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Is general practice stuck in the past?

The CBI's Neil Bentley argues general practice has not responded to the needs of a modern workforce and must be overhauled urgently, but Dr Nigel Watson counters that change for change's sake will disrupt traditional general practice and prove detrimental to patients.

The CBI's Neil Bentley argues general practice has not responded to the needs of a modern workforce and must be overhauled urgently, but Dr Nigel Watson counters that change for change's sake will disrupt traditional general practice and prove detrimental to patients.

'YES'

Last autumn, the CBI argued that the UK's family doctor service is not always delivering what patients want.

We suggested that the service is too often unresponsive to the real needs of patients in today's world, and should be reformed.

We put forward ideas as to how this could be done.

Our report on primary care services, Just what the patient ordered, acted as a metaphorical tendon hammer.

The knee-jerk reaction from some in the profession was to describe our report as "poorly researched". Our motives were called into question. It was suggested that we don't want a healthy workforce but just one that turns up to work on time.

We were accused of wanting the ‘privatisation' of health services – not true if by that people mean public assets being sold off and rather strange in any case because the vast majority of GPs are already very firmly in the private sector.

We do not believe our proposals represent a threat to most GPs. In fact, we believe the best practices should have more opportunities to expand, and to extend the range of services they offer.

Many GPs already recognise that nine-to-five opening hours, while appropriate in some areas, are not suitable for most people's modern lives. It can mean taking considerable time off work to see the doctor, even for minor but chronic complaints. Or, worse still, it means they don't go at all and can store up problems for the future.

To combat this, we want to see people being able to register at more than one practice, for instance one near work as well as one near home. We believe that most GPs would agree that this was a positive step forward.

We want more primary care services being made available over the counter from qualified pharmacists. It is estimated by the Royal Pharmaceutical Society that each GP's workload could be reduced by up to 16 consultations a day if self-medication were encouraged for certain minor ailments.

More in-store nurses and walk-in centres in train stations and elsewhere should be encouraged.

New providers should be able to enter the primary care market, not least in those areas with too few doctors, many of which are in disadvantaged neighbourhoods. Yes: that might threaten a few GPs, but it does not threaten the ethos of the system. It will, though, require poor performers to get their act together or to do something else.

Practice-based commissioning should be used more effectively, and the funding dictated by patient choices and care outcomes. This too would enable the best providers to flourish and require poorer providers to improve or close.

It must be made easier for people to switch GP if they are unhappy with the service they are getting. And in the medium term GPs will need to see these market signals reflected in their income.

The need for change is there. Independent research from Boots shows 3.5million working days were spent last year by people waiting at the doctor's. This cost the nation some £1bn in lost earnings.

Department of Health figures show 10 million adults in England alone cannot book an appointment with a GP more than 48 hours in advance.

We have never criticised individual GPs. But the system they operate in should and must change, and both the Comprehensive Spending Review and Lord Darzi's interim report on the NHS support this view.

Like most GPs, we want to see high quality services being delivered to the public. We want to see value for taxpayers' money. And we want to see the best possible health outcomes for our workforce and population as a whole.

Whatever we do, patients' needs must come first. Forward-looking, achievable reforms that have this at their core are to be cheered, not feared.

'No'

The CBI claims GPs are costing business over a billion pounds a year by requiring workers to take time off work to see their doctor. Around 3.5 million working days are lost a year, apparently - four times the number lost to industrial action. The CBI has warned: ‘Employers don't want to pay for a health service that is not flexible enough to cope with the modern world.'

So the charge laid at our door is that access to GPs is poor - we do not offer appointments at a time convenient to employers and cost the country large sums of money. The only solution, so we are told, is a ‘fundamental rethink of a service that has changed little since the NHS's foundation in 1948'. The CBI adds: ‘An outdated and rigid family doctor service is resulting in less effective and unequal healthcare and placing an unnecessary burden on employees and businesses.'

These criticisms come even though the Department of Health recently conducted a patient satisfaction survey involving over 2.2 million patients, 84% of whom said they were satisfied with the opening hours of their practice. It is interesting also to note that the CBI's solutions include recruiting alternative providers to offer appointments at times when people are not at work. The CBI of course represents many of those who would be considered alternative providers.

Nevertheless, it is worth considering whether it is true that general practice has remained almost unchanged for half a century, and whether also major reform is now needed.

The CBI is correct than some things in general practice have not changed. These include:

• Care from cradle to grave

• A life-long medical record

• A registered patient list

These are some of the strengths of British general practice and change would be to the detriment of patients.

But in many other ways general practice has undergone significant change on a regular basis since its inception, and has responded to the many and varied challenges placed before it. Many practices do already offer early or late appointments for workers, and the GPC is willing to engage in the debate over extending hours.

Dr Laurence Buckman, GPC chair, recently said: ‘If the CBI really wishes to change things for their employees, a good starting point would be to talk to the people providing the care to see if things can be moved forward.'

But there are real questions over whether the Government's drive to extend hours, which comes apparently in response to the CBI's demands, is really necessary.

If patients have an acute illness, any responsible employer would surely deem it appropriate for them to take time off work to recover, or if still at work to see their GP. Employers may themselves be responsible for some of the working days currently being lost. The CBI, in a previous report, complained that in 15% of cases where patients take time off sick, they are not actually ill.

Employers are concerned about staff taking time off unnecessarily, but instead of investing in an effective occupational health service, they insist on staff attending a GP for a sick note, often wasting the employee's time as well as the GP's.

Even if extended hours are offered, the fact is many workers will continue to take time off work to see their GP rather than do so in their own time. Some practices who have tried offering appointments outside usual opening times have found these appointments are not always used by workers, but by those who could attend at normal times. Many of these practices have found demand for extended opening appointments is poor.

Current funding for general practice was agreed for the delivery of a comprehensive and high-quality service between the hours of 8am and 6.30pm from Monday to Friday. Reducing the availability of appointments during these times, to enable appointments to be offered at times convenient to employers, could potentially have a significant impact on patients who need to access services during normal working hours.

So the question is, is general practice funded to deliver a service to those who are unwell, or to provide a service for employers? The first statement defines general practice in the UK, the second seems to describe an occupational health service.

Dr Nigel Watson

Chair of the GPC's commissioning and service development subcommittee and a GP in Hampshire Dr Nigel Watson Dr Neil Bentley


Director of public services at the CBI Dr Neil Bentley Bentley

Forward-looking, achievable reforms are to be cheered, not feared.

Watson

General practice has undergone regular change since its inception

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