What is the fucking point? (part two)

This is a guest piece, 'Extended Opening Hours: A View from the Coalface', by Dr Ian Rubenstein.

Sorry if it comes across as a rant but I just felt moved to tell it like it actually is from someone who has to do the job and make sense of what actually is government nonsense.

In an ideal world our surgeries would be open 24 hours a day, we'd be well funded and have the freedom to organise things as we want. GPs would be able to employ people round the clock. In fact in the mid-nineties this is what we almost had in my surgery: we had a local co-op of 35 GPs based at our surgery. The problem was that our patients over-used the service and the other GPs complained that they were always seeing our patients. However left to its natural conclusion I'm sure that we would have worked closer together, set up some sort of super-surgery, pooled resources etc. We actually all enjoyed meeting each other on shifts, even though out of hours was still a pain, and we took a pride in running a service which was extremely popular with out patients.

However: the dead hand of the DOH decreed that we were too small, that we had to answer the phone on three rings etc. The quality issues were ludicrous and, despite the fact that it all worked well and the patients loved it, we couldn’t meet the requirements. The only option was to get bigger and we thought: hang it, we'll merge with the local big co-op. It actually cost us less (economies of scale) and we didn't have to do any shifts if we didn't want to.

Then, of course after a few years we were encouraged to drop OOH completely (the money we gave up was used by the PCT to fund the large local co-op).

The problem is this: This was all in 1996. I've been a GP for 25 years now. For the past 8 years I haven't had to do any out of hours. I'm 52 years old, my colleagues are mostly over 40, and two in their sixties and this applies to most GPs in our area. I've re-arranged my life as have my partners and frankly we've all got other commitments in what used to be our OOH time. New GPs all seem to want to have a better work-life balance than I ever had: we couldn’t recruit any new partners until we were part of a co-op.

I now have a life outside work and it has actually made me a better doctor. My work has changed: In the old days we had 15000 patients and five partners. Surgeries could sometimes have thirty patients and there might be five or six home visits for EACH doctor after morning surgery. Now we have seven partners and 12000 patients. There are less demands for home visits and the work has shifted more from acute stuff (our nurses see a lot of this) and more to managing chronic disease that when I first started would be managed in hospital. Try to get a decent generalist consultant opinion nowadays: the only ones who can seem to manage an overview are the geriatricians. So we have to be more clinically astute. If we go back to the old days, then we’ll have to do everything we used to do, plus a load of the stuff the hospital used to do (and we are doing now).

The entire GP OOH infrastructure, receptionists, special computer system, office space has been swept away. That's all been taken up by all the staff we need to manage QOF. There really is no money to fund this plus extended opening hours. All this nonsense about GPs earning megabucks is just so much hot air. In my practice we have seriously financial issues and are worried about where we are going to get the money to fund staff. We actually had to make one member of staff redundant.

To all my non-GP colleagues out there: this stuff doesn't just happen, we have to make it happen. Plus we have to see all the patients, and take the flak for all the fallout from a hospital system which is failing. When I first qualified I remember being amazed that elderly people didn’t want to go to hospital because they equated it with the workhouse. That generation died off years ago. Now, amazingly, I have another generation of people (young and old alike) who don’t want to go to hospital in case they get C.diff, MRSA and who tell me horrendous stories of the care they received. My patients really cannot understand why it takes three weeks for me to get a routine X-ray report! (it used to take a week back in 1982).

GPs get all the flak for this, however much we try and deflect it. It’s incredibly demoralising.

Also: what the hell's the point? I used to be very enthusiastic with stuff like fund holding etc. But as soon as we set up one system, the government change it! There is no stability at all and we waste time and resources going round in circles. It's not just a waste of time, it's a dangerous waste of time.

A good many of us were concerned about the implications of the new contract and in fact the government were warned (if they had listened) that the sums didn't add up. They didn't listen.

They now have the consequences of their extreme stupidity and I'm buggered if I'll take the flak for this from anyone.

If we expend money and energy trying to make this work (having spent money and energy dismantling a structure that did work in pursuit of some wild goose chase) who's to say that five minutes later we might not have to dismantle this in favour of some other hare-brained scheme.

This is not good management. In fact it's dangerous nonsense. I remember the "old guard" when I was young debating proposed changes to the NHS. The accusation then was that "it's a waste of medical time". Of course everyone then thought that medical time was a precious resource. And it still is: just ask our patients. The government seems intent on squandering this in just the same way as it has squandered billions on ephemera.

Having said all this I still enjoy being a GP. The patients are just the same and the only way I can cope is by trying to ignore all the crap and focus on the patient. But it gets harder and harder. My wife is a doctor and she works in family planning and is the one of the few doctors locally who can do difficult coil insertions, plus she is a trainer. She has similar problems with her department.

If you are healthy and have a job you like, why retire even at 65? That’s how I used to feel. But the way the things are going we actually are wondering how we could afford to retire sooner.

It beggars belief that a government can spend so much on the health service and thoroughly piss off the very people who have to make it work.

Gerry Robinson: where are you?

This piece was first published on DNUK on the 22nd of December, 2007.