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At the heart of general practice since 1960

Patient demand is driving GPs into the ground

‘Cyberchondriacs’ and other ‘worried well’ patients must learn to use the GP properly, writes Dr Fiona Cornish

We read headlines of about reaching the ‘crisis point’ in general practice every day, with GPs on their knees and burning out through impossible workload. The components of the crisis are now well known: increasing patient demand, inadequate funding to provide all the interventions and drugs available, and an aging population.  As GPs we can’t magically increase the economic wellbeing of the country, and therefore NHS funding - and we are partly to blame for keeping patients alive for so long. But can we exert any influence over patient demand?

Ironically, Aneurin Bevan predicted at the start of the NHS that the demand for healthcare would decrease as people became healthier. In fact, the opposite is true. As GPs, we generally like to keep patients happy and to be liked, but there is a limit to our goodwill.

Patient consultations in England rose by 75% between 1995 and 2008, according to the RCGP. This is against a backdrop of growth in GP full time equivalents of 18% since 2000, compared with a 61% growth in hospital consultants. Workload has now become a political issue, and it is no longer acceptable for us to be told to work in ever ‘smarter’ ways.

Information for patients was thought to be a panacea: give them access to information, and they won’t need to see the doctor. How wrong that assumption is. As we know to our cost, information is seldom valuable without the doctor’s advice or interpretation. Patients come flocking in, proudly bearing a printout from a health website - particularly that highly educated, well-informed, health-aware breed who attend my surgery in Cambridge. These are the famous ‘worried well’. They are just checking that they are taking the right kind of vitamins, or that the capsules I have prescribed are suitable for vegetarians.

We have spawned a new entity: the ‘cyberchondriac’. We live in an instant society, with information available at a click, and the corollary is that we expect equally immediate answers, responses, and appointments to see the doctor. This is where the doctors and the rest of world diverge. Every patient questionnaire or political focus group comes back with the response that surgeries should be available for evenings, weekends, early mornings, and that patients would all like to have longer appointments and more time with the GP. But we know this is not the solution - like opening a new motorway lane, it will fill immediately, and demand will only increase again.

We don’t expect banks to be open all night just in case we need to pick up our Euros to go on holiday. We can get cash out of the wall in an emergency, mirroring the out-of-hours service for emergencies, but we know that paying in a cheque, like a sore throat can wait until the following day. NHS Direct has, paradoxically, increased demand - the advice for many calls, after hours or minutes of algorithms, is to ‘see your GP as soon as possible’.  

Most patients are decent people trying to get on with their lives, and are not remotely interested in my explanations of why I am not allowed to make certain referrals, or why the alternative to warfarin, which their consultant has advised, is on my blacklist and so I can’t prescribe it. The argument about payment as a deterrent is a thorny one, and provokes outbursts of disapproval and muttering about the Holy Grail of the NHS. But this is something to consider seriously - and carefully, given that it is such a hot potato. My instinct is that there should be a straightforward mechanism for payment and then some would be eligible for part or full reimbursement. This system is used in France, so why not here? Recent discussions at the BMA’s Annual Representatives’ Meeting in Edinburgh have begun to address this seriously.

For now, helping patients to understand how general practice is funded is the best method for tackling the problem of demand. You could start by hanging notices in your waiting room explaining that the consultation is 10 minutes long, how much it costs, how many missed appointments there are per month, what the allocation of funding is per patient per year. And what if all prescriptions and investigations showed what the cost is per item?

The patient should be advised to ‘help the doctor to help you’, and encouraged to use self help remedies before they come to see the doctor. They should be reminded not to come in to the surgery too soon - or to cancel appointments if symptoms vanish.

Even common sense advice bears repeating: be clear about what you want the doctor to help you with, don’t wear tight sleeves to a blood pressure check.

Although GPs seem to be the scapegoat for all the ills of the NHS, patients still value our time. They just need to realise that we are a valuable resource, not to be abused or exploited.

Dr Fiona Cornish is a GP in Cambridge and president of the Medical Women’s Federation

Readers' comments (60)

  • People get mixed messages. One minute doctors are slamming the 'worried well'. The next there is a national campaign to visit a GP if a mole starts itching slightly more than usual. Most people do not have God knows how many years medical training so are very unlikely to be able to reassure themselves that a symptom is of no importance and so seek it from their GP.

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  • Roll on the introduction of electronic health cards, which, apart from confirming NHS entitlement, would painlessly deduct £5 from each patient whenever they had a consultation and eventually reduce demand for appointments. This payment would go direct to the Government rather than into GPs' pockets and would be ringfenced for healthcare use.

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  • Making plain the 'burden' that each appointment and prescription represents is a double-edged sword. I don't believe it would achieve your goal of making it easier for genuinely needy patients to access their GPs.

    As GPs know best of all, the chronic conditions which take up so much of a GP's time and require so many prescriptions don't exist in a vacuum - they need a host body, a whole person, who lives with them daily.

    Add in the complications of polypharmacy and a good pharmacist will limit these patients' ability to self-treat - "yes, we sell fluconazole and decongestants over the counter, but in your case we'd like you to see your GP and get a prescription."

    Although you don't use it yourself, the use of the word 'burden' with reference to (people with) chronic health problems has become the norm. Inevitably it has an impact on the self-image and mental health of those who need to use the GP's time most frequently, and require most prescriptions.

    So - the problem with these suggestions - making plain that appointments are 10 minutes, being more open about their cost, putting the price of pharmacy items on prescriptions - is that chronically unwell people frequently need longer than 10 minutes, take up lots of appointments (sometimes for 'trivial' things) and are on numerous or expensive drugs over which they have little control.

    I suspect providing these details would have little impact on the worried well who don't think to try simple self-treatment, and significant impact on the truly sick - who can easily 'self-manage' themselves into acute admissions by skimping on their 'expensive' medicines or moving on to the next pharmacy and being less honest about their health and current prescriptions.

    Of course I don't have a solution, but I do believe that encouraging patients to add up what the NHS spends on keeping them alive each month through GP appointments and prescription items is likely to act as permission for people who consider themselves 'cheap' to consult over vitamins and a barrier for those who need the NHS the most to bring 'another' issue to their GP.

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  • Interesting that Dr Cornish only considers demand-side factors here. What about some consideration of supply-side factors?

    Dr Cornish could take a pay cut and work for half her current pay and employ a second GP at the same rate. This salary cut would align Dr Cornish with her peers on the European continent.

    Between the two doctors they could cater to the needs of what Dr Cornish calls the "genuinely needy" as well as those pesky "well-educated" patients who want to discuss their health with a professional.

    Health services should be designed to cater to the needs of all patients. Suppliers of healthcare should consider the role they play in using up limited resources.

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  • Dear Anonymous at 10.35,

    You are right about "supply side" issues but I disagree on nature of same. Either we have more Gp`s-actually lots more -OR GP`s be paid per consultation via HRG tariff. A private GP charges £90 per consultation. Then we will know if its fair. I suspect Dr. Cornish would earn at least twice of per present income. Of course the government would go broke! So they may charge a small amount per consultation to reduce demand.

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  • Our contract says we see patients 'who are ill or believe themselves to be ill' . Doesn't cover those perfectly well but totally neurotic middle classes wanting to discuss vitamins / Botox etc.

    It will unfortunately be probably after some absolutely tragic GP suicide that the government / media suddenly wake up to the abuse of us GPs which is happening, in terms of flogging us to death with work .

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  • Dear anonymous at 10:59

    The point is, Dr Cornish wants to appropriate the European system of charging for the demand side but ignores the European approach to the supply side.

    I paid Euros 26 for a GP appointment on the continent. A native of that country would have had 70% of that cost subsidised by insurance and would pay 30% out of pocket (unless unemployed/debilitated). The country where I had the appointment has double the number of GPs but they get paid less. The cost for a specialist appointment is 40 Euros.

    Why not adopt the European approach to the supply side? More doctors at lower pay leads to a better patient-centred service for patients.

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  • Dear Above
    26€ good!
    30 appointment this morning
    Think I'll work mornings only, 4 days a week and take 6 weeks off a year.
    143520€
    Bring it on!

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  • Unfortunately, this calcuation is overly simplistic and neither here nor in Europe would the whole of the consultation fee go to the GPs personal income.

    This amount would have to fund premises, staff, IT, investigations, and GP salaries

    Also, if patients are actually paying £26, they will be unlikely to accept a 10 minute consultation as easily.

    The bottom line is that in Europe, rightly or wrongly, the GP income is less than here, using this system.

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  • I agree with dear Anonymous @ 10:59.

    A fairer idea however, might be for all GPs to retire at 50 and draw their more than adequate pensions to live off.

    They could then return to work to use the benefit of their experience to see all the patients who cannot get convenient appointments in a reasonably short time.

    They would do this for no extra pay as they can live off the perfectly reasonable pension that they earned from those very patients. It is about time they put something back.

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