Club Tropicana announce their new primary care service.There’s clearly dissatisfaction on both
patient and doctor sides with the current state of NHS primary care.
There seem to be unmet expectations and false assumptions flying round the system. In this piece Dr Rant wants to look at a positive vision of what a good primary care service would look like. Notice I say primary care and not general practice, as I don’t think general practice is the right place for all primary care, and I’m not sure it should be.
Firstly I want to describe primary care as including
all first contact work with patients. (I.E. The
point at which patients pitch up saying, “I need help”) On this basis A+E departments should be considered as part of primary, not secondary care. Secondary care is where a patient is referred on from one health sector to another. Primary care would include A+E departments, GP
surgeries, the district nursing services, GP Out of Hours (OOH) services, and various PCT (badly) provided services such as chiropody, health visiting. NHS 24 and NHS direct would have to be included (although Dr Rant thinks we could close these down and use the cash better on other activities) The Ambulance Services must come under the primary care umbrella as well. Dental and optical work also come within primary care.
Secondly I want to describe all diseases as fitting into one of three time categories, namely
acute (Short lived/fast onset e.g. coughs, cold, food poisoning, meningitis, sub-arachnoid haemorrhage, abscesses, stroke),
chronic (long term, lived with, tolerated e.g. hypertension, diabetes, epilepsy, COPD, asthma, rheumatoid arthritis, IHD, HIV)
and
acute on chronic (sudden worsening of an existing condition e.g. exacerbations of COPD, flare ups of ulcerative colitis, myocardial infarction)
This division is useful as it indicates the time frame within conditions develop, and over which they should be treated. So for example a sub-arachnoid haemorrhage needs very quick treatment as the patient will either be dead (
“you wake up dead with one hell of a headache”) or recovered very quickly.
Other conditions such as hypertension are unlikely to suffer from waiting a bit. It doesn’t much matter whether your blood pressure is checked this month or next, as long as it is measured every so often.
Acute on chronic conditions need treating on their merits at the time, and the patient’s prior knowledge and experience here is often very helpful both for doctor and patient. (
“If it’s the same thing again, then the successful treatment we used last time will work again” is a very handy GP shortcut with about 90% accuracy)
The key thing for primary care is that it should be able to respond well to patients presenting in all the categories of acute, acute on chronic and chronic presentations.
The NHS currently fails to do this. GP and OOH services are swamped with minor acute self limiting illnesses, viral infections, gastro-enteritis etc which whilst unpleasant, are unlikely to cause much harm. The truth here is that in most of these the patient will get better whatever the doctor does, and the art here is to do “
as much nothing as possible” and avoid “doing any harm” (The longer I go on in medicine the more I realise Hippocrates’ dictum “
First, Do no Harm” is harder to achieve than it looks)
The GP swims in symptom soup trying to spot the one serious case amongst the many minor illnesses. Every so often we get it wrong and
the Wailing Classes say GPs are useless/uneducated/lazy/ignorant….and why
don’t they scan everything and so forth….but in doing this they demonstrate only their own ignorance of the
difficulties of general practice work.
Thirdly in terms of actually helping people deal with health related problems the organisational and financial divide between “
health needs” and “
social care needs” is unkind, unhelpful, and intellectually false. It leads to a
false distinction, and much sophistry as patients/clients and social workers and doctors (and worse still PCTs and social work departments) try to classify care needs into various categories. The arguments are really about cash, and who will pay for what. They distract government funded care workers from actually doing what they are paid to do, i.e to care for patients/clients.
“The secret of caring for patients, is actually to care for patients” as Sir William Osler said. Too often the needs of the system trump those of the patient- the system needs changing.
Fourthly
PCTs are a great disappointment in primary care. There has long been a need for an overarching body to bring together the disparate elements of primary care into a clear organisational whole. Sadly PCTs aren’t doing this. Instead they are being reorganised, and their main function seems to be to try and pay for hospital care without going bankrupt. Their credibility is
low, and
eroding as fast as Scarborough’s hospital services.
Fifthly we need to realise that providing
medical treatment services will not of itself solve the
problems of social inequality. On Dr Rant we want to provide medical services fairly to all those who are ill on a basis of need, and this applies as much to a laird with colon cancer as to the poor man at his gate. So
we support equality of access and provision. We do not expect equality of illness frequency or illness outcomes.
However all though medical treatment is (well should be) useful it cannot of itself do any more than cure, remediate or palliate the effects of illness. At best, it can only return a patient to
where they were prior to the illness. It doesn’t make people better in a physiological or moral sense. Nor can it stop
the fact that poorer people get ill earlier, more severely, and more often than richer ones.
Sixthly we need to accept that
finance for health and social care is finite. On this basis we will not achieve perfection, and will have to aim for a rough and ready, “good enough”
On the basis that money is finite we need to say that primary care will not be able to give everything to everyone. Rationing is a fact of life, and Denial is not just a river in Egypt, but a government’s way of avoiding thinking.
In primary care we cannot give into crude consumerism, “I want my doctor to appear in a puff of blue smoke whenever I want him or her.” We cannot spend all our time dealing with
noisy neurotics, and their tiresome demands. We can over-investigate and be too careful. We cannot continue underwriting for free every newspaper and magazine scare story about whatever symptom is popular this month. “If in doubt just go and see your doctor for advice”
We cannot continue holding out the idea that the NHS will make you slim, beautiful and calm just by endless prescriptions, and psychotherapy appointments.
We cannot keep on expecting the NHS to provide an answer to all life’s problems, and all the UK’s social problems.
Seventhly we must recognise the importance of relationship between doctors and patients. If you think that your GP is rushing, keen to get you out of the room, and onto the next patient you are probably right. Sadly GPs work under
intense time pressure and try to see too many people with too many problems each, in each working day. Dr Rant has concentration for a certain number of patients and after that his concentration goes, and they all blurr into one. Sorry about this, but it’s the way I need to do it to get all the patients seen. It’s not great for either me as doctor, or you as patient.
A good primary care service would
actively provide better conditions in terms of time, space, and lack of interruptions in which patient and doctor could meet. The
long term continued relationship between doctor and patient is actually the bedrock of good primary care. It is good for both sides, producing
greater understanding and less inappropriate referring and prescribing. It is based in
trust and respect and as such is
salutogenic in its own right. It is a source of
social capital, that is rare in our disintegrating and somewhat atomistic society.
The people who try to cram ever more into each consultation whether it be the patient with a list of ten problems for a ten minute slot or the
Twaterati with their latest good ideas (eg QOF, Choose and Book) are overloading the consultation and need to be stopped.
I think I have the basic considerations in place above to start answering the question in the title.
A good primary care service
must respond to patient’s needs. It must be able to react appropriately in acute, acute on chronic and chronic illness scenarios. It must be able to deliver this 24 hours a day. It might even have separate centres for each of these, so that acute illnesses go to A+E or a Darzai polyclinic whilst the regular planned, booked chronic work goes to GPs.
At present GPs spent a lot of time dealing with things that are
urgent but unimportant. If you look at what is actually important it is actually the detailed management of long term chronic conditions, so that fewer exacerbations and complications develop. It’s in this area that the GP practice (possibly with some hospital specialists moved out alongside them- there is something to be said for geriatrics, diabetology, much gynaecology coming out of hospital and into primary care settings) really score well, and in which the long term relationship helps. Perhaps it’s time to have a simple “any acute illness” channel running in A+E departments, with discharge to the GP if the problem is not acute.
The current demand for GPs to
open 24 hours is largely pointless, (and a bit of a Gordon Brown distraction therapy from real problems elsewhere) and would simply reduce most GPs to resignation or exhaustion. The strain the
24 hour commitment imposed was one reason for the shortage of GPs and the need for the new contract.
It’s time we got
an overall body in charge of primary care in an area, and pulled together the work of GPs, ambulances, district and practice nurses, social work, mental health teams, geriatricians, A+E departments, psychiatrists, and many others. At present each is working in its own silo and thinking the others should do something different. It’s a jumbled organisation, and it could be significantly improved. Primary care trusts should have been doing all this planning for ages but instead they have been severely distracted, wasting time and money and goodwill on sorting out their own internal structures (At Government behest)
Dr Rant doesn’t see privatisation as helping in any of this. If the NHS works at all it does so on the basis of
shared risk, and
social solidarity. Allowing rampant me, me, me consumerism to destroy this would be negligent, and ultimately more expensive for lower quality.
