Columnist Dr Katie Musgrave reflects on how providing a good quality of care has become nearly impossible in the current NHS without sacrificing her own health
How does being a GP make you feel at the moment? Content? Rewarded? Satisfied that you can do a good job? I don’t know about you, but I’m gradually falling into a pit of despair at the state of the UK’s health service. How can we go on like this? How can I get up every morning and drag myself into work, when there is such a gaping chasm between the quality of care that I would like to give, and the care I feel forced to deliver?
Just do what you can for the patient in front of you, you might say. But where does that end? Does it include the little old lady crying in the reception area, who says she desperately needs to be seen? Does it include the phone call at 6pm from a suicidal teenager’s mother? Does it include those lab results, documents and prescriptions that could result in a life-changing error? Okay, then, stay late until it’s all done properly. But what about my tired and fractious children, desperate to see mummy before they go to bed? What about my husband with a disability, who can’t manage them alone? What about them? Okay, leave on time, do the best you can with the time you have.
But then I feel guilty. About the shortcuts I know I have taken, which I feel I have to take if I am to get through my call list, manage the rest of my workload and perhaps make it out on a home visit. About the messages I send to inform patients of scan results, because I know they would like a call – everyone would like a call. About the elderly patient with a skin problem that I ask a nurse to photograph and manage remotely – the family would like me to visit. Everyone would like me to visit.
Remote working has had its advantages. The patients who are, shall we say, a little too familiar with the GP surgery, can be gently kept at arm’s length. Perhaps we are weaning some people off an unhealthy dependence on seeing a GP. But, by and large, I feel uneasy at the direction of travel in UK general practice. Remote consultation via phone and email is proving more accessible for younger, healthier adults, but less accessible for the frailest and most vulnerable. Even a small diversion of care from the elderly towards the young could have catastrophic downstream effects. Statistically speaking, older people will be more likely to have serious pathology: cancers, heart disease, strokes, dementia, severe infections. The reverse is true for younger adults, who are statistically speaking far more likely to have minor self-limiting illnesses. Every minute a GP diverts from the old to the young, scaled across the UK, will have an impact on rates of early cancer diagnosis, rates of avoidable hospital admissions, rates of cardiovascular disease. For our older and more vulnerable patients, a stitch in time really does save nine. But for a 20-year-old with a sore throat? They generally didn’t need the appointment.
And then there’s the inaccessibility of meaningful treatments. The patient with severe bone-on-bone arthritis needs a hip replacement, but a self-referral to physio will take months to come through, then they might get referred on to orthopaedics and wait years for their op date. The teenager with autism who can’t function at school waits years for a diagnosis and appropriate support. Wouldn’t it be great if the older lady with a pill-rolling tremor could see a neurologist? Chance would be a fine thing. All these illnesses, and all these dysfunctional services. It’s so demoralising.
So, back to the chasm. What can I do about it? I can defend myself and leave work at a reasonable hour, putting myself and my family first. Or I can sacrifice myself and my family, and stay as long as needed to do the job I think I should be doing. But then there’s the nagging feeling that my best – whatever that is – would never be enough. The gaping chasm is getting wider. One day it might just swallow me up.
Dr Katie Musgrave is a GP in Devon and quality improvement fellow for the South West