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A faulty production line

GPs are losing their core roles

If some sort of catastrophe strikes the country in the near future, it is possible that there will be no local doctors, nurses or equipment capable of providing basic generalist care any more.

If some sort of catastrophe strikes the country in the near future, it is possible that there will be no local doctors, nurses or equipment capable of providing basic generalist care any more.

I agree wholeheartedly with Professor Haslam's comments about losing our key roles and skills in favour of superspecialisation in the July issue (Practitioner 2008;252[1708]:38).

I live in an area where it usually takes about an hour to drive to the nearest DGH, but can easily take 90-120 minutes, or longer, when there is summer traffic or winter floods.

Our DGH is in fact the smallest in Britain, and constantly under threat of losing its DGH status because it does not offer sufficient throughput to keep up specialists' experience in most specialties. The neighbouring DGHs are several hours away. This means that it is difficult to meet the call-to-needle time within the ‘golden hour' for heart attack patients. Likewise, trauma patients will not reach hospital within the hour, and certainly not within 30 minutes.

Generalist skills in basic, non-specialist assessment and resuscitation would therefore seem to be useful, but sit awkwardly with clinical governance guidance that we should only do what we do frequently.

Even daily general practice does not actually offer large numbers of identical problems: half the morning surgery may be depressed, some as a result of illness but others will have suffered a bereavement or have problems at work.

I am in favour of care being provided by people with up-to-date knowledge and experience and good outcome statistics. I gather it is planned that ambulances attending 999 calls for ‘chest pain' will only go out to the case if they have a cardiology senior house officer on board.

This sounds fine for those patients who are seen by the senior house officer within the time needed. But, since there are not enough senior house officers of any kind based in my area, let alone a stack of superspecialised ones, does that mean local patients will be denied care until this superspecialised doctor in training is actually available?

Why can't interim care be provided, to the best of their ability, by those staff who are available? Even if they have to stop short of inserting cardiac catheters, they will be able to ensure basic resus so that casualties reach the DGH in a reasonable state.

At our local cottage hospital we have lost, progressively, our acute medical care, bed numbers, inpatient EMI care, delivery suite, EMI day hospital, EMI community team and acute GP inpatient care over recent years. Now our casualty department, which was first redesignated MIU (minor injuries only, no children, no acute resus of emergencies), has closed abruptly with the loss of the associated provision of crutches, entonox, support bandage applicators, ECG tapes and urinary catheterisation facilities.

Our neighbouring cottage hospital has also lost its ability to apply POP casts and to thrombolyse on site, which the GPs did until just a couple of years ago.

I remember, when I came for my GP VTS scheme interview in 1992, that the gynaecologist on the panel asked about use of forceps by GPs. I answered that I did not think GPs would be required to learn and practise forceps extraction any longer, as anything not possible with a ventouse should probably be done by a consultant in a DGH. At the time this was not considered a suitable attitude, and I was put right on the point.

Now all facilities for GP obstetrics in my area are being removed, bit by bit, and it has even been suggested that all patients should travel past our DGH to a bigger one a few hours away.

If some sort of catastrophe strikes the country in the near future, it is possible that there will be no local doctors, nurses or equipment capable of providing basic generalist care any more.

Dr David Church, GP, Machynlleth, and assistant to the Regional Surgeon, St John Ambulance Brigade, North Wales Region.

GPs began to lose their key roles back in 1948 when they, mostly reluctantly, signed up to the National Health Service. With the new system their independence was lost. And this was soon followed by their respected position in society.

Very soon young newly qualified doctors could no longer go straight out into general practice, which had been a traditional way of beginning practice, learning from their peers.It was a false economy to draft them into cheap hospital practice as assistants and ‘housemen' on the wards.

Back then there was satisfaction somehow in doing a ‘hard day's work' in coping with the winter flu epidemics and full waiting rooms. No one had to wait more than perhaps half an hour in a busy waiting room. One might have to leave a warm bed and go and deliver babies in cold bedrooms in distant cottages but there was still that feeling that it had been worthwhile. Even when snow was on the ground and one carried out three deliveries in one night.

When the morning surgery ended, there was the country visiting list to be worked out among the partners, each fielding a different sector of country on different days of the week.

One's schedule was dictated by the number of people to be visited and medicines to be made up. So a midday lunch was out of the question. A snack meal would be taken hurriedly before attending to a town list of patients to be seen before an evening surgery.

That was the daily routine.

Dr George Yuille Caldwell, GP, Singapore

GPs are losing their core roles

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