Posted by: Margaret McCartney21 May 2013
Here’s Jeremy, in reply to a Labour MP’s question in Parliament on 16 April:
‘The reason why there is so much pressure on A&Es is the disastrous GP contract negotiated by the hon. lady’s party in government, since when - I do knot know whether she was listening to what I said earlier - an additional four million people every year are going to our A&Es. That is what is causing the huge pressure, and that is what we are determined to put right.’
Is he right?
Let’s recap. In 2004, Labour and the BMA negotiated a deal which allowed GPs to opt out of out-of-hours for £6,000 per year. There was a recruitment crisis in general practice, and GPs at the time said they opted out because of the stress, the exhaustion, and the impact on family life.2
However, many GPs were already working in GP co-operatives which had been set up in order to provide safer working environments, often with drivers to take GPs to patients unable to travel to the surgery, better equipment, and which were organised so that calls could be triaged appropriately.3 The truth is that the demand was unsustainable. The NHS Charter, originally published in 1991, had enshrined patients rights, and reflected the social market which the Conservatives wished to create within the NHS.4 Night calls were no longer about suspected heart attacks or strokes, or care of the dying, but about people who had run out of medication, or people who wanted an opinion on a longstanding rash, or reviews of children with minor viral illness. Demand on this scale did not allow doctors to function safely the following day. Instead, high intensity working required GPs to work in shifts.
So where is the evidence that this change - GPs now working in shifts - represented the cause of the rise in numbers of people presenting to GP? In 1995, the average practice held 21,204 consultations with patients; by 2006, it was 29,446. By 2008, it was 34,200.5,6 We are not doing less, we are doing more. GPs cannot be blamed for wishing to organise themselves safer to deal with governmentally unchallenged patient demand on out of hours staff.
Nor is it clear that A&E attendances are genuinely increasing. The King’s Fund has produced data showing that attendances in type 1 units - major A&Es - have fallen, but attendances in minor illness and walk in centres have increased.7 As for why A&Es are too busy and why beds remain in
corridors: an RCP report found that bed numbers in the NHS have reduced by a third over the last 25 years; on a background of an aging population, this has to be described as unsustainable.8
Some GP co-operatives have worked extremely well. Many were set up by and run by local GPs who wanted to create a sustainable service. Others have failed; for example, in Cornwall, Serco was contracted to provide out-of-hours from 2006. They were found to have been understaffed, and to
have changed performance data.9 Nor does there seem to be any joined-up policy on behalf of government. When we know that over a third of A&E attendances are related to alcohol, it is notable (if not tragic) that commitment to alcohol minimal pricing in England was missing from the Queens’ Speech.10
I used to like working in the local GP co-op. Friendly faces, a sense of camaraderie, and a feeling that I was part of a team. But who will want to create profit for a company which cares most for the bottom line and which will cut staffing to save money? Politicians must realise that doctors are working to jump through the endless contract hoops they have created, and feel dismayed by the constant political sniping and degrading of their profession every day. We, as well as our patients, need to be cared for and allowed rest, time with our families, and not to be overburdened. We cannot do more with less - we can scarcely do what we are currently asked. There is a breaking point.
It is the Department of Health that is responsible for out of hours care, and not GPs. We should not be blamed for what we aren’t responsible for. Neither are our politicians taking responsibility for reducing the disease burden to start with with fair public health law. We cannot go on pouring gallons to pint pots. Most of the time, it is the professionalism of staff which keeps the NHS afloat. Erode that with the current morale-sapping anti-GP media campaign, and we all start to sink. Tread carefully, Mr Hunt, because the flight of doctors out of partnerships, to Australia, retiring early, or retraining entirely, may be nearer than you think.
Dr Margaret McCartney is a GP in Glasgow
1 Hansard. House of Commons, oral answers to questions, health. 16 April 2013. www.publications.parliament.uk/pa/cm201213/cmhansrd/cm130416/debtext/130416-0001.htm
2 Independent. Who’d be a doctor these days? www.independent.co.uk/life-style/whod-be-a-doctor-these-days-1590381.html
3 BMJ. GP cooperatives can improve lives of doctors and care of patients. www.bmj.com/content/314/7085/975.2
4 Farrell C. The Patient’s Charter: a tool for quality improvement? Int J Health Care Qual Assur 12/4/1999 129-134
5 Information Centre. Trends in consultation rates in general practice 1995 to 2006: Analysis of the QRESEARCH database. https://catalogue.ic.nhs.uk/publications/primary-care/general-practice/tren-cons-rate-gene-prac-95-06/tren-cons-rate-gene-prac-95-06-rep.pdf
6 Information Centre. Trends in consultation rates in general practice 1995 to 2008: Analysis of the QResearch database. https://catalogue.ic.nhs.uk/publications/primary-care/general-practice/tren-cons-rate-gene-prac-95-09/tren-cons-rate-gene-prac-95-09-95-08-rep.pdf
7 The King’s Fund. Are accident and emergency attendances increasing? www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing
8 Royal College of Physicians. Hospitals on the edge? The time for action. www.rcplondon.ac.uk/sites/default/files/documents/hospitals-on-the-edge-report.pdf
9 National Audit Office. Memorandum on the provision of the out‑of‑hours GP service in Cornwall www.nao.org.uk/wp-content/uploads/2013/03/Out-of-hours-GP-services-Cornwall-Full-Report.pdf
10 Institute of Alcohol Studies. The impact of Alcohol on the NHS www.ias.org.uk/resources/factsheets/nhs.pdf
(All sites accessed on 21 May 2013)