Talking about death is not outrageous—reducing it to a tickbox exercise isBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5369 (Published 29 August 2014) Cite this as: BMJ 2014;349:g5369
- Margaret McCartney, general practitioner, Glasgow
The Daily Telegraph was outraged. The headline read, “Elderly patients asked during home visits by nurses: would you want to be resuscitated?”1 The offending question is part of the direct enhanced service for unplanned admissions.
Essentially, GPs are being paid to try not to send people to hospital. On the basis of recent attendance patterns we are meant to identify patients at high risk of being admitted and work out a plan, as the NHS specification puts it, to “identify factors which could have avoided the admission or future A&E [accident and emergency] attendance with a view to taking appropriate action to prevent future episodes.”2
The bias is obvious: no equivalent specification pays doctors for admitting patients to hospital when it is the best place for them. But millions of pounds are being spent on the illusory idea that millions more pounds can be saved if GPs make a plan for patients that avoids admitting so many to hospital. This is patently nonsense; evidence has shown that this kind of “case management” doesn’t reduce admissions.3 4 And where is the evidence of safety or the search for harms? How do we know that GPs’ time is being well used? We don’t.
We are all living longer, with more long term conditions, but (as if planned in a parallel universe) the number of NHS beds is going down.5 We need what we’ve always needed: highly trained GPs with the professional freedom to listen and respond tactfully when people want or need to talk about death.
Tickbox forms always insist on binary answers. But life is complicated and messy, and being ill, alone, or scared can make us vulnerable. Talking about death is not a bad thing to do, but when health professionals are driven by a policy designed to save money rather than serve patients, we hardly deserve our patients’ trust.
This is all part of the government’s belief that the work of general practice—which has always included appropriately timed and careful talk of what we want to happen at the end of life—can be splintered off into disparate tasks and forms. Those services can then be contracted out to the cheapest short term provider. Why aren’t we furious that our professional and vocational lives are being run on non-evidence based policy?
Cite this as: BMJ 2014;349:g5369
Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I’m an NHS GP partner, with income partly dependent on Quality and Outcomes Framework (QOF) points. I’m a part time undergraduate tutor at the University of Glasgow. I’ve written a book and earned from broadcast and written freelance journalism. I’m an unpaid patron of Healthwatch. I make a monthly donation to Keep Our NHS Public. I’m a member of Medact. I’m occasionally paid for time, travel, and accommodation to give talks or have locum fees paid to allow me to give talks but never for any drug or public relations company. I was elected to the national council of the Royal College of General Practitioners in 2013.
Provenance and peer review: Commissioned; not externally peer reviewed.
Follow Margaret McCartney on Twitter, @mgtmccartney