Evidence and rhetoric about access to UK primary careBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1513 (Published 31 March 2015) Cite this as: BMJ 2015;350:h1513
All rapid responses
This is an interesting article but the authors repeat the flawed strategy of trying to adsorb GP roles onto non-doctors often touted by politicians etc. rather than challenging this. The authors of the cited article: 'Substitution of doctors by nurses in primary care.' state the following "However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less." (1) This article cited by Thomas E Cowling, Matthew J Harris and Azeem Majeed hardly garners confidence if we are to seriously thinking of nurses performing doctor roles.
Furthermore many practices are having great difficult in recruiting nurses to fulfil the busy job of working as a practice nurse. Do we really think that adding GP responsibilities onto their role is going to aid recruitment and help General Practice? There now seems to be an impetus to fill in GP gaps with other healthcare professionals. To do so is sending the wrong message regarding patient safety. On the one hand we demand GP trainees to go through a lengthy three year training process with an expensive AKT (Full rate: £530.00) and CSA examination (Full rate: £1780.00) process to work in General Practice. On the other hand, we want to permit pharmacists, nurse practitioners and physician assistants to fulfil GP roles without any such assessment process. Is there not an issue of patient safety here? Are such professionals wanting to work in General Practice roles (but who are not doctors) going to have a similar rigorous appraisal and revalidation process as GPs do? The onus of revalidation and appraisal has causes tremendous discontent on a proportion of GPs who could have been enticed to stay on/return after retirement but appraisal and revalidation are one of many stumbling blocks in their path. The question is as to why politicians are seeking to make it so easy for other professionals to fulfil GP roles at the expense of patient safety whilst making life/training for the existing workforce of GPs so intolerable?
Mote Medical Practice, Maidstone, Kent
(1) Substitution of doctors by nurses in primary care.
Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.
Laurant M1, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B.
Competing interests: No competing interests
The Tory promise on 8-8, seven day access to a GP, is based on the false premise that’s what patients want. Our evidence on demand shows in contrast that when in-hours access is easy and rapid, OOH demand is low to very low. Spreading GP work into less used periods costs more, wastes their time and hits morale, therefore cutting access and continuity.
The Labour promise on 48 hours to see a GP failed last time and will fail again. 61% of patients want same day, but by punishing non-compliance with the target, GPs will make 48 hours in effect the only option. These appointments will be snapped up first thing every morning, patients will then be told to call back tomorrow, cutting access and continuity.
What we need is a proper understanding of demand in general practice. Method is more important than money in improving performance - 50 examples here of how the waiting time can be drastically cut with no need for targets, incentives or extra resources. http://gpaccess.uk/evidence/the-dover-chart-collection/
Competing interests: I run GP Access Ltd, which helps GP practices transform their access and continuity through interventions, training and online services.
Just as drugs have to undergo an agreed process to be licensed which includes trials to assess benefit, safety, adverse effects, and cost, so too should Government health policies.
Can we have a template which a politician needs to complete before making promises to the electorate? The template would include questions such as: What is the aim of your policy? How will this benefit the public? How will this policy affect the existing way the service works? Are there any unintended consequences? Have you discussed this with any professionals & what has been their reaction? How will the policy be funded? This template should be made public on the internet, and open to comment by the public, including staff having to implement the policy.
A word of caution about government pilot schemes and 'independent evaluations'. It is important that the pilot scheme is actually a test of the policy, and that the independent evaluation is both truly independent and truly an evaluation of the policy. I say this as a GP who has followed closely the process of promoting and implementing the Government policy to abolish GP practice boundaries. There was indeed a pilot in 2012 but it did not test the policy. There was indeed an independent evaluation of the pilot, but it did not evaluate the policy. I know because a colleague and I met with the authors of the evaluation after its publication. Their evaluation was a serious piece of work, but it missed some very central flaws in the policy. This was not their fault; it was the fault of the design of the evaluation which was set by the Department of Health.
Competing interests: No competing interests