We read headlines of about reaching the ‘crisis point’ in general practice every day, with GPs on their knees and burning out through impossible workload. The components of the crisis are now well known: increasing patient demand, inadequate funding to provide all the interventions and drugs available, and an aging population. As GPs we can’t magically increase the economic wellbeing of the country, and therefore NHS funding – and we are partly to blame for keeping patients alive for so long. But can we exert any influence over patient demand?
Ironically, Aneurin Bevan predicted at the start of the NHS that the demand for healthcare would decrease as people became healthier. In fact, the opposite is true. As GPs, we generally like to keep patients happy and to be liked, but there is a limit to our goodwill.
Patient consultations in England rose by 75% between 1995 and 2008, according to the RCGP. This is against a backdrop of growth in GP full time equivalents of 18% since 2000, compared with a 61% growth in hospital consultants. Workload has now become a political issue, and it is no longer acceptable for us to be told to work in ever ‘smarter’ ways.
Information for patients was thought to be a panacea: give them access to information, and they won’t need to see the doctor. How wrong that assumption is. As we know to our cost, information is seldom valuable without the doctor’s advice or interpretation. Patients come flocking in, proudly bearing a printout from a health website – particularly that highly educated, well-informed, health-aware breed who attend my surgery in Cambridge. These are the famous ‘worried well’. They are just checking that they are taking the right kind of vitamins, or that the capsules I have prescribed are suitable for vegetarians.
We have spawned a new entity: the ‘cyberchondriac’. We live in an instant society, with information available at a click, and the corollary is that we expect equally immediate answers, responses, and appointments to see the doctor. This is where the doctors and the rest of world diverge. Every patient questionnaire or political focus group comes back with the response that surgeries should be available for evenings, weekends, early mornings, and that patients would all like to have longer appointments and more time with the GP. But we know this is not the solution – like opening a new motorway lane, it will fill immediately, and demand will only increase again.
We don’t expect banks to be open all night just in case we need to pick up our Euros to go on holiday. We can get cash out of the wall in an emergency, mirroring the out-of-hours service for emergencies, but we know that paying in a cheque, like a sore throat can wait until the following day. NHS Direct has, paradoxically, increased demand – the advice for many calls, after hours or minutes of algorithms, is to ‘see your GP as soon as possible’.
Most patients are decent people trying to get on with their lives, and are not remotely interested in my explanations of why I am not allowed to make certain referrals, or why the alternative to warfarin, which their consultant has advised, is on my blacklist and so I can’t prescribe it. The argument about payment as a deterrent is a thorny one, and provokes outbursts of disapproval and muttering about the Holy Grail of the NHS. But this is something to consider seriously – and carefully, given that it is such a hot potato. My instinct is that there should be a straightforward mechanism for payment and then some would be eligible for part or full reimbursement. This system is used in France, so why not here? Recent discussions at the BMA’s Annual Representatives’ Meeting in Edinburgh have begun to address this seriously.
For now, helping patients to understand how general practice is funded is the best method for tackling the problem of demand. You could start by hanging notices in your waiting room explaining that the consultation is 10 minutes long, how much it costs, how many missed appointments there are per month, what the allocation of funding is per patient per year. And what if all prescriptions and investigations showed what the cost is per item?
The patient should be advised to ‘help the doctor to help you’, and encouraged to use self help remedies before they come to see the doctor. They should be reminded not to come in to the surgery too soon – or to cancel appointments if symptoms vanish.
Even common sense advice bears repeating: be clear about what you want the doctor to help you with, don’t wear tight sleeves to a blood pressure check.
Although GPs seem to be the scapegoat for all the ills of the NHS, patients still value our time. They just need to realise that we are a valuable resource, not to be abused or exploited.
Dr Fiona Cornish is a GP in Cambridge and president of the Medical Women’s Federation