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The splintering of healthcare

The splintering of healthcare

Columnist Dr Shaba Nabi says continuity of care has fallen victim to the proliferation of additional roles and access routes in primary care

I was fortunate to complete my specialist training in a busy district general hospital, where I was responsible for admitting a wide range of patients without the need to shunt them off to local centres of excellence for cardiology or neurology. You could argue that as a non-specialist I was offering suboptimal care, so I can accept the use of specialist centres in secondary care.

It is harder to accept the splintering of generalist care, where traditional GP work is now being split between us and other healthcare professionals. In primary care, the rationale is not the need for the clinician with most expertise, but simply for a patient to be seen amid a growing GP workforce crisis. But this argument only worsens the GP retention issue.

Decades of underfunding the core contract have inevitably led to workload and workforce problems that push practices to use more allied healthcare professionals. GPs are left to see more complex patients, carrying greater risk without the buffer of continuity of care. 

This slicing up of care risks becoming formalised, with last year’s Fuller Stocktake advocating a separation of planned and unplanned care. This has echoes of the 2004 contract, this time with in-hours urgent care decommissioned rather than out of hours. I fully understand the attraction of this as GPs are trying to cap daily contacts while drowning in same-day demand, but it would be as irreversible as that last big contract change. 

So, let us look at the costs of splintering healthcare, which are both financial and emotional. First, the financial cost. Before my contract fell victim to yet another NHS restructure, I was CCG prescribing lead for four years. I developed numerous PGDs, for example to enable community pharmacists to treat tonsillitis and urine infections. I was helping local practices with demand/capacity mismatch. But I knew that pharmacies were receiving the equivalent of 20% of my global sum for treating each of these patients, for a condition I could manage in five minutes. If that investment went instead into core GP funding, I’m certain it would reverse workforce shortages.

The emotional cost is trickier. GPs have always prided themselves on being the last generalists, when all around us we see consultants specialising in the left thumb. But since our first-contact physios arrived, I can’t recall when I last examined a back or a shoulder. Similarly, I rarely see a mole since we trained up our PA in dermatology. This isn’t a major issue for me as I’ve spent 20-plus years doing those things, but newer GPs may never gain enough experience in such aspects of the role.

Aside from the obvious deskilling, I mourn the loss of continuity; I may see a patient for the first time for breast cancer, having missed out on simpler consultations earlier in her life. 

This emotional cost is compounded by the profusion of transactional care, especially on call. The digital explosion lets us manage presentations without even speaking to the patient. We fire off antibiotics, fit notes and questionnaires based on emailed images. Patients can join and leave the practice without me ever setting eyes on them. 

As practice clinical lead, I’m aware I am embracing these access solutions. But in a deprived area with major GP workforce shortages, what choice do I have?

Dr Shaba Nabi is a GP trainer in Bristol. Read more of her blogs here



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

David Church 10 November, 2023 6:45 pm

Ah, but there have been some changes :
I too was responsible for a busy generalist medical on-take ward, once upon a time. We admitted several things, besides acute gastro-bleeds (our specialty) and bad chests.
Heart attacks were admitted, rested, comforted, reassured, nursed, given a large aspirin, and enough morphine to relieve the pain, and oxygen for, I think, 48 hours at high flow until they took it off to eat, and then 2 litres nasally.
We did not do thrombolysis, invasive vascular clot removal, or emergency vascular surgery (surprise surprise, we were not a surgical unit, but a medical one).
It did not really matter if it was a heart attack or a dissecting something, as the travel time to a hospital able to do AAA surgery was greater than the survival time, and the treatment was roughly the same – pain relief, oxygen, supportive, and occasionally CPR, punching, and electrocution.
Then one day, someone suggested giving our heart attack victims snake venom (Streptokinase), and then a cocktail of ACEIs, BBs, statins (to stop them growing ?), and the whole thing became rather specialised;
and then the interventional radiologists got involved, and then coronary vessel surgeons, and finally interventional cardiologists.
A similar situation prevailed in Gastroenterology, where most were admitted, supported with IV lines and possibly blood transfusion, and a dose of H2 blocker. Then our unit had a consultant who could stick a tube down the oesophagus and stop the bleeding, but if you were in a peripheral hospital, they were unlikely to reach suitable care in time. Now the tubes are more available, but nobody knows if it is a medical or a surgical procedure.
There is a lot more different treatments available, and generalism is potentially widening infinitely.

John Graham Munro 11 November, 2023 5:17 am

@ David Church———could have been written by me

Paul Burgess 11 November, 2023 8:57 am

There may be something in Shaba’s scepticism re community pharmacists but you can’t deny their business acumen.
But the real elephant in the room is remote consultations by GPs. Invariably the ‘consultations’ are low value, ‘can-kicking’ and inefficient. And to compound the problem the GPs working in this way learn next to nothing from their ‘patients’.

Michael Green 14 November, 2023 8:09 am

@Paul – bingo, remote consultation is the killer. If you can’t be bothered to bring yourself and your itchy 4th right toe to the practice to see someone, then it clearly isn’t a real problem.

“Oh but there are never any appointments.”

No, because the appointments are full of people seeking help for nonsense while scrolling on their phones on the sofa watching TikTok clips.

Yes we always used to see the anxious and worried well and terminally lonely, but in 10 minutes you could eyeball them, provide reassurance, even lay hands, and done. It might have felt like you saw them every week but this is nothing compared to the tsunami or consults and emails and accurx and telephone consults.

Remote consultation, especially initiated by patients, is too often a complete waste of time. Millions of unnecessary follow ups, repeated presentations, stupid tests, stupid referrals.

Every back pain booked with physio because you couldn’t be bothered to see the patient. This is efficient? Is the patient really interested in doing physio?

Just a crap way of practising medicine. Now the WFH cat is out of the bag and nobody can be bothered to get off their fat behinds and come in, us included. Newsflash: Covid is over!

Some Bloke 16 November, 2023 11:16 pm

Decades of experience in musculoskeletal stuff, log book full of DHS, hemi- and total hip replacements, carpal tunnels, caudal epidurals, trigger fingers and such- I still think that a physiotherapist will be better at assessing and diagnosing MSK than most GPs, better than myself for sure.
At the same time, as partialists continue to narrow their visual fields, generalist will have to widen their vision, potentially infinitely. As beautifully reasoned in D Ch comment