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GPs buried under trusts' workload dump

The Department of Health is responsible for out-of-hours care, not GPs

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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

References

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)

Readers' comments (31)

  • Well done Margaret.The best summary I have read of the nature and causes of the current crisis.Unfortunately your article is unlikely to get anything like the coverage that Jeremy Hunt gets with his inacurate statements on G.P.'s

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  • Mark Struthers

    Dr McCartney said,

    "I do blame the QOF"

    I blame the QOF too. I blame the QOF for creating divisions among physicians and for dividing doctors. I blame the QOF for destroying the professionalism of GPs. I blame the QOF for making donkeys out of doctors. I blame the QOF for the destruction of General Practice.

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  • If you've got an MP print this off and send it to them with a covering letter asking them to forward it to Jeremy Hunt.......

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  • Thanks Margaret McCartney for your effort. Good article. I know that nothing will change our politician's plan to GP Bashing. Unfortunately, public media like BBC is preaching the hatred against GPs without considering the complex issues of consumerism versus patients' need (limited resource).

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  • Extremely well written and to the point Margaret, well done.

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  • Chris Kenyon

    An excellent measured, well researched and well argued article Margaret. I share the other commentators' fears that it won't reach the mainstream media. As for Mr/Ms Anonymous, s/he is the victim of QOF & perhaps a blunt administrative system. S/he needs to understand that the overwhelming majority of GP's really are interested in high quality personalised care but that the policies which have been implemented and the demand that has been created have made that very hard to deliver.

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  • very good and true article-it is high time Govt. opens their eyes-also GP's need to be strong and united.

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  • Do GP's not have an input into QOF? Surely the only people qualified to set the QOF are doctors or patients? Who else knows more about what patients need or want?

    Now correct me if im wrong but during the negotiations in 2004, it just seems the BMA just got so excited about how much extra money could potentially be made by general practice that they lost sight of the patients best interest.

    Then the BMA had the government in its pocket. They negotiated an end to responsibility for ooh without any suferring any pain and created QOF as a way of channelling billions of pounds more into GP. Did the taxpayer get value for money? Now we're at a point where an average GP in England is paid more than any other GP in Europe and nearly double that in France.

    If all the problems in our NHS are down to money, perhaps its because too much is spent just in salaries?

    Doctors need to start defending patients interests- lord knows they cant do it themselves. When you had the chance in 2004 all you did was steal from the cookie jar.

    You cant keep blaming politicians when you know full well they're not capable of deciding whats best for patients.... Stop conning us.

    All thats ever really upset you lately is being forced to contribute more to your pensions when it should have been how much money has been wasted through ineffective QOF all these years.

    But if you follow the money, you'll see that its very much in a GP partners interest to keep the status quo. Good for doctors, bad for patients. We trusted you, when did you become so treasonous?

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  • mr anonymous 3;47
    unfortunately the QOF needs to be carried for income which helps to pay for the staff and running of the Practice. this is DOP created and not the GPs. He/ she may not benefit from this exercise but there are some patients benefit from this and helps them to live longer which puts burdon on NHS.

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  • When I started in the NHS, I did 80 hour weekends in 1:2 rotas, 168 hour weeks in hospital and in General Practice. Now. I do 10 to 13 hour days excluding meetings and medical reading. Why are they picking on and bashing us ? We are not lazy. Our take home pay per consultation is about £ 3.00. We are not over paid.
    But, since the papers, the Govt and ? the public think so, let us all leave and resign from the NHS.
    Let us be like the other professionals and charge them at the door - whatever our market value might be. End of story.

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