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Partha Kar: Making sense of the health multiverse

BMJ 2021; 375 doi: (Published 26 October 2021) Cite this as: BMJ 2021;375:n2570
  1. Partha Kar, consultant in diabetes and endocrinology
  1. Portsmouth Hospitals NHS Trust
  1. drparthakar{at}
    Follow Partha on Twitter: @parthaskar

The world of Marvel movies and comics involves a whole multiverse where it can be hard to make sense of what’s really happening—which Spider-Man exists in which reality, or which main characters are actually dead or alive. As it’s a fantasy world, we can enjoy the moviemakers’ artistic licence in the spirit intended.

A problem arises when that sort of fantastical approach starts to take hold in the NHS, when people create a parallel universe where the pandemic has been overcome, with no shred of the virus left. It’s in this world that government pronouncements on GP access have arrived. Amid some well meant intentions by the NHS to look at variation, along with “offers of help,” one initiative has caused much consternation—a government drive for more face-to-face consultations, despite an escalating infection rate and the near complete dismantling of social distancing rules and mask use.

It’s as though Daily Mail readers or the tweets of a Paul3467 with two followers on Twitter have convinced everyone that, during a pandemic, face-to-face GP consultations are exactly the area to concentrate on. Add in the media focus on “naming and shaming” poorly performing practices and sending in “hit squads,” and one might think we’re in some universe where the pandemic no longer exists. Those terms may be the ones chosen by the media, and they may be a misinterpretation of the overall intention, but in the media’s hands any such publicly available datasets will have a huge impact, akin to Thanos being gifted the Infinity Stones.

Then there’s the issue of morale. Among all of the mistakes made in handling the pandemic, one thing we did get right was the vaccination programme, delivered mainly through organisations fronted by GPs. The opportunity exists to build on that goodwill, work with primary care, train many more GPs to avert an even bigger crisis in training places, and (for once) maybe even take an approach to healthcare based on background deprivation. In another universe, maybe that’s happening.

But let’s pause and look at what did happen in this one. Sections of the media launched a coordinated attack on one section of the health workforce, the very one without which we wouldn’t have a “world beating” vaccination programme (ah, the nostalgia for early 2021). Anecdotal poor patient care was highlighted by sections of the media; GPs lashed out, inadvertently fuelling the anti-GP rhetoric; and we saw an old school media response about “failing” surgeries. Imagine us taking that approach to patient care. “Not taken your daily exercise? We’ll send a team to make you run.”

And let’s not forget the subtle nuances of background deprivation, plenty of datasets suggesting that GPs from ethnic minority backgrounds are localised in areas many others don’t want to work in, and the fact that certain sections of the media like to create and engage in societal divides based on ethnicity. It’s as though we’re walking into something in slow motion with eyes wide open.

So here we are, about to enter winter, with a pandemic very much all around us. We have a booster programme that needs a concentrated focus, we’ve seen little progress in reducing the health inequalities facing deprived communities and ethnic minorities, and we have a Joint Committee on Vaccination and Immunisation whose approach works along the lines of “we know better than anyone else.” Among all of that, we’re alienating the workforce we so desperately need if we’re to catch up with the care backlog.

For what it’s worth, parts of the GP plan could be useful and could help tackle unwarranted variation. Indeed, there are existing methodologies in the NHS such as Getting It Right First Time (GIRFT), which does exactly that in specialty areas and shows that this can be done without the profession being up in arms. From my personal experience, it’s no good having public lists of diabetes specialist centres that ignore background issues, and don’t provide opportunities to work with struggling centres, as the approach to improve variation needs to be collaborative. Understandably, then, the media focus on “naming and shaming” has ignited passions.

Now is the time to step back from confrontation and rebuild relations. Delaying publication of practice level lists until all nuances of background factors such as deprivation are resolved would help to cool heads, calm the rhetoric, and enable primary care to recover from the pandemic.

Anger and frustration could yet turn into something useful. Jeremy Hunt learnt (eventually) from the junior doctors’ dispute that the underlying problem with seven day services was the lack of doctors, not simple contract issues. Perhaps Sajid Javid will realise that we need a massive expansion of the GP workforce, much more than the promised 6000, and a viable plan to get there: perhaps thousands more undergraduate medical places in deprived areas and long term visas for international medical graduates. Mr Hunt is in a phase of reflection, and he could perhaps share his experience with the current health secretary.

In a world of competing interests, I still believe that clinicians in any organisation are capable of setting their differences aside, swallowing their pride, and looking at the bigger picture. The Marvel Universe was ripped apart in the Civil Wars, but its leaders also all came together in the end to tackle bigger challenges. And if we as clinical leaders can’t do that, amid the biggest crisis in a generation, who can?