‘Getting to see you is like trying to get tickets to see a rockstar’ a retired lady observed yesterday in clinic. This was probably the most polite expression of a patient’s frustrations around access to a GP that I’ve heard in my career, and it summed up the plight of UK general practice perfectly.
You see in a system where 1 million patients are seen in GP surgeries daily, where demand for such services is increasing yearly, and where no money is exchanged directly by the patient for this service, there are only 3 ways to allocate appointments: a lottery system (who can get through first when the phones open); a waiting list; or an assessment of ‘need’.
Now in the case of my practice I see about 30 patients daily, for 10-15 minutes each, as well as checking all results, running the practice, keeping my knowledge up to date, visiting patients at home, developing innovative service models and supervising and training other staff. After 12 hours of this I can’t safely do any more work. So why don’t I employ more doctors?
To understand this one has to understand founding history of the NHS. Aneurin Bevan famously said that he persuaded the doctors to join the NHS in 1948 by ‘stuffing their mouths with gold’. Less well understood is that the general practitioners (GPs) declined this offer and have remained independent contractors to the NHS ever since. This currently translates to a flat fee to the practice to provide medical services, with some incentives around chronic disease management, which amounts to approximately £100/patient/year, regardless of the number of appointments. Average consultation rates are approximately 5 primary care appointments / patient / year.
© Dalius Baranauskas
What’s this to do with rockstars? – one might ask. Well, the main issue facing me and my colleagues is we’re too good at our job. As our practice offers extra services, such as warfarin monitoring, specialist diabetes nurses, extended opening hours and 15 minute appointments, we attract more local patients with complex conditions, as they are most incentivised to find a good practice. These patients require a lot of clinical time, yet are still paid at the above flat fee which is still less than the cost of yearly hamster insurance. Thus the financial incentives in primary care penalise those who provide the best care.
Despite this doctors remain the most trusted profession (Ipsos Mori polls) and as such the machinery of government, education and business has started using GPs as a kind of cut price notary service for all aspects of someone’s life.
The kind of life events that are now medicalised, mostly as a completely rational response to external pressures by individual patients, include: unfit for work; unemployable; bereavement; conflict at work; requests for housing; requests to move house; requests to stay in the country; requests to bring family into the country; not fit for exams; didn’t do well in exams; too anxious to work; proof of existence.
In essence much of what we do, and much of our patients’ responses, are affected by our unsought role as a judge of need. This is explicit of course in the NHS founding aims: free at the point of use; meeting everyone’s needs; based on need not ability to pay.
This superficially laudable concept probably sounded good at first, but like the Twentieth Century Motor Company, rapidly deteriorated into a perverse system that, in the case of the NHS, penalises self-care, encourages dependence and creates resentment between patients. Commentators, media, politicians, patients and doctors can all be found espousing the same views that somehow poor access to services is due to patients attending A/e, GPs, hospitals, walk in centres when they ‘don’t need to be seen’.
Call me a lightweight, but I find the concept of deciding who is ‘ill’ difficult enough after 15minutes of history, examination and investigations, and I’m paid to do this. Then try and ‘judge’ competing claims for appointments amongst self-employed builders with work injuries; unemployed depressives whose benefits have just been stopped; patients who need a medical review before going abroad at short notice next week; those who think they are dying; those who probably are dying and it’s no surprise that often access is decided by he who shouts loudest. And, as my receptionists known, there is a lot of shouting.
Fortunately there is hope. The same profession of GPs who declined becoming salaried employees of the state in 1948 retain an independent streak today. GP training and research in the UK has a long history of emphasising the personal interplay between a GP and the individual sitting in front of them, from Balint in 1957 through to Pendelton in more recent decades, the role of the GP and patient working in partnership for mutual benefit is one that can be viewed as consensual trade. The work of others such at Berne’s transactional analysis (1964) has also been used, with the understanding that the default state should be doctor and patient interacting as adults, rather than one taking on the role of parent and the other child. My own views on liberty have been developed and sharpened at work by witnessing both the benefits of these adult-adult transactions and by noting the real disabling nature of systems that treat us as children.
GPs also remain businessmen and women, which probably explains how £100/patient has lasted so long without complete implosion of the system! And, alongside many libertarians, we don’t like being told what to do.
So where is the opportunity in this industry that affects all 60+ million people in the UK, is a £7 billion sector representing 8.4% of the entire NHS healthcare budget yet accounts for 90% of all NHS consultations?
The obvious answer would be to free up this sector, which currently crowds out all other low cost healthcare. A ‘medical home’ (primary care) is recognised by the World Health Organisation as particularly important for good healthcare yet there are few private GPs in the UK. The GP role is important – whilst private or public hospital specialists might have incentives to promote their own treatments (usually involving a tube in an orifice or a cut with a knife) there is a need to build on the trusted medical expert skills of the GP. A good GP can help patients avoid unnecessary, dangerous and expensive hospital care, and help manage the risk and uncertainty that is unavoidable in life and health. These skills are particularly necessary given the increasing morbidity as we manage more long term conditions into old age.
3 massive barriers to private GPs exist however.
The first is NHS prescriptions. Only NHS GPs can issue NHS prescriptions. As prescriptions can costs thousands of pounds a year privately, yet should only cost a maximum of £120 / year in total for those not exempt, all but the wealthiest are incentivised to keep an NHS GP.
Secondly, only NHS GPs can refer to NHS secondary care. Whilst many pick and choose for elective secondary care, paying for one time operations privately, they still wish to use NHS services for catastrophic care and long term conditions, especially as the ‘free’ healthcare crowds out alternatives. Again, this makes having a private GP more hassle than it saves.
Thirdly, existing NHS GPs cannot offer any added or extra services to their own registered patients.
Thus three actions that could instantly allow the market driven development of improved, more accessible, GPs would be to allow private GPs to issue NHS scripts and refer to NHS consultants on the same terms that NHS GPs do, and to allow NHS GPs to offer extra services to their patients.
This would instantly improve extended hours access, continuity of care, improved use of IT for communication and encourage the self-care agenda that leaders in the NHS constantly talk about, without understanding why this doesn’t occur.
A spontaneous change to the rules would be preferable, but perhaps a patient could influence this change via a legal challenge to their ‘right’ to NHS care, or a private GP could gain access to NHS services via competition rules.
Many models of care would arise, from concierge medicine paid like a gym membership with guarantees regarding maximum GP list sizes, through to pay as you go services to be used as needed.
For the GPs they would take back their autonomy and, instead of feeling that queues to be seen were a sign of failure, would instead see their services being properly valued, and would thus strive to improve them further.
For patients they would gain control over their health and would take a more active role in their own health.
And perhaps over time, seeing that the system didn’t implode, and that they were still alive and healthy, the whole country would feel a little bit more free, a bit less like a hamster and, maybe, even a little bit more libertarian.