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A faulty production line

Adjusting to the ‘new GP normal’

Dr Shaba Nabi

Following months of pleading, my kids finally persuaded me to agree to a puppy last year. I was not prepared for the deluge of bodily fluids and dog hair that followed. Post-canine arrival, I spent months pining for the house I had lost instead of adjusting to the house it had become.

In a similar way, the general practice house is also in a state of flux. It used to contain small pockets of GP partners given the autonomy to serve their local community, but it will be soon bulging with an army of shift workers ranging from paramedics to social workers.

But we can either grieve for what we’ve lost or move on to the acceptance phase, and create an option B.

Continuity of care, the cornerstone of general practice, can still be preserved if we shape new our reality. This continuity would no longer be solely with the GP, but could be with a small team of professionals, each playing to their strengths. Instead of ‘the doctor will see you now’ patients could hear ‘the red team will see you now’. If each team was responsible for no more than 10,000 patients, we could still retain the small practice feel.

Just consider some of the other advantages. No more sick notes – they could be delegated to occupational health nurses. No more prescription queries, which could be the preserve of pharmacists. No more GANFYDs – they could be dealt with by support workers. All we would need to complete this well-oiled machine is a brigade of triaging Healthcare Navigators to ensure the most endangered species, namely the GP, was protected from extinction.

Of course, we would also need to make some form of ‘crown indemnity’ part of our new reality. We could not assume responsibility for the work of others and each cog in the wheel would need to work autonomously. The words ‘doctor informed’ would be banned; a patient would either be independently managed by another professional or be booked in for a GP appointment. Our new reality could not include seeing a patient with complex comorbidities, while simultaneously fielding screen messages from three other team members.

The greatest opportunities could be achieved through career progression. Each team could have members in lead roles who meet with other leads to discuss practice strategy. Opportunities for portfolio work and special interests could be realised through a pan-team approach, and the more management minded could work in operational lead roles such as IT or education. And all this could happen within a culture of flexible working and job sharing, with protected time for handovers and team meetings.

Let’s be honest, I would prefer there to be another 10,000 GPs, just as I would rather have my old, clean and doghair-free home back. But the chances of seeing a sudden deluge of new GPs are even slimmer than those of the dog succumbing to rabies.

So I guess I’ll just have to accept the new reality.

Dr Shaba Nabi is a GP trainer in Bristol




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Readers' comments (10)

  • Shaba Ive always enjoyed your articles, and have found your thoughts well formed....but whilst you present an eloquent vision, I would have a contrary position. Simply I would ask what would attract students to work in this brave new world utopia? One is surely better off being a specialist...... what you are describing is more hospital like..... but a 'sub-hospital'.... less than a hospital.... its a murky half way house. In this vision we loose what made general practice great - the therapeutic relationship with our patients, the continuity of care..... I spent nearly an hour with a patient (Last one thank goodness) as she struggles to cope with her daughters descent into the lost world of drug abuse (They are/were a lovely family, they're worth the effort)...... perhaps she should have seen the drugs and alcohol counsellor? what she wanted was to speak to someone she knows.... she trusts, who knows her......and when she was there we sorted out her contraceptive prescription, did her asthma plan, checked out a mole on her back with a dermoscope... whilst all the time allowing her to vent her worries and fears ( I must confess I aint mother Theresa, I marked off quite a few bloods in my inbox as well whilst continuing to look sage and interested at all times). THIS is the value of general practice, not three or four separate appointments with different 'subspecialists'.... one, good value for money, practitioner able to juggle all her needs and send her home feeling that little bit happier with the world.....this is the lost and dying art of true general practice..... this is where our true value lay...... if we are not going to be true GPs, then what is the point? Adapting to this new world is fine, but in doing so we loose ourselves and our purpose and we become part of the machine. I cannot fathom how we will be able to recruit if we go down this pathway, going to 'have a special interest'?- why accept a halfway house to becoming a specialist.......without the benefit of private practice., without the crown indemnity, without the respect (or status)... its like we all become staff grades.... why the hell would any student choose this route? What are we offering them? What is the career progression? The idea of all these 'people' in the team is great... in metropolitan areas, but not for rural and remote areas. Do you really think a nurse will ever say no to a sick note? What will they do between sick notes? How many sick notes per hr will we expect? What about opportunistic healthcare, spotting the dodgy incidental whilst the patient comes in for a prescription? General practice should be what it says on the tin..... the vision you describe seems to me a step towards becoming some staff grade/ house officer job/ sub (as in less than) specialist.... we loose our differentiation, we become amorphous.... we become a sub grade hospital. There is another issue .... you are describing a lot more people in the team, what you envisage will cost a lot more money that the current system......I sincerely doubt it will be more cost effective than the 'old ways' with people going sick at the drop of a hat, paid education, paid annual leave...... secondary care has always been more expensive than primary care, in a time of budgetary restraint will these 'super-clinics' become cheaper at delivering care or require considerably more money than current models? I mean this with greatest respect, but I am concerned you are imagining a best case scenario, the realist in me feels this vision will not be realised, and that the loss of true independence will further deepen our crisis as students fail to see the attraction of being in a hospital like system, but without any of the perks. As an independent practitioner we once had control over our premises, how we do things, small and nimble we could be spontaneous.... with corporatisation or nhs-ation we loose our freedom.....students came to General practice to escape the politics of hospitals.... what you are describing sounds like we are building them.. we agree there will be no deluge of GPs.... I am afraid what you are describing will finally turn off the tap on what has already been reduced to a trickle.

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  • Cobblers

    In that reality Shaba it may pay to start up a private GP business. I suspect the better off would choose personal service and leave the hoi polloi to the common denominator NHS you are espousing.

    Lose = become unable to find
    Loose = not firmly or tightly fixed in place

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  • We simply need our hands untying. Allow us to see private patients if we wish, allow us to dispense to all if we wish. Sort out the indemnity. Not ideal at all but would make GP a lot more attractive.

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  • All co-workers unable/ unwilling to make a decision or unable to say 'no', will use 'doctor informed'. There will be the predictable sunami of this. Risk aversion and consumer rights continues on the up and up. Nightmare!

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  • Agree with watchdoc. If we were truly liberated and able to charge for non-core NHS services, just as our consultant brethren do, the innovation we GPs could come up with would astonish. Weekend opening? No problemo : just £30 per appt at time of booking please. Problem is and always has been we are neither fully inside the NHS (indemnity, employee rights, etc) nor fully out (restrictions of GMS), but instead some murky middle ground. Amazed the Tory party, supposed liberators and ardent free marketeers, have not done this at all.

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  • Mcdonalds medicine makes a good point

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  • David Banner

    A brave stab at optimism, but before we arrive at this future nirvana partnerships will collapse, many hard working GPs will be financially & mentally ruined, premises will lie empty, and patients will wonder whatever happened to "their" doctor. The GP bonfire will destroy Primary Care long before any Phoenix rises from the ashes.

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  • Vinci Ho

    All I know is I still believe what I have been believing in this war ,Shaba. Who are we? What are we? The day I stop believing is the day I will walk.....

    ''The probability that we may fall in the struggle ought not to deter us from the support of a cause we believe to be just; it shall not deter me.''
    Abraham Lincoln

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  • McDonald's medicine 11.12 agreed as GP's we are experts in undifferentiated presentations, biopsychosocial medicine and common sense and triaging our patients to other services will stop all that

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  • Oh Dear Shaba!
    NorthwestDoc has the real point - a good all-rounder is what is needed, and none of the other kinds of personnel meet the bill- possibly because they have neither the training/experience of a GP, nor the vision/ethics of one.
    You are right, you would need an army of 'sub-GP's because none of them would put in the hours/continuity/commitment to do everything that a patient needs.
    I would say, if only we had access to the resources (and necessary support resources that respected our delegation), we could do a better job : but no, they do not do as we decide is needed, instead they create unecessary GANFYD extra work!
    The (Shaba's) model is neither Gp- nor patient-friendly, and I cannot see how one GP per 10,000 patients can offer the same personal continuity.
    We just need to dump the non-medical stuff like unecesary sick notes, triplicate prescription writing by hand, multiple referrals and explanations to patients why they can't get necessary services (unless they pay). Private GP would achieve that, since they could all pay, or choose not to, at will.
    (but it would fail to provide 'community' health care to the needy).
    The electorate needs to decide if it actually wants GPs : if it lets the status quo continue, it is clear that it does not, and is happy to do without helthcare!

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