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A faulty production line

I am being driven around the U-bend

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Those of us fed on a diet of cheap Hollywood box-office hits will be familiar with the term ‘mission creep’ to refer to the gradual shift in objectives during a military campaign.

But I recently heard the related business term ‘scope creep’ and I was struck by how this more or less sums up the GP contract.

This analogy refers to uncontrolled changes or continuous growth in a project’s scope and occurs when the scope is not defined, documented or controlled. Sound familiar?

No-one really knows what is in our core contract. Without this objective defined, the piling of more work onto GPs has become a strategy to manage the financial deficit. Patients who would have previously been hospitalised for two weeks are now admitted for day-case surgery. Those who would have been followed up in outpatients for several years are now discharged after their first visit and GPs pick up the pieces.

In the last 20 years, the work of a GP has changed beyond recognition. We have become the new general medics, elderly care physicians, providers of complex wound care and house officers to hospital consultants, to name but a few. And while doing this we have also been expected to reduce elective referrals and unscheduled admissions.

Gone are the days when patients who had suffered an MI or a stroke were advised bed rest and to hope for the best. We now have an entire pharmacy to play with. And waiting for patients to become ill and come to us is no longer good enough. We are forced to pro-actively find more cases of dementia, diabetes and hypertension and then to drag them kicking and screaming into the surgery for treatment.

So why have we sat back and allowed this to happen? The main reason is because we are too nice.

We prescribe for the UTI because the consultant didn’t have an FP10 pad in their community clinic. We request pre-operative investigations because we want to save the patient another trip to the hospital. We take on the prescribing and monitoring of the growing number of shared-care drugs because we are asked to, and we do not question performing the tasks of other health professionals who claim a lack of capacity as their reason for not doing them. In short, we are the world’s largest toilet that allows any number of dumps on our doorstep.

If we were train drivers or teachers, we would have the backing of a strong union who would be fighting against this insidious drip-feed. Instead, we have the BMA, which seems to have forgotten about inflation when benchmarking for private fees. Imagine being able to notarise documents through a solicitor for only £15 instead of the £75 my husband recently paid.

The reality is that no-one has got our back. Workload is mushrooming and income is dwindling. The only way to survive is to set boundaries ourselves and say ‘no’ to anything we are not contractually obliged to do.

Dr Shaba Nabi is a GP trainer in Bristol. 

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Readers' comments (15)

  • and we do! recent things I have said no to...
    1) pre op check for private hopsital ...absolutley not. they did it themselves
    2) do 2 urine samples for urology follow
    3) prescribe noacs for a do it yourself
    4) check lfts for patient started on
    5) repeat cxr post bronchoscopy....hell no. what the hell is wrong with you!
    6) chase numerous results post discharge...not a chance. even got an apology from the consultant and a promise he / she would do it themselves.
    Fight back or die. You get nothing for being nice...nothing except more expectations that you will carry on being a door mat for your patients and hospital colleagues (if you can still call them that).
    The list goes on but

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  • as above we need to stop doing all this stuff which is clearly the responsibility of another doctor/organization.

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  • Shaba,
    as usual you've hit the nail on the head. This tidal wave of abuse of GPs by secondary care especially, is making it harder and harder to justify our existence as a profession. We have now become the metaphorically bag men of the health service, picking up the slack here, step and fetching there. There is no point relying on the BMA or RCGP to give protection, what is needed is a new collective of activist GPs who can represent this profession before all is lost and all that remains is the android GP that NHS England are so desperate to create - working 24/7/365 for nothing.

    Disillusioned GP Partner (1.5yrs)

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  • Lol Shaba. Hats off to you. As usual your aim did not miss the nail`s head. ` Mission creep` soon as I read that anal-ogy, I felt my sphincter defensively contract, to prevent more stuff being added into that proverbial global sum that has photophobia. Yes, we are indeed to nice. Nice being the term for spineless, gutless and clueless. The sooner we stanfd and fight or the house of cards that GPLand is falls, the better. Those who have other skills should lok at using that to get out .Thanks again Shaba for not mincing words. I love reading your posts. may there be many more who wil say that they can see the Emperor`s wrinkly scrotum, rather thanh those that what us to feel the texture of the finest silks that adorn him.

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  • Happy to take the cash from secondary care but not the workload. Hmm, buying in to popular conceptions of GPs again.

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  • What cash from secondary care?

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  • Whatever is mentioned in the letter is just minimum but do we have any option to address such problems?
    1. Every other day the Government does something to raise patients expectations without making resources available to doctors.
    2. Most managers do not use discretion they have, in the interest of the service. Good managers usually leave the NHS to have a better career elsewhere.
    3. BMA is very ineffective, I wonder if doctors should continue to be members, I have left the membership already.
    4. CCGs are asking GPs to prescribe less and reduce the number of referrals to the secondary care, a good NHS ploy to save.
    5. Secondary care doctors prescribe expensive medicines and GPs are required to go for cheaper versions, creating conflict between primary and secondary care managements.
    6. GPs are wasting a lot of time allowing dozens of Pharmacies to collect prescriptions from surgeries thus creating an extra burden and confusion. Although this activity is not a part of contractual obligation but it is still widely followed. I wonder if GPs have preferred one or two Pharmacies
    7. However, I support the CQC but unfortunately there are no funds available to GPs to improve their respective practices in par with CQC outcomes.
    The list can go on and on.

    I must propose at least few changes to be constructive:
    1. Let patients who do not keep their appointments to pay for wasted time.
    2. Let patients pay 50 pence per item of prescription as one tariff for all to remove this anomaly, it will also prevent a lot of wastage.
    3. Ever expanding 'Underclass' in the UK must be addressed, as their existence is based mainly on social services and the NHS.

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  • Saying 'no' is the only way forward. And I think particularly on towns where there is a shortage of GPs we should all be saying 'no' to the same things together. So the thing that currently wastes a lot of our time is 'sick notes' - this workload has increased exponentially since ATOS got involved (I know they are to be replaced). So we have decided to get our patients on long term sick to complete a proforma rather than clogging up our appointments- our practice manager rang up the local practices to see if something like this already existed as we knew another surgery would only deal with repeat sick notes in writing- it seems now this proforma and sick note policy will be uniform throughout our town and our pratices are working together to have the same policy to deal with our exponential work load in a uniform manner. No longer are we a popularity contest to compete for increased list size- we are standing shoulder to shoulder to deliver efficient healthcare to those in need.

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  • You can't say a blanket no to anything that secondary care asks you to.That would be ridiculous.If a consultant is asking you to do a blood test as part of patient's monitoring you'll be on on treacherous medico-legal territory if you refused.However i totally agree with the point of general practice being the NHS's dumping ground.It's too late for us who are already in it but young doctors should stay well clear of general practice.Nothing will change until there is a real biting shortage of GPs at the coal face.

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  • Kevin Hinkley

    Thanks for the sharp, penetrating analysis Shaba, much appreciated.

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