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GPs go forth

Get me some adrenaline, I feel a petition coming on...


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For reasons I won’t bore you with, I’m allergic to petitions. So, to avoid anaphylaxis, adrenaline etc, I usually avoid them. Still, a petition for safe working hours in general practice? Surely a no-brainer?

Sure. Except some might say that a petition about controlling GP workload generated by an NHS GP who also runs a private home visiting service employing other NHS GPs has a certain irony – and that ‘some’ might include tabloid editors who aren’t that familiar with the nuances of the GP contract or how general practice works.

Plus, the petition’s demand for 15-minute appointments will, yawn, invite the predictable NHS England response that GPs can set whatever appointment lengths we damn well like, requiring us to have to respond, double yawn, that yeah, but we can only extend appointment times when workload is cut enough to give us the slack to do so.

And as for a General Practice Working Time Directive to introduce a maximum working week per month: fine in principle, but, in practice, come on, we’re not just going to down tools when the clock ticks past six, are we?

We should get the acute stuff siphoned off elsewhere, leaving us time to deal with the patients who really need it

We need ideas to match the resolve, but appointment and time caps are too fraught with problems to do the job. So how about a different approach? Such as: define and limit our responsibilities alongside the type of work rather than the hours endured or the number of appointments seen.

Sound complicated? It doesn’t need to be. Simply let patients self-define ‘urgent’ as something that has to be seen on the day – because of discomfort, distress or genuine disease. Then divert them to a local urgent care centre which would use the infrastructure and funds already available thanks to the existing various efforts which faff around the edges of our problems rather than solve them. Whereas the subacute/chronic are retained within standard general practice where continuity and wisdom count.

Result? General practice is no longer doing two jobs at the same time: the acute stuff gets siphoned off elsewhere, leaving us with the time to deal with the patients who really need it.

Yes, there are problems. Your acute care ANPs might need retraining as chronic care nurses. And general practice might become even less attractive as it turns into a multimorbidity dump – so we’d just emphasise the portfolio angle to those who’d like to maintain their acute skills with stints at the local urgent care centre.

And I probably don’t need to emphasise, except perhaps to the politicians, that the splitting off of acute care shouldn’t come with a commensurate cut in money. Remember, chaps, the idea is to fund the two roles properly rather than cram both into a single under-resourced one.

It almost makes me want to start a petition. Not easy when your tongue’s swelling.

Dr Tony Copperfield is a GP in Essex




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Readers' comments (8)

  • Rearranging the deck chairs on the Titanic, Tony. Opening up access only results in increased demand. What do you think is going to happen when either acute or primary resource is overwhelmed? Fund both roles properly? So spend MORE on healthcare? Increased taxation? We trust no politicians, but we seemingly trust them to spend MORE of our money? No, fundamental change is needed. Direct and full responsibility from the user, and for the state to only provide minimal/emergency medical care, is what works best for the vast majority.

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  • Christopher- I actually came in to medicine on the back of the principles of Nye Bevan.
    I suspect there are many things that can be done to reduce unnecessary demand- and I agree with you that it is the politicians that often unnecessarily stoke that particular type of demand.But where I fundamentally do not agree with you is devolving full financial responsibility to the individual. It does not work best for the vast majority as you so innacurately put it- some of us will develop illnesses we have no control over , and in the end we all become old.
    We do not spend a vast amount of our GDP on our health system as you suggest so considering spending more is not an unreasonable place to start. It is way more efficient than privately based medical systems.

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  • Angus - Oh I would happily agree that the principles of Nye Bevan were most likely noble. But the NHS of 60 years ago and the NHS now are not the same thing. You've again failed to acknowledge points that I've brought up elsewhere. Globally, having the individual take more financial responsibility over one's health is more common and works fine. It also results in a smaller state and state expenditure and as a result a larger private sector (the drivers of the economy). Well yes, life can certainly be harsh. But that is still no excuse to remove the incentive to strive for all individuals, or to compel others (through taxation/force) to help. I would happily persuade anyone to be altruistic. Also, what makes you think we don't spend a good chunk of our GDP on healthcare AND welfare? My point is that anything more than the bare minimum harms us all. 'efficient'? How is encouraging the population to be reliant and dependent on the state 'efficient'?

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  • Christopher- a few points.
    Our GDP or health is less than equivalent European countries and about 7% less than the USA (where interestingly the management costs of the 'efficient' private sector are greater than the NHS- who'd have thought?).
    The commonest cause of bankruptcy in the USA is medical illness.
    it is ironic you can get acute care there for your diabetic ketoacidosis and then die because you can't afford the illness. in the states medical treatments are often dictated not by the clinician following good practice but by the insurer following cheap practice.
    The cost of the welfare State is far less than the total amount of uncollected taxes from unscrupulous individuals and the 'efficient' private sector (in this sense I would have to agree they ARE efficient).
    A country with unchecked capitalism without a system or 'state' to protect all its citizens especially those who are poor or lack capacity might also be termed a 'fascist' state.

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  • Angus - in reply - I never said we were the WORST example of such socialist policies. Or that I want to be where other European countries or even the USA are. Of course, there are other factors about different countries that would determine the level of government spending on healthcare provision. How's Europe in general doing by the way? Not great lol There's clearly a difference here that you've chosen to ignore too. So what if the management costs in the private sector are more than the NHS (which I would be looking into by the way), if it is driven by free market forces then it is accurate, and the cost is borne by the private company providing the service, not the general public through force of law. yes life can be harsh in terms of healthcare responsibility. Doesn't mean that the individual shouldn't bear it as much as possible. More so when if the responsibility is transferred to the state it harms everyone else. Again, I would debate your facts, but would be happy to concede that our tax system is anything but efficient or 'fair'. You clearly don't know the meaning of the word 'fascism'. I'm advocating free market and personal responsibility, the exact OPPOSITE of fascism. You're arguing for INCREASED state authoritarianism in terms of taxation and spending, and that is MORE 'fascistic' in nature. Protect all of its citizens you say, well the best system for wealth creation and distribution that we know of is free market capitalism. Like I mentioned elsewhere, you really need to know your history. And by the way, how much do you trust our politicians? Enough to give them more of your money to spend 'responsibly'?

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  • Your overwhelming evidence has convinced me. I think we should step back and let the free market ie Capita, G4S, Serco and Virgin etc lead the way.
    Oh, wait.....

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  • And more state “ regulation”- turning us into cheap replaceable commodities- the more pathways and protocols they enforce- the harder it is to practice autonomously and individualise our patient care ....
    all our innovative excellent schemes (A&E avoidance, paediatric care, mental health ) -all disallowed A’s other practices couldn’t offer the same- essentially we have a dumbing down to the lowest common denominator!

    The demand is enormous and never ending......expectations are unbelievably high about what people are entitled to and demand.....we have a skeleton service ( colleagues off sick long term- ) currently going 14 hour solid days- no break. The limitations have to come from us- so we bear the brunt of complaints.... despite trying desperately to be all things to all people- A&E, shortfall from hospital, mental health, sexual health- don’t worry- we cover it.....
    The secondary care services are watered down cheapest delivery options from lowest qualified staff- as cannot meet the numbers.....
    The system needs to learn to say NO- it can not provide everything- and we already pay for it so Dr Ho is right - I’d rather spend the money than the government- )IT billions- for a shit service?! ). Angus the ideas seem sadly idealistic and naeve ..... throwing money at it won’t improve it?! It’s broken.....
    we carry on due to our sense of duty and care.....which is why we all work over and above......
    But. The new work force coming through won’t stay till 10pm- don’t want to be partners and are used to a different way of working with the new contract!
    It is stupid that prescriptions ALL prescriptions are free for people with thyroid disease and diabetes....

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  • Angus - 'competing' for state funds is not free market. There are totally different variables. Competing for funding directly from the consumer is true competition. The fact that you don't know the difference says a lot. And again, no acknowledgement of any of the points I brought up. Just sarcasm, which if unaccompanied by a salient point, is rarely humorous.

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