GPs are delivering preventive care for populations, but have forgotten about the individual, says Professor George Freeman.
General practice has never had it so good. We’ve never been better paid and have the highest status in our history – and now we are going to control the NHS! Our buildings are better and our practices bigger than ever. We are world leaders in computerising our records and implementing evidence-based guidelines. And we’re still delivering a comprehensive service to all comers free at the point of delivery. Our millennium has truly arrived. Oh really?
While we may seek to convince others, we shouldn’t delude ourselves. In fact, we seem to be unwittingly casting aside the very features that have made us special – above all to offer care that is timely and personal. We ultimately depend on these abilities to make us useful, valued and distinctive and hence to stay in business as GPs.
Timeliness means being available; personal means knowing the patient as an individual and fitting their care to their own context. But our care is neither continuous nor comprehensive. It is very difficult for patients to access care from anyone who knows them outside of office hours. Even in office hours we’ve abandoned personal registration and often seek to share workload equally. So it’s not surprising that many patients no longer ask to see an individual doctor, and see clinicians as interchangeable.
Our growing emphasis on prevention, entirely laudable in itself, is dominating medical discourse. GP consultation rates rose by a third between 1995-2008, but how was this huge rise in activity generated? ‘Prevention is better than cure’ is an admirable maxim, but much of our activity offers little benefit to the individual in front of us (I nearly wrote ‘consulting us’ but so often it’s us inviting the patient in!).
How often do we honestly explain to patients that the number needing to take the preventive medication to avoid one adverse outcome is seldom less than 20 and often 50 or even 100?
If we had time for such frank discussion and obtained truly informed consent, we might be prescribing far fewer statins and antihypertensives.
We’ve given up responsibility for care outside office hours and allowed public demand for better access to pass us by. A&E attendances continue to rise – our schedules are so jammed with proactive care that those who fall ill suddenly have no choice but to go to there. I’m not just talking about minor injuries. How are we coping with the ever-increasing number of older people with multiple conditions? Like many doctors, most of my experience on the receiving end has come from friends and family. A close 85-year-old relative was with a very nice practice, but when she had sudden-onset epigastric pain – following years of taking NSAIDs for osteoarthritis – they merely gave her an antacid prescription. She collapsed with a perforated ulcer the same afternoon. Her confidence shaken, she moved to a large group practice.
Here the medicine was better but she was distressed that it was so hard to see the same GP twice. Her last admission came when she consulted a GP she didn’t know after passing a black stool. She was issued with a prescription for a laxative before the GP took her blood pressure – apparently as an afterthought (for QOF?) – and, finding a systolic under 90 admitted her straight to hospital. Her independent life ended there.
I do not advocate going back to isolated, overworked single-handed practice – referring patients with the archetypal ‘please see and treat’ one-line letters. But I do think we need to critically examine where the profession is going. Have we lost some of the values of general practice? Can we truly say we still provide personal care?
Professor George Freeman is emeritus professor of general practice at Imperial College London and retired as a GP this year
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