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The gaping chasm is getting wider

The gaping chasm is getting wider

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


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Please note, only GPs are permitted to add comments to articles

David Church 25 October, 2023 9:49 am

Before the chasm swallows you up, prioritise action to address the current corrupt government’s plan to destroy all mutual, cooperative and societal efforts and institutions and replace them with individualist consumerist capitalism – through the ballot box?

Ben Lees 25 October, 2023 11:32 am

Katie, thank you for putting into words how many of us are feeling right now. Look after yourself and your colleagues won’t you? The day in, day out moral injury of NHS healthcare is getting too much for many great colleagues. I hope you and your team are ok.

Mrutyunjaya Kuruvatti 25 October, 2023 12:49 pm

Thank you. A very thoughtful and candid piece and indeed how many of us are feeling at the moment. Thanks for being so honest. I always enjoy reading your articles.

Scottish GP 25 October, 2023 1:18 pm

If all of this had been presented to us as the future 30 years ago, we would not have believed it. Letting down patients and doctors in equal measure. I just feel sad that it has come to this. Heck of a lot of ‘non-illness’ as well, promulgated by social media.

David Simpson 25 October, 2023 3:09 pm

Work as efficiently as you can and only leave late if due to an emergency. Being a Gp is no longer a vocation. We must be able to leave our work at work. Otherwise, we will be micturating into a hurricane and no matter the force of our flow it will make little difference

Cameron Wilson 25 October, 2023 9:58 pm

Very poignant article Katie! Why the caring,empathic individual is very vulnerable in this end game. Should be essential reading for NHSE,HMG,and the GP bashing media. They won’t of course, you will be just collateral, if you are unfortunate enough to get a bit of bad luck, the type we all know can happen.
Too late for me, but the status quo is unsustainable and your skills and qualities will hopefully be rewarded appropriately when reality prevails!

Karen Finch 26 October, 2023 1:49 pm

Very eloquent and well said. My advice would be to be tuned to your own needs and listen to that. The rise in workload and responsiblity is inexorable. I count myself as a casualty of this having suffered burnout during covid, I clawed my way back from that but the anxiety related to the shortcuts we are being forced to make all day every day I found unbearable. The changes in the way we work are compromising patient care and the most disadvantaged groups are worst affected, this leads to moral injury for many of us.
You can’t fill the chasm, better to try to define what you can manage alongside your other commitments and then set a boundary one way or another (it may mean changing jobs) otherwise your health will suffer which will mean that you can’t be there for your patients or your family.

Dr No 27 October, 2023 1:04 am

Katie. Slightly tearful reading your prose. Struggled with exactly same emotions in recent years. My sadness often sublimated into anger, but only here, never at work. The only way I’ve been able to cope has been to drop to 2 days, well, more like 3 in reality. Those two patient-facing days are just as intense, but the other half of the week is such a breath of fresh air. If going half-time allows you to maintain your professional position, and you are too young to retire (your pic suggests so) then go for it. Things can only get better, and when they do, you can put your time back, till then, look after yourself because the government sure as hell won’t.

Andrew Jackson 27 October, 2023 7:50 am

A really important article: Thanks for writing it.
In amongst this mess we are doing a lot of good and we have many grateful patients.
It is possible for the profession to unite and negotiate a contract with workload control if it has the desire and leave us the option of a FT career if we want to do this and not have to reduce sessions to save our sanity.

David Banner 27 October, 2023 10:43 am

Another brilliant article from Pulse’s finest contributor.

The advice in the comments above is excellent.
My own observations would include…..
– always but always take a lunch break…..away from the building!
– never ever stay late unless a genuine emergency
– delegate, delegate, delegate and delegate again
– cherish and reward high quality nurses/managers etc, they are life savers.
– go Part Time if you can afford it
– embrace the Consultant GP model now that ARRS are plentiful whilst other GPs are scant. (But as you delegate less complex stuff to ARRS, don’t forget to reduce your own appointments as your Supervising role increases, otherwise you will drown!)
– train staff to triage results/mail to keep your inboxes to a minimum
– home visits should only ever be for Palliative Care or occasional extraordinary circumstances. If they’re too ill to attend and a phone call can’t sort it, they need the emergency services
-and tell everyone loud and clear, GP is NOT an emergency service

Carpe Vinum 30 October, 2023 1:57 pm

A large part of out primary care issues center around the inablity to say “sod off, you’re wasting my time.” In the bad old days of patriarchal medicine, doctors were renowned for being pretty brutal with their tongue-lashings, and, quite rightly, we moved away from that extreme and flip-flopped to the other extreme where we are so paranoid of complaints and retribution that we swallow the bile and smile sweetly at the time waster in an emergency appointment with the bad back they’ve had for 3 months and today have decided they are fed up about. Or the snotty child with an obvious URTI who’s simpering parent thought “they’d just get them checked out to make sure it’s not a chest infection”, or the endless gen-X with health anxiety, the “mental health” problems which translate as “normal life events that I don’t like”. Get rid of the chaff and we would have much more time to tend to the wheat. But of course we don’t because we are not respected, dare not irk the volatile masses and so we cement our position as the first port of call for all of societal ills – with a smattering of pathology thrown in like the elusive needle in the haystack – and for which we have inadequate time and resource to handle properly