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A faulty production line

It's time to tackle patients' addiction to GPs

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One of the first concepts I learned during my GP training year was that ‘the doctor is the drug’. Indeed, there was a certain sense of familiarity about this mantra as it evoked childhood memories of being visited by our GP (on reflection, a completely pointless home visit) and feeling instantly better as soon as he entered the room.

We are hugely therapeutic to our patients, with or without our prescription pads. The effect of placebo treatment is well established, but we tend to underestimate this in terms of our behaviour during a consultation.

The child who enters my room, opens all my drawers and tries to break my weighing scales is still given a top-to-toe examination. Maybe I do this for fear of a lawyer’s letter, but it is also partly to fulfil the expectations of my patients and their carers.

With any treatment, one needs to consider the indication, the dose and the inevitable risks and side-effects. The doctor-patient relationship is no different.

Demand for this ‘doctor-drug’ has mushroomed in recent years. Patients are receiving very high doses of it with little thought about its indication. And each dose of temporary relief for the patient simply reinforces their belief that they need to return for more. So now it is crucial to prescribe the scarcest drug – ourselves – appropriately and responsibly.

This has been under the spotlight recently in Devon, where a GP practice was forced to withdraw a leaflet advising patients on other places to access before contacting them. Managers made some flimsy arguments about the risks of missing pathology, but, in reality, the crux of it was that these GPs were no longer prescribing themselves prn.

But a change of mindset is needed if we are to tackle this unfettered demand on our time. In a world of telephone triage, multi-professional working and targets, we can no longer afford the luxury of the co-dependent doctor-patient relationships of the past.

The indications for this type of therapeutic relationship are obvious in palliative care and less so for acute, simple physical ailments – but there is a whole spectrum of illness behaviour in between.

One justification for having firm boundaries about how much of myself I give is the knowledge that I must have something left in the tank for those with greatest need. Of course, this is a value judgment, but it is a relatively easy call given my role and what I have been trained to do.

Successive governments have acted as pushers for the doctor-drug. Yet if we do not ration it, we will encourage an overdependent patient population that lacks self-care skills and knowledge of self-limiting ailments.

We all need to help wean patients off this drug. After all, if it’s a choice between indulging the parent of a perfectly healthy toddler and visiting a palliative care patient, I know how I would rather spend my time.

• Thanks to Dr Dominic Maginness for his help with this column

Dr Shaba Nabi is a GP trainer in Bristol

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Readers' comments (24)

  • Or alternatively you could give up gatekeeping and boundaries. Then no patients would be forced to attend.

    Patients could access the care they need themselves without visiting the costly middleman who apparently feels so put upon.

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  • "Patients could access the care they need themselves without visiting the CHEAP middleman who apparently feels so put upon."

    I've corrected that for you.

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  • Ivan Benett

    It's a pity I like Shaba so much or we could have a field day here. The doctor drug is a concept rather than there being any objective evidence that it is effective. Certainly no scientific trials against placebo, with outcomes. However, let us assume the doctor (more than nurse, priest, carer or loved one) has a therapeutic effect on it's own. It's effect is variable, inconsistent and we don't know which is better - generic or branded. But that's about where the analogy ends.
    Putting obstacles in the way of accessing a GP (people prefer their our own) means they go to A&E instead, delay presenting with serious symptoms and generally have lower satisfaction with the service.
    What we need is better access and continuity. This means more GPs and better training and funding, and availabuility when people can come.
    Not rationing. Unless we want to move away from a Health Service free at the point of do we assess need if we don't have access to a GP (or similar)?
    The worry is that people in real need get put off - you know, the quiet, unassertive ones, or those who don't speak English too well or for other reasons can't stand up for themselves. These are the ones that miss out when you put obstacles (what Shabe calls 'rationing'.

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  • I agree with Shaba but disagree with Ivan. Until recently I worked in a practice with very open patient access (including Wednesday afternoons Ivan!). The practice had brilliant patient reviews. But it was all at a cost of a demand that always eventually outstripped availability. It had no effect on our patient AE attendance. I became a burnt out Twinge-ologist. I have recently moved to a practice that has much more controlled and defined access and with identical AE attendance to my previous practice. I now treat far more illness than perceived illness.

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  • It's going private ..Shaba look at United Health books backdooors , Rumours are around that 120 billion ..the government will pay 25 billion to in total to have a private access( like state health insurance ie , 500 pounds per person ..obviously weighted for age area etctc )we state workers will be asked year on year to save from initial budget to 0 that is 90 billion year one and 80 billon year 2 etc -- to do the same amount of work ..and if you can't guess what -- yep you got it
    Private companies will pick up the slack ,pts will have to pay ( top up insurance payments ) and the blame will come to Gps first Dr will just migrate to private hospitals aka USA
    The system will be flooded with 2 year course studied PA ,nurses and overworked 10year studied disillusioned Dr all having to work on a low low salary ...after all supply and demand , eventually all pts will pay private

    See how 120 billion becomes 25 billion saved .isnt that what everyone wants ..naturally hiding behind loads of convoluted wordings

    Why should anyone be a gp , when you can study 2 years and get paid the same As people with probably less responsibility
    Study be a specialist or better still don't so Medicine --

    If you think the above is inaccurate think again ...its what's going to happen in ones opinion

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  • I disagree with Ivan. Wake up and smell the coffee. Well done Shaba. You have mine, and I can safely say, the vast majority of GP's in this countries backing. Keep it up.

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  • @3.22pm

    I had some difficulty with your use of language, but completely agree with your sentiment.

    7 years post banking bale out and debt still spiralling up with no prospect of any return to UK plc profit
    60% further austerity cuts to come
    GPs will be put in charge of most benefits (see plan for London) and blamed for the demise of the NHS and the whole welfare state.

    I will get out of GP very soon.

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  • @11:37AM. From official NHS figures (including infrastructure costs):

    Cost of GP appt: £36

    Cost of hospital appt: £108

    So if less than 75% GP appointments result in a hospital appointment then GPs are cheaper option.

    In fact the figure is under 10%. So no, not expensive.

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  • Ivan, are you genuinely unaware how offensive your tone is??
    You accuse Martin Brunet of being headline seeking (unjustified in my humble opinion) and then offer to ridicule Shaba but graciously forbear because you like her!
    I think her article is a reasoned and well thought out suggestion to address the infinitely spiralling demand to get every trivial illness "checked out"!
    Your response appears to be that rather than ration care (as has been the case since the foundation of the NHS) we should throw open the doors 24/7 so that people don't "need" to go to A&E!
    And yet we all offer more appointments, more access, longer opening hours and A&E attendances have never been higher!
    Your suggestion is analogous to suggesting that if we make the M25 ten lanes in each direction we will never have traffic jams again!

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  • Richard Mitchell life some people you will walk down a dark alley with some you do not
    However as Someone who is very powerful in this world allegedly said of a certain person , that if someone is going to urinate on you then it is better they do it inside your house then from outside onto your house -- as this way you can always direct to the lavatory
    The above is an opinion heard in a bar any relation to anyone fictional or non fictional is purely coincidental

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