But it is shocking how much of this is falling on GPs, who often have to work beyond their competence to monitor patients with eating disorders, perform weekly ECGs, initiate antidepressants in children and so on.
There was a reason we chose to focus on mental health. It is where the lack of access is most obvious and the pandemic has increased the numbers in need of support. Most of all, though, it’s because GPs’ own mental health is suffering.
It should be the case that a GP does not feel the weight of responsibility for a patient once they judge specialist care is necessary. But unfortunately, that’s not the world we live in. What makes GPs great is that they will do all they can to help vulnerable patients shut out by secondary care. But when this proves beyond them, the GPs suffer ‘moral injury’ – a phrase that arose all too frequently in our feature, referring to the damage to someone who is unable to prevent acts that transgress their values. In other words, when GPs feel helpless to support patients with mental health problems, it exacerbates their own.
Sadly, this doesn’t just apply to patients with mental health problems. The cover feature could have been written about any number of specialties, and the same issues around moral injury can occur for GPs whose patients are unable to access pain clinics, for example.
To highlight the problems of secondary care access, it is now official policy in England for GPs to take on responsibility for many patients who would normally be seen by specialists. The increasing use of advice and guidance (A&G) seems to have bypassed much of the media and the public, but it represents a fundamental – and worrying – change. The uncertainty around who holds liability if anything goes wrong underlines what a shift this is – and the potential threat to patient safety.
I understand why NHS England wants to promote A&G, as secondary care is under unprecedented stress. But general practice is also under unprecedented stress.
I’ve argued before that warnings from the profession each winter (and, increasingly, spring, summer and autumn) that the NHS ‘is on the verge of collapse’ are unhelpful. There will be no collapse as such. What happens is GPs take on more work they are not trained for, secondary care gets steadily worse, mortality rates rise and those who can increasingly use private healthcare. In such a stressful environment, primary and secondary care point fingers at one another.
Now, I said at the start of the column that the cover feature was grim, and I accept this editorial is no lighter. But I’ll leave you with a more positive thought. GPs and specialists are on the same side. Doctors in general are trusted by the public and they are stronger when speaking with a single voice. The profession must not turn on itself. No specialist wants A&G taking the place of hospital appointments, or GPs acting beyond their competence. Secondary care doctors should avoid the trap of blaming poor GP access for A&E pressure (as should paramedics). Equally, GPs must not blame specialists for a lack of referrals.
As soon as we’re all pointing our fingers where they should be pointed – at a Government whose austerity has damaged the NHS and all public services – the more likely it is that this situation will start to change.