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Few would disagree with Howie et al that all is not well with General Practice today. However the authors' sweeping statement that “the move to improve GPs’ work-life balance has gone too far” cannot be left unchallenged. Without the changes introduced by the 2004 New Contract, including out of hours opt out, General Practice would not have been able to attract and retain new recruits into the profession. Given the recent imposition of extended hours and the gradual erosion of GP remuneration, it is likely that GP morale is set to deteriorate to pre-New Contract levels, and adversely affect GP recruitment for many years to come. The criticisms and exhortations of Howie et al are likely to be music to the ears of those including Lord Darzi who take every opportunity to criticise and undermine General Practice. Competing interests: Full time Principal in NHS General Practice |
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Ghislaine C Young, Nurse Practitioner BD183EE
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There is much to commend in the Personal View of Professors Howie, Metcalfe and Walker. In particular I agree that we need to safeguard all that is good in current general practice, such as the high level of individualised patient -centred care, often built up over many years of doctor-patient relationship. Less certain however, is that "team care" is a cause for concern and yet this is listed as one of the key factors threatening the standard of general practice. Since the early 1990s primary health care teams have developed hugely and so has the number of services provided by practices. Thus practice nurses provide a whole host of services including chronic disease management, health promotion and women's health. Nurse Practitioners (NPs) also complement medical care as part of a multi- disciplinary team by seeing and treating patients with same day acute problems and giving a nursing perspective. Pharmacists can be invaluable members of the team by acting as a resource in medicines management and advising on all prescribing issues. None of these health workers in any way replace the "known doctor" but each adds to the quality of care patients receive, by working in active cooperation with the GP. Effective team working is not only good for patients, it is one of the great joys of working in the health service. Competing interests: I am a Nurse Practitioner working in general practice |
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Charles B Fearn, retired surgeon rh17 7tb
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General practice has evolved over the generations. There are now treatments that work, amongst other improvements, but one thing has not changed, the personal relationship of a patient and the patient's family with the doctor. This is developed over years, and sometimes generations, to produce a state of trust between the parties and an often deep understanding of social, domestic and other matters. Such will not be available to the range of healthcare workers who are planned to take over this work in health factories (sorry! polyclinics). Potential patients must be educated in this truth. And how can we expect an academic superspecialist professorial surgeon to understand general practice? What experience has he had of the subject that qualifies him to even express an opinion, never mind destroy the work of generations. Competing interests: I am a current patient of my GP. |
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kamal Sidhu, General Practitioner Sunderland
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A debate on the most of the issues raised by the authors is the need of the hour.Whereas, the politicians are eager to be seen to be doing something with NHS, the medical profession stands disunited and disgruntled.
Within the last three years since I joined General Practice, its face has changed beyond recognition. Continuity of care is no longer a priority.'Cradle to grave' attitude has given way to one-stop service with the rather forced idea of polyclinics. Miscalculations on behalf of government that resulted in significant pay rises for GPs are apparently being compensated by back door initiatives like extended hours in form of 'less damaging option A'. Pace of the change is too fast resulting in all time low morale of the front line staff. Negative media spin about 'massive' rise in GP earnings coupled with problems with patient access had already pushed the GPs against the wall.Of course, it was the ideal time for the government to bring in its agenda of extended opening hours on its own terms, the threat of private care providers and Darji Polyclinics(even if evidence backs the contrary) Job prospects for newly qualified GPs have dwindled and with hardly any partnerships available which is another issue the profession needs to debate amongst itself. While most will agree that patient access needs to be improved and some of the services can be moved closer to patient home,Is this the right way forward.There is a clear conflict between patient, doctor and Government agenda. Can a disheartened and disappointed GP provide quality care? Do the patients want any of the drastic changes being forced upon the profession? What is the long term future of NHS and its backbone, the primary care? Are we moving away from a health system which provides guaranteed health care to a system which is more consumer driven and a profit making organisation? Only time will provide all the answers but one thing is for certain that if remedial steps are not taken soon,it may well be the beginning of demise of NHS. Competing interests: I am a newly qualified GP. |
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Lee Mantini RN, MHScN, CDM Coordinator Prince Edward Family Health Team
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Change is not easy when one has always worked autonomously and is now being asked to work in an interdisciplinary team environment. A way of practicing which has become familiar and comfortable for General Practitioners is shifting to an approach that requires new ways of thinking, communicating, and responding to patient needs. Howie et al. express concern about loss of tradition, and a ‘new culture’ of care. They fear that practice change could potentially be harmful. Understandably, GPs want to safeguard their doctor/patient relationships. As approaches to care evolve, it is important for all to understand that a team approach does not require General Practitioners to relinquish their responsibility for the ongoing care of their patients. A well functioning team works collaboratively to help patients set and meet realistic health goals. Interdisciplinary teams can provide the intensive one-on-one and group education and skills development needed to improve patient self-management; something there is little time for in a busy general practice. Other time consuming activities like discussions of emotional and social factors impacting on patients’ health can take place without causing major scheduling delays in the GP’s office. Using a team approach, patients can be seen by the most appropriate care provider. Interdisciplinary teams are ideal for taking on health promotion and disease and injury prevention initiatives, extending the reach of health services into the community. There is justifiable concern that a team approach could cause fragmentation of care especially for patients with multiple co- morbidities. As a Registered Nurse and Chronic Disease Management Coordinator for one of the 150 new family health teams in the province of Ontario, Canada, where GPs are now members of interdisciplinary care teams, I have found that a team approach is most effective and efficient when the team has: 1. Clearly articulated roles and responsibilities 2. Access to user-friendly electronic medical records 3. A mechanism in place so that all care providers are aware of the patient’s and GP’s health care goals 4. Well defined processes for ensuring timely feedback to GPs, and timely follow-up appointments with GPs 5. Explicit guidelines for when and how to contact GPs, and 6. Regular team meetings for case reviews and discussion of challenges, concerns, and possible alternative approaches to care. Competing interests: None declared |
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Edoardo Cervoni, M.D. SIAM, Southport, PR9 9JA
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The experience, judgment, and wisdom of Howie, Metcalfe,and Walker are so much welcome. Nevertheless, I don't see GPs fighting the cause. They struggle to capture policymakers’ attention and many of them have already adopted the new trends launching themselves in "managerial adventures", such as buying and merging practices in Super GP Surgeries/wannabe polyclinics (?). What should they do now? I can clearly see what the Authors are writing about, but I am afraid only the introduction of a parallel, "old-fashioned", alternative, Primary Care System is now possible. I'm not sure how these Primary Care Providers following the principles indicated by Howie, Metcalfe,and Walker will finance themselves, but this is an idea that could be worthwhile pursuing. Competing interests: None declared |
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Stephen A Rousseau, Medical Microbiologist retired
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The article by Howie, Metcalfe, and Walker has produced a fairly predictable burst of opinion, looking to me awfully like nostalgia. Oh, if only we could all be Finlays and Camerons once more. I gave up general practice in its glory days (the late 1970s - my opinion) to retrain as a microbiologist, and to augment my drastically reduced salary at the time, I worked for the BMA Deputising Service in my nearest big city. I could see the sun setting even then - very few female doctors would do this work, I thought as I negotiated dark stair wells in tower blocks. Householders welcomed me as the "night doctor", and the triviality of calls steadily increased. The baby of continuity of care from one GP was thrown out long ago with the famous, or infamous, bath water of unsatisfactory work/life balance. I can't always see "my" GP now when it's convenient to me, but at least two other doctors in the practice know me fairly well, all my details are on their screens, and - dare I say it - I get some interesting differences of approach. The idea of a parallel system of "old fashioned" GPs made me smile. The problem will indeed be manning such a system, and I fear it will require one additional "old fashioned" recruitment methodology - the press gang. My only other suggestion, probably equally unhelpful, is for young doctors to watch all those old episodes of "Dr Finlay's casebook" and see how it was once done. Competing interests: None declared |
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