'ST Pen V'
30 years ago that entry on a Lloyd George NHS records card would have sufficed for a young girl presenting with a sore throat. Nowadays one has to type the following:
'Sore throat. 3 days. Gradual onset. OE (on examination) Big red spotty tonsils. No nodes. Temp. 37.6 No cough. On COC (combined oral contraceptive). Chlamydia screen+. No allergies to penicillin. Missing school. Rx: Pen V 250mg 2qds x40'
Recently, the front page of a national tabloid was covered with a photo showing a queue of people outside a GP surgery in the half-light of a dank winter's morning. The headline and article that accompanied the picture quite rightly highlighted the shame of an NHS primary care service that can no longer meet the needs of an ailing population. For once, I agreed. But how has general practice come to such a parlous state that, well into the 21st century, patients, in effect, are doing what they did over 60 years ago and queuing in the cold to see a doctor? The article could not provide any answers. The doctors interviewed repeated the well-worn mantra- 'more doctors-more funding'. Yet in the past decade both those points have been addressed and yet the service continues to deteriorate.
Go back to the first three paragraphs of this blog. Both entries in the medical records cover the same presentation of a patient with a sore throat. The first has 6 characters; the second 170. Why the difference? In a word- 'scrutiny'.
Previous generations of GPs were very much independent contractors to the NHS. They operated with scant regard for what anyone thought of them bar the most important person at that time, the patient sitting in their consultating room. They did what was necessary and moved on. In essence they managed time effectively. They worked smart.
They try to do the same in the modern NHS but with a subtle, but nevertheless substantial, twist. Everything they do might be scrutinised by an external agency whose deliberations may have a profound effect on their livelihood. They have to justify everything that they do, in writing, not for fear of litigation from patients (still remarkably rare in primary care) but from censure by their profession, peers or local NHS management.
Here are some examples of what a contemporary doctor has to deal with. GPs have to meet the requirements of an annual appraisal covering competence; of five-yearly revalidation in order to keep a licence to practice; of surgery inspections by CQC looking at the overall patient offering; of Quality Outcomes Framework audits (QOF)affecting income; of CCG policing of hospital referrals and prescribing..... The list goes on and on.
But surely all this scrutiny and regulation must be a good thing, or at the very least reassuring for the patient? Well it might be if patients really cared about the NHS' predilection for navel gazing? However the response of patient surveys would suggest they don't. Those surveys have one constant response, year after year and that is - a desire to be seen ( preferably quickly and by their own doctor). Everything else comes way down the list.
But surely doctors must be safer with all this regulation? Well, not so. There is no evidence or data to support any view that patient safety, morbidity or mortality has in any way been improved by this policing of the profession.
All that we have achieved by years of 'quality improvements' has been the counterproductive removal of doctors from front line services. This, coupled with the alienation and disenchantment brought on by the senseless jumping through bureaucratic hoops resulting in early retirement and poor recruitment, has exacerbated a situation to the point where the scene of patients lined up outside a GP surgery will become the norm rather than the exception. And if access to GPs is delayed or denied then surely that must impact on their health.
If the government wants to get serious about providing a first class primary care service to the UK's population then it must embrace a novel but totally counterintuitive idea. I promise no harm will come of it.
Scrap the regulations, unshackle the profession and watch those queues vanish in a brave new year.
Dream on!