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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

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Readers' comments (60)

  • I wonder if those suggesting that GPs accept a cut of half their salary or going back to work after retirement for nothing would do this themselves in their job?

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  • @JeremyCox

    The author drew comparisons with the system in Europe (but concentrated solely on the demand side - charging patients for appointments) and appeared to overlook the European approach to supply side issues.

    European nations train more doctors but pay them less. These doctors often do their own on-call and their own admin. European patients can choose from a wide range of providers and services.

    Meanwhile Pulse has articles detailing how UK doctors can increase their pay, maximise their incomes, keep their 4-day a week work schedules, while reducing, limiting and rationing services for patients.

    In the interests of patient welfare, it is therefore beneficial when discussing the problem of limited resources in the NHS, to draw a comparison with both the demand side and the supply side of healthcare in Europe.

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  • @Shaba Nabi

    Thanks for your comment.

    Re your first point, we don't have any plans to stop doctors posting anonymously - we believe it's important to allow proper debate that doctors are allowed to leave a comment without leaving their name if they wish. On stories concerning GMC guidance, for instance, it's very apparent that some important discussions about the merits of that guidance simply wouldn't happen if GPs were forced to identify themselves.

    On your second point, however, we are on the case - Pulse is very much intended to be a site for GPs and other healthcare professionals. Our previous website allowed us to restrict comments to just those groups - unfortunately that's not possible at the moment with our current site but our technical team are working on it.

    Many thanks

    Steve Nowottny
    Editor, Pulse

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  • Are you lot actually GPs? If not you are on the wrong page. This is a GP site, so go away!!
    GPs in this country take a lot more responsibility and cover a lot more conditions than primary care Drs in France. We are not simply gatekeepers and sign posters; we do a complex job where we hold a great deal of risk.
    If you lose us, you will indeed get a European style GP, and you will deserve everything you get......

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  • Drachula

    Congratulations, Fiona, on generating such an entertaining debate. So, who's off to Australia? Ad who will be left behind to do the job? Will anyone miss us?

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  • Alot of the Daily Wailers are led here by Google News where its not uncommon to come across Pulse articles.Its partly driven by the fact that several of the main online media outlets are setting up paywalls forcing Google to look elsewhere

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  • Dear Steve

    I am glad you are working on the technical aspects of the website in order to make it a doctor's forum and not something I would read in the comments section of the Wail.

    I still feel that anonymous comments;

    1. Lose credibility as the person is not willing to put their money where their mouth is
    2. Lead to a shedding of the normal etiquette and respect within normal human interaction. When we speak to someone face to face, it is very hard to be rude or disrespectful. Some of those barriers break down when you are on the phone, break down even more when you are on line, and if you post anonymously there is little to stop you losing all conventional social niceties.

    I am not in favour of censorship - I am in favour of people standing up for what they believe in and being accountable for it.

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  • This comment has been deleted by the moderator

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  • I really do not know how many times all of the above has to be said before anyone actually does anything about it. Unfortunately we do not yet live in a utopia where we do not rely upon money. We still live in a world governed by money ie. money is still what makes the world go around and until we find a better way to function as a society, the only way to make patients truly appreciate the value of the care they are receiving is to charge them money in addition to the minute amount of their taxes that is paid into the NHS. Then and only then can we all move forward. The general public have been spoiled rotten for 65 years and it is now time for them to "un-spoil" themselves and wake up to the reality that if they want the cake with the icing and the cherry and top and then to eat it , then they must be prepared to pay the money for it.

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  • Has any research been done to look at the impact of QOF on demand? By which I mean the impact of constantly calling patients in for reviews impact on appointments/staff time chasing reluctant patients? There is an article on GP magazine about some research which states that QOF reviews have little imapct on patients. It says patients see the reviews as irrelevant to their needs

    I think patients should have the option to opt out of QOF. If GP's can opt out why are patients being denied the same right? The slogan could be "Do you want to be treated by a politian or a doctor". Please choose a tick box and sign here!

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