The whole is other than the sum of its parts (Kurt Koffka)
He was twenty minutes late again. Not that it was a problem. He was sure nobody would have been looking for him. These days his arrival to work was barely noticed.
Dr Axel Foot was the only primary care consultant at the practice. He entered the building through the admin block and headed straight for his office at the end of the corridor. He no longer had to walk through busy waiting rooms, with patients peering at his every move, hopeful that they would be the next ones to be called in. That was just one of the benefits he noticed after things start to change some time back.
His office was small but tidy. As he walked in he realized he had forgotten to bring his doctor’s case; in a hurry he had left it at home. Admittedly, it wasn’t the first time. It just didn’t seem to be the first thing he grabbed these days as he left the house.
He sat at his chair and admired the lack of clutter on the desk. No stray paperwork, patient notes and bits of paper with important information scribbled over them. He leant back in the chair and closed his eyes. Not a sound! He remembered the days when he longed for such moments of solitude but all he could hear then was the din of unsatisfied murmuring, coughing and spluttering interspersed with loud shrieks from a little child. The ancillary staff now had all the rooms close to the waiting room whilst his office had moved further and further back to the rear of the building over the years.
The oft repeated slogans seemed very attractive then to burnt-out GPs
It was twenty, perhaps twenty five, years ago when things started to change. General practice was getting a bad press and all the partners at his practice were trying to keep their head above water. Soaring demand and funding cuts meant that practices were struggling to stay afloat. Vacant posts became difficult to fill as no one wanted the stress of working full time in general practice. 100 patient contacts a day was not unusual; things were becoming unsafe.
Something came over him and he decided to head towards the clinical block. He walked past the various offices lining the corridor: musculoskeletal physician, psychotherapy, acute care…
‘Oh, hello Adam.’ He was almost startled by the sudden appearance of Adam, the paramedic who led the acute care team.
‘What brings you down to this part of the building today.’ Did he detect a hint of sarcasm in the question? Surely he only imagined that.
‘I was just going to make myself a cup of coffee. Anything I can help with today?’
‘That’s very kind Dr Foot but we seem to have it all under control at the moment. It was fairly busy. But we had a full team today so didn’t really break sweat. We had two complicated cases but I got Sharon (the physician associate) to have a look at them as she had a few spare slots. We’ll call you if needed, but we hope not to bother you as usual.’
‘I see, well I’ll be in my office.’
The arguments in favour of change had been quite persuasive and were led by GPs themselves. The restricted funding meant that GPs were working harder for less money. As the older GPs started retiring, the arguments got stronger. The need to replace doctors with cheaper staff seemed to be the way forward. The oft repeated slogans seemed very attractive then to burnt-out GPs struggling to employ and retain staff and maintain a decent income.
COUGHS AND COLDS ARE JUST A WASTE OF GP TIME
DIRECT ACCESS TO THE PHYSIOTHERAPIST FOR PATIENTS WITH MUSCULAR PROBLEMS
SPECIALIST NURSES CAN MANAGE CHRONIC CONDITIONS AS PER PROTOCOL
PHYSICIAN ASSOCIATES CAN MAKE INITIAL ASSESSMENT AND CONTACT GP WHEN NEEDED
‘We need to free time for GPs so that they can see the more complex cases and the elderly patients’ was the general thrust of this argument. Replace a doctor with three nurses; they cost less, see all the acute cases and free up time for the doctor.
GPs became primary care consultants and were rarely replaced when they reached retirement
For the partners there was an obvious benefit of stabilising, or even increasing, their income. However, things didn’t stop there. Soon home visits became too much of a constraint on GP time leading to a paramedic replacing the next retiring doctor. If they had any concerns they would call the GP.
‘Mrs Jones seems like she may have pneumonia. Is it ok to organise an admission?’
Mrs Jones… Mrs Jones… He was sure he once knew Mrs Jones well, and her rather eccentric husband, but as he scrolled through the notes, he noticed that the last six contacts were all on the phone with paramedics for a variety of minor ailments.
‘Perhaps I’ll pop over and see her when she returns from hospital,’ he thought.
A few days later he received notification from the hospital that Mrs Jones had succumbed to the pneumonia while being treated as an inpatient. No call from the husband. For some reason the case of Mrs Jones stuck in his mind but he wasn’t sure why.
Soon trained counsellors were employed who would see patients with mental health problems, muscular problems went straight to the musculoskeletal physicians and chronic care nurses dealt with chronic conditions, working superbly to protocol, barely bothering the doctor. Anything that was left over got passed to the physician associates. GPs became primary care consultants and were rarely replaced when they reached retirement. The truth was that there weren’t many primary care consultants around anymore anyway. New medical recruits opted long ago for careers in hospital medicine as primary care slowly dwindled away.
He pulled open his desk draw. In it he had a pristine looking copy of Cronin’s The Citadel. Almost guiltily, he looked around before taking it out of his desk. He felt like Guy Montag, the exasperated fireman from Farenheit 451, who hid books in his fireplace, nervous at the thought that his secret should be found. He didn’t fear being condemned though, just ridiculed for having a romanticist view of how things were once done in primary care. He was once all of those, whose offices he had walked past this morning. He felt a sense of longing for the days when he didn’t know what was going to walk through his door, the satisfaction of a completed on call shift and the joy of home visiting just to reassure poor old Mrs Jones. It was all the things he had advocated to get rid of all those years ago that his heart ached for the most. But it was too late now.
It was 3:30pm. No ring of the phone, no knock on the door. He didn’t expect anyone to come looking for him now. He walked through the admin block once again, straight into the car park. He doubted whether anyone had noticed him leaving. He got in his car and drove away in a hush of silence, just like general practice had done some years ago.
By Dr Samar Razaq, GP, Buckinghamshire