“If Tesco can open till midnight every night, why can't our GPs open till midnight every night?”

At Dr Rant we suspect Mr MacKinnon may well be right that further OOH tragedies will occur. Despite all the wisdom of hindsight and regret it’s doubtful any lessons will be learnt. The fall out from such cases is one of the reasons GPs mostly avoid OOH work now.

Firstly we will express our sadness for the death of Penny Campbell. Whether as doctors we would have done better than those who did treat her we do not know. Dr Crippen discusses things well here. I’d echo Dr Crippen’s respect for the “rule of threes” which basically states “first time you see a patient you can do anything, second time you must get it right and if the patient presents for a third time you need to ask someone else (usually a consultant).”

However Mr MacKinnon asks a very good question about GP opening hours, and it seems worth a go at answering it.

There’s a simple reason why TESCO stays open so long. It gains a profit margin from it. Or it finds it needs staff on 24hours a day to accept night time deliveries, and restock stores, and decided to pay a few check out operators to work whilst all the deliveries are going on. So it may be an example of fringe costing, that expands availability, improves the service, at very little cost to TESCO and gets some extra revenue in. Whatever TESCO’s exact economics, they clearly gain from their long opening hours. But their income comes from the pockets of consumers who make the choice to shop with them.

Some weeks ago we published a piece on “The NHS: What is to be done?” Mostly the reaction was favourable, but two comments from right wing observers criticised us for rejecting market based solutions to the NHS’s problems. This criticism prompted Dr Rant to read more widely about economics and see whether he could make sense of their criticisms. He read John Kay’s book “The truth about markets” We don’t think that the NHS “internal market” bears any relation to any real market.

Now from this book Dr Rant learned about the joys of disciplined pluralism and order emerging without design. The risks of any enterprise should be spread throughout a population in a series of small scale experiments, frequently reviewed and with disciplined review of results. The joy of such systems is that they cannot stay too wrong for too long or they go bust. Also even if one enterprise goes bust, it doesn’t take the whole lot down with it.

The NHS is clearly not such a system, and it is probably best described as a centralised, bureaucratic monolith that measures its tractor production quotas each year for Comrade Splatzy to produce at the annual party conference.

John Kay’s book is excellent on the problems central bureaucracies have with getting supply and demand balanced by conscious means of measurement, commands and controls. The medical analogy could be diabetes mellitus. In most of us (those without diabetes) we can feed variable amounts of sugars to ourselves and the pancreas will produce just enough insulin to handle this sugar. Our blood sugar level will stay between 3 and 8 mmol/l. We don’t know this is happening, we can just take it for granted. Everything functions fine.

In the diabetic population the pancreas stops working, fails to produce insulin and therefore the patient has to administer their own insulin. What we find is that even with the best monitoring and control the blood sugar goes either too high or too low (hypos) Conscious monitoring is a poor substitute to the pancreas working normally, it takes a lot of effort, and is far from a smooth process. Supply of sugar and demand for insulin are never all that well balanced.

It’s a bit like the NHS. Sometimes too little. Then too much. Wild swings from feast to famine and back again.

Now to get back to Mr MacKinnon’s question, “If Tesco can open till midnight every night, why can't our GPs open till midnight every night?”

Now if GPs were true businessmen some of them would be trying things like longer opening hours. They might find they made some extra income and profit for their efforts or they might find there wasn’t really any demand for the service. However one or two practices would innovate, some practices would be early adopters and some would be late adopters and some would retire or go bust.

But GPs are hamstrung by a fixed central contract. The PCTs are hamstrung by rules. They can convene committees and meetings for hand wringing, but they don’t have authority to try things out. Nor do they have agreed criteria for success and failure of pilot projects and the NHS endlessly insists that “the views of all stakeholders must be considered” which means that no one can make a decision for fear of offending someone else. Passive aggression gets people to the top of such organisations as they can manipulate fear without appearing to do so. “All animals are equal, but some are more equal than others.”

So there is no room for small scale experimentation in most surgeries. And at the Macro level there are only fixed numbers of GPs available, and it’s a slow process even to get basic GP training completed (10 years minimum from med school entry to independent practice). So even if they the existing GPs have lots of slack time to spend on new enterprises, they will tend to do this at expense of existing commitments. The problem is of making a scarce product go round. Even using nurse practitioners is only a partial compensation for the overall lack of GPs.

So the reason why GPs are not open to midnight is that they work in a monolithic centralised system, small scale experimentation isn’t possible, and fixed supply of money and resources leads to ossification of decision making processes. The status quo staggers on, and somehow it muddles through.

This misdirection of government monies in the NHS is currently appalling and when we, as voters, fully appreciate this we will make the government pay dearly for its mistakes. In primary care we could have had improved GP surgeries, longer opening hours, and better phone access. The money has instead gone to QOF, to walk in centres, to expensive PCT reorganisations and NHS redirect. It has been wasted rather than used to improve existing structures.

Government as usual thinks it knows better than those who work in the service and so it tries to bypass the GPs.