There is much bleating and gnashing of teeth at the DH as they cannot deliver access to dentists and/or GPs. If they’d stop gnashing their teeth they wouldn’t need either of course.
Now I know that the access at my practice is not as good as it could be, but I’m not sure this matters.
This may strike readers as non-patient centred and not politically correct thing to say. But I’ll say it again- I’m not sure it matters.
Not at least in the grand scheme of things that do matter.
It matters at the trivial levels of convenience, time off work, personal impatience and so on. But these are base consumerist notions, and the phenomenon of supply induced demand will soon swamp any improvement we do make.
But at the level of seriously ill patients going untreated I’m not sure access does matter that much. If I thought seriously ill patients were unable to get treated at my surgery I would be worried. But I see no evidence of this, and I read the hospital letters, casualty reports and other messages carefully. (They’re not going elsewhere)
At the level of what really matters in medicine such as cancer treatments and other serious illnesses their claim on limited NHS monies is greater than that of patients wanting GP access now matter how shrill the siren voices are. At the end of the day the main job of the NHS is to treat serious illnesses well, not to give empathy to IBS patients, or attend yet another meeting.
So let’s look at what patients will bring to GPs if access is increased:-
1. GANFYD requests- get a note from your doctor- for housing, school, work, prisons, and any one else who thinks that “a doctor’s note” (Middle C anyone?) will allow some minor bureaucratic admindroid to do something sensible, but not of their own volition.
2. Acute minor illnesses. GPs are being (rightly) castigated for giving out too many antibiotics for these. If people can get to us very early in their illnesses you end up seeing minor viral illnesses 3 or 4 times in one week. If you see your GP too often they will eventually give out ADT (Any Damn Thing) to try to get you out of the door. If GPs are full the patient arrives a week later and says, “It was bad last week but it’s gone now” The GP thinks, “You never really needed to see me at all…and anyway there’s next to nothing we can do for minor viral coughs and colds…and you’ve shown you can fight it off yourself… so you are wasting your time around here mate” (Exit patient stage left)
3. The neurotics “I have no life…and my atypical chest pain…or is it my irritable bowel…is giving me lots of pain.” The doctor is thinking, “Yes dear, you’ve had a bad day at work, you always get these funny pains…and have been for years…and you have dealt with them before…and you’re only here now because I am open now.”
As you can see opening up our surgeries longer is really going to get serious illness better dealt with. It will pander to the worried, the neurotics, and the feckless, and it will reduce people’s abilities to cope with illness even further.
Supply induced demand will emerge and the patients will turn up and pack out the surgeries. I just think I won’t see any more real major illness than I do already. I think I’ll see the usual suspects, later at night, and more times a year. Pandering to sympathetic nervous system hyperactivity disorder (Copyright Dr Rant) is a waste of time and money.
Gordon Brown, Alan Johnson and Lord Darzi have no clue about really matters in medicine, and are currently stoking up a consumerist madhouse. They have the political power to get their way, but I predict it will come back to haunt them.
The problem is that symptoms are common. (Symptoms are sensations that a patients thinks may be related to a disease and might need medical help) Most of us have two or three symptoms every day and rightly judge them as harmless. Disease is actually quite a rare cause of symptoms.
So there are many people with symptoms and yet few with serious illness. So doctors spend a long time sorting out the worried well, the neurotics and the hypochondriacs from those with real illnesses (on whom they should spend more time money and attention). The aim of a good GP appointment system is to keep the neurotics wailing at the door and get the seriously ill ones seen and sorted. And to keep the neurotics away from potentially dangerous and harmful interventions at the hospital. The longer Dr Rant practices the more he realises just how demanding a commandment “First Do no harm” is to achieve in practice.
Simply increasing access will open the door to the neurotics and the polysymptomatic symptom generators and entitled demanders. They’ll love it…but it’s a waste of medical time and NHS resources and our tax revenues pandering to this group.
The NHS needs to ratchet down demand, and focus more on the most serious illnesses well. That actually means making it less easy to access doctors, and drugs, and tests, and doing less medicine overall. Much of what is done in medicine is already over cautious, defensive and fear driven. And antibiotics are given out as GPs and patients are nagging each other to pieces.
Of course if I was working entirely privately I’d be as nice as pie to well heeled neurotics, double my fees, and test to my heart’s content. I’d be richer than I am, and my ethics would have gone to pot, but I’d be ever so patient centered and customer focused. The patient would be worse off, financially and medically, as a result.
I know UK GPs tend to be rushed and a bit irritable. But if you give patients and GPs too long together they find far too many things that need investigating and testing and prescribing for. And so costs rise.
One of the great achievements of NHS (Treasury are you listening?) has been to keep doctors so busy that mostly they don’t do too much unnecessary investigations and treatment- indeed if anything UK doctors under investigate patients) This has kept patients away from an excess of incidentalomas (minor, irrelevant,non-serious lesions found on unnecessary MRI scans) and serum hyperrhubarbaemia. (a funny chemical that clever doctors measure…and then have no idea what to do about…and patient is no better off as a result of the knowledge…but now they have a condition with a label. Better not eat too much custard, or the rhubarb level will rise still further.)
One of my psychiatric profs said, “Anyone who wants to see a psychiatrist must be mad” I’d agree with him, and enlarge it to “Anyone who wants to see a doctor must be mad” You should want to see a doctor only if you are seriously ill, and the alternative of not seeing a doctor and taking his poisons is worse. That is that the NHS should respond to NEED, and not to WANT.
The first duty of the doctor is to educate the public not to take medicines…and in the name of good medicine we should abandon the access demands.
However the great clunking politburo chief wants to squander taxpayers pounds on a showpiece improvement and he seems to have found GP access as his vanity project. God help us all, and save the country from bankruptcy, and the patients from an excess of medicine.
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27 comments:
Dr Rant,
I think you are on a loser if you continue this line of arguement. The public want more access and the government have identified this as a stick to beat GPs (and eventually replace them with nice 24 hour available pharmacists and nurse practitioners).
Recognise that the world has changed and figure out how you can provide the service.
On a personal note I suffered from an attack of iritis this week. I couldn't abandon work to visit my GP during the day and, quite frankly, did not wish to risk my sight waiting for an appointment. Luckily, in my position, I was able to see a consultant opthalmologist at my work and got it sorted without major disruption or cancelling lists but, surely, isn't this what we should be providing for everyone?
dr ray, he certainly is on to a loser. (Luckily your reply has somewhat assuaged my fury,)
We wouldn't want to be confusing access for acute problems like Iritis with extended access for routine and mundane stuff would we?
GP is free at the point of abuse as well as use - if we have better availability it will be wasted by selfish impatients. People are not naturally utilitarian or altruistic in their outlook. The small minority that already vaccuum up the majority of our resources would fill their boots even more.
There isn't the capacity to go creating more demand when we are frankly struggling already.
Dr Rant - you would have to drag me over hot coals to see a doctor [no disrespect] - I have NEVER taken antibiotics [except as a nipper, possibly], nor would I, unless I had TB or pneumonia, or meningitis, etc.
In my mind I'm storing it all up for when I'm diagnosed with cancer, or have a heart attack, or suffer a serious injury/illness, etc.
Of course when I really need a doc most of them will be far too busy PROVING to the worried well what they had suspected 90 seconds into the consultation, that the vast majority underestimate the awesome power of their own immune system.
Certainly the junior doctors in A&E are obsessed with CRP and troponins, etc - when/how did doctors mutate into test-geeks ?
Woe betide any junior ordering clotting [unecessarily] when a certain god-like A&E consultant used to be on the shop floor in our place.
Why can't people leave doctors to those really in need of medical expertise, because one day it will be be their turn. Then one or two of them might begin to really appreciate the uncounted cost of medical arse-covering.
We wouldn't want to be confusing access for acute problems like Iritis with extended access for routine and mundane stuff would we?
we wouldn't want to be expecting patients to be able to tell the difference between iritis and conjunctivitis, would we?
jayann - certain docs don't even expect quacks to know the difference, let alone patients ;o)
a & e charge nurse, lol
Well said Jayann. I knew it probably wasn't conjunctivitis but I had no idea what it was or how urgently it needed to be treated.
How could a lay patient or GP receptionist decide how urgently they need to be seen?
Conjunctivitis is an acute problem as well - My eye is red and hurts.
I was comparing with - "my gym says I need a letter from my GP before I walk through the door because I had an ingrowing toenail 20 years ago."
or
"My weight loss club needs a letter to say that it's safe for me to adopt a healthy lifestyle and eat fewer chips before they well let me join."
Access for acute problems is what we would all like to improve. Prebookable appointments on saturdays and in the evenings will not help. Neither will surgeries reducing the number of appointments they offer during normal hours to compensate.
The bottom line is that the suggested 'improvement' will result in a reduction in the total number of appointments on offer. How will this help?
Most normal people (I would add at the risk of seeming sexist- particularly men) would, like A&E charge-nurse, need to be at death's door before they go to see a doctor so, by definition, the people Dr Rant sees most are the wimps and wasters. This colours his judgement in the same way as policemen think everyone is a criminal.
The problem is that when normal people are occasionally acutely ill, they don't want an appointment in 48 hrs or have to argue with a receptionist. Genuine people with real acute illness need to be seen straight away. The problem is sorting the wheat from the chaff.
Another personal example- I have an excellent GP but when my 2 year old got lobar pneumonia on a Sunday I had the choice of waiting hours for a deputising service doctor whom I did not know or to pull rank, take her into my own hospital and x-ray her and then ask the on call consultant paediatrician to treat her.
I am glad I did the latter but I feel uneasy that a lay person would have ended up with a very sick child without the access I had available.
Perhaps a fee is the answer (it costs me the odd bottle of single malt) but then how do you deal with people who genuinely can't pay.
Since most of the middle classes have long since conceded paying for treatment for dentistry (where we live the standard dentist dodge is "if both parents join our practice dental insurance scheme we'll take the sprogs as NHS patients"), I come back to the "£ 10-20 upfront add-on payment for the evening surgery". I usually manage to get to work a couple of hrs later when I need to see the GP, but if I really couldn't make it until 7 pm, and was ill enough to really need to go, I don't think 20 quid would bother me much.
Dr Rant - "there isn't the capacity to go on creating demand".
This is exactly what happened after the 4-hr A&E target was introduced.
Instead of staff having additional time to deal with those patients who really need emergency care [because we got more patients through the department quicker] - we simply ended up with more and more patients piling in through doors [rapidly absorbing any spare capacity that had been created through efficiency].
The problem is, of course, that a fair proportion of these patients could be sorted out elsewhere, and a significant minority should be able to take of themselves [uncomplicated back strains, coughs & colds, minor headaches, trivial injuries, etc].
These days I suspect A&E are seeing a growing number of patients that once upon a time would have been quite content to see their GP, who, after all are considerably more experienced than your typical A&E FY2/SHO.
AnE CN -
Unfortunately, the tests keep you in employement when the punter represents with eg their MI.
It's no use trying to explain to his/her honour in court that the patient was low risk and the test was unnecessary and expensive when in actual fact the patient did have something worng with them. Judges understand law not medicine and medicolegal lawyers will always dig out a convincing body of practice expert from somewhere.
I don't like it. I also don't like being unemployed and beggared by legal bills.
As has been said earlier, people are not altruistic. They also pretty rarely take responsibility for their own actions.
Unless the culture of ambulance chasers changes I forsee more and more needless tests.
Dr Sniper
Agreed Dr Sniper - nobody can complain about doctors becoming increasingly concerned about litigation - it's a very real problem, why should we expect docs to jeopordise their careers for the sake of a simple blood test ?
But as the over-investigation culture becomes more established, the THRESHOLD for tests will get lower and lower [especially x/rays & bloods, and even ECGs to a certain extent, since everybody thinks they have cardiac chest pain nowadays].
Behave more like a GP I tell the FY2s but of course I have conveniently overlooked the fact that they don't have the experience [yet] - I see no way of this expensive, consumer driven, dilemma.
And what worries me is that treatment of the big diseases is being hampered by these expensive, and time consuming developments.
Dr Sniper, my local hospital's more public corridors contain video monitors displaying large ads for no win no fee accdent/injury laywers. (As well, I think in my more angry moods, they might.) Their response to complaints, though, suggest they are well aware that most people are really very unlikely to sue (the culture of compensation, the data show, is a myth). However: if indeed unworthy suits are haunting hospitals and/or they are unable to find sufficiently convincing expert testimony on their behalf, could they not stop advertising these perhaps rather dodgy and certainly ambulance-chasing services (particularly on monitors to whose cost patients contribute...)?
Behave more like a GP
Hmmmm :)
Jayann - GPs manage an incredibly high level of risk, their main weapon [bloody hell, now I'm starting to sound the Spanish inquisition] is clinical nous, combined with examination skills.
What did Wanless estimate, something like 250mil GP consultations take place each year - the health of the nation [in the sense of disease detection/management] is in their hands to a large extent, and a great job they do too [most of the time].
GPs learn to function without the need for endless investigations [notwithstanding Dr Snipers earlier comments, which I think applies especially to hospital based doctors] - and without routine access to immediate specialty back up as well, incredibly they usually get it right.
I almost always end a shift worrying about something or other that almost happened in A&E, God knows how GPs sleep at night [presumably slightly better since the OOH changes, I hope].
You may be right that the actual number of negligence claims against doctors is not actually rising, but certainly the perception that the UK is at risk of following in the footsteps of the USA is unlikely to be ameliorated by the apparent intention to privatise the NHS by stealth.
If GPs do a "dentist" then this will really hit some people hard - I have just paid £550 for a single porcelain crown, there was a time when you could probably have had a hip replacement done for a similar fee [incidentally, I was too vain to accept the standard NHS el-cheapo prosthetic, even though it was £300 less].
Jayann - you might be interested in the Legal & Medical website.
http://www.legal-medical.co.uk
The NHS Litigation Authority [NHSLA] paid out a record £613 million last financial year, including £424 million in clinical negligence cases.
[add.... /news/11642.html]
You are righ to suggest that the overall number of complaints has fallen slightly, but this trend could have been anticipated given the spike in complaints during the mid-to-late 90's.
a & e charge nurse, I wasn't attacking GPs, I was simply slightly amused.
(Rise or not in complaints, amount paid out: my point is rather that we do not live in a 'compensation culture' -- I do have more on this somewhere... . I do think we live in something of an 'entitlement culture' but also think that doctors are not immune from that themselves... .)
You and dr sniper have managed to decoy me from my main aim of attacking dr rant! -- I know people come to A & E with all kinds of minor problems -- I must get back to that main aim.
I posted on a previous thread that our largest local hosp (urban teaching hosp) has a "GP emergency" clinic right next door to A&E, with Children's A&E on the other side. The opening hrs for the GP centre are something like 10-10 weekdays, 10-5 w/ends.
I would hope this arrangement works to shift at least some of the people who don't really have an acute A&E problem to the GP clinic.
staff grade doc's other half, my city's OOH works like this (with two GP clinics, one next to the city's only A & E department, the other at what was a much loved city centre general hospital). But that's OOH (i.e. before 8.30 am Monday to Friday, plus Wednesday afternoons plus one Tuesday a month plus weekends). Presumably the people who attend your city's GP clinic on weekdays can't get an appointment with their own GPs...
I see I got decoyed again...
So let’s look at what patients will bring to GPs if access is increased:-
1. GANFYD requests
so right now, people are doing without letters (for which you can charge, BTW?) and possibly missing out on something they should get? (A GP once refused to give me a letter confirming I suffered from the tenosynovitis he'd diagnosed -- 'It is no part of my duties under the NHS.... ' -- luckily the Disability Employment Officer went ahead, helped me anyway, illicitly, but she was unusually pro- the disabled.)
Also: is it beyond the wit of a GP to devise a system (other than refusal) for handling such letters without having to, you know, have patients taking up their time? (I am fairly sure my current GPs have such a system. But as looking into that and telling you about it is no part of my duties as a patient, I won't.)
2. Acute minor illnesses. GPs are being (rightly) castigated for giving out too many antibiotics for these. If people can get to us very early in their illnesses
You'll be glad to know I failed to get to my GPs very early in my shingles outbreak; my immune system zapped the shingles but it took me a hell of a long time to recover.
3. The neurotics “I have no life…and my atypical chest pain…or is it my irritable bowel…is giving me lots of pain.” The doctor is thinking,
might these 'neurotics' need help they can only get by visiting their GP?
Dr Ray is 100 per cent right. Go on like this and pharmacists and nurses will take over.
(Already, people go to pharmacists for advice and buy medicines they could get free - here in Wales -- on prescription, and also ask for medicine they're told only a doctor can prescribe; indeed, I've come across a teaching hospital doctor getting help from a pharmacist. How come? why aren't these people, who can be at the pharmacy during office hours, not at their GPs' surgery? Could it be they weren't able to ring at 8.30 a.m. and/or could not get an appointment?.... )
And any ensuing blood of the kind you doubtless foresee, as non-GP HC personnel fail to diagnose all the things only doctors, apparently, can diagnose, will be on your hands.
Jayann, as you probably know shingles is a herpes virus...so getting to your GP early wouldn't have helped would it?
I'm also unsure of the vitriol about the 8.30 appointments? So how should we help these people? shold GP's know which of the people who did get appointments not be seen and thus make room ofr the obviously needy who were so ill they went to the pharmacist for advice?
I'm not actually sure how you would improve the GP appointment system.
i think youre on a total looser on this line of argument
to be honest for once i do have some sympathy with the current state of affairs from your point of view
however the whole bloody point of docs is to help non medic ordinary punters work out if some weird and wonderful symptom is serious or not, is it a harmless rash or something thats going to kill me? docs get this wrong quiet often its hardly surprising the public need help figuring out whats going on
the routine stuff that you dismiss so easily such as ear ache is no fun if youre the patient in agnony unable to sleep, and the uk and its general response to this as a for instance is somewhat different to the rest of the developed world, and again the small percentage of cases where it turns out to be something more serious are done no help by the general lack of concern implies by your general attitude
and then of course we have the folk with long term conditions, who should whereever possible be helped to live a normal life, and that means holding down a normal job, probably 9 to 5, and this means such folk need access to their docs in the evening or weekends, like they would be able to get without fuss in the entire rest of the fucking world including the 3rd world i may add
BUT the uk system of no cash changing hands when visiting a GP, and the rather good state benefits if you can claim long term sick, do tend to lead to allsorts of crap queuing up in the average GP surgery, and this must stop
im the average punter, who through most of the middle of my life only needs to see a doc ever few years, it is however an eye opener to find out how rude the reception staff are, how long it takes to get an appointment, how long it takes to get through on the phone, the lack of choice re appointment slot, and generally how none customer focussed and unpleasant the whole experience is, it really doesnt need to be like this
so while i sympathise, i think you really need to step back and look at the issue through the eyes of the genuine patient
love you all
no one
Dr Ray - you made me laugh: You HAD to stay at work but your eye condition could have left you blind had you not seen a specialist?
That's your priorities that are screwed, not your GPs.
If you feel you're so indispensible that going blind is a reasonable alternative to taking the morning off and going to see your GP, then sadly there is no way of reasoning with you.
In simple words:
THIS WAS NOT YOUR GPs FAULT. YOU CHOSE NOT TO ATTEND.
cat1
you are v mistaken to believe that everyones time is less expensive or valuable than the GP
lots of us contribute more than the GP to society sounds like including Dr Ray, and the idea that we should fucking bend to the will of the GP is as ridiculous as suggesting we should wait at home for the dustmen to arrive
the sooner there is some commercial reality and GPs only get paid when they actually see me the better
dont tell me to go private id love to, there aint no private GPs round here, mores the pitty
Well I never thought I would be saying this but I agree with "no-one"
The situation with my eye was that I left it a bit late hoping it would get better by itself but it got worse.
I don't know whether I could have got an appointment with my GP that morning as a normal patient. Every time I phone a practice I seem to get an answering machine and I just didn't bother. I could have phoned one of the partners at home but I don't like to abuse my position unless it's a dire emergency. I had a patient list myself that afternoon and canceling this at short notice would have been a disaster. I also stood to lose considerable income if I could not work the following day so I needed to be seen around my commitments rather than alter them. People with acute and possibly serious illnesses shouldn't need to jump through hoops to get seen and treated.
The problem with introducing charges would be that the unemployed/single mothers/workshy/retired would claim they are being denied the same standard of care as paying patients and would demand to be seen at all hours and have exemption from charges. The other problem would be that once introduced the charges would become another stealth tax on the poor middle class working cash cow.
dr ray the real free market price of a GP appointment would be remarkably cheap, it certainly is in most countries where there really is a commercial free market in GP services
the unemployed/single mothers/workshy/retired can have the money to pay for appointments in their benefits, let them decide whether a 4 hour wait is worth the money, even they would start picking the best balance of service/price if they controlled the spend, unless they have a long term serious condition in which case again they should just be given the money to buy the service where they get the best reception
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