In part one of this post, I explained how GPs are at breaking point with their workload. I suggested that the work of a GP can be divided into four categories. I described the first two, namely:
2. Treatments of limited value
I shall now explore the remaining two categories.
3. Non-medical interventions
No-one understands better than GPs that social factors (affluence, living and working conditions, exercise, diet, relationships, religious group, hobbies, weather) influence health infinitely more than medical interventions (Marmot, 2009). Indeed, as Bastiaan Kole explained in his piece "GP or social worker?", such an understanding is vital and comes to GPs as second nature. However, influencing social factors is, in all honesty, beyond the gift of GPs. Not only that, but a GP has neither the training nor the perspective to judge the needs of their patient relative to those of another in social need.
Patients have become accustomed to consulting their GP when distressed in relation to difficulties at home or at work. Of course, for a minority, prompt medical treatment for mental illness will be the very best option. For many others, however, one has to ask whether assigning them a medical diagnostic label and offering them a shoulder to cry on in 10 minute instalments is really the best way to meet their needs.
As a society, we have immense questions to answer to understand why our most vulnerable see no alternative but to turn to doctors in such circumstances.
4. Managing risk factors
Another massive change has been the drive to identify, manage and treat medically not disease itself but risk factors for disease, such as raised blood pressure, cholesterol and cardiovascular risk, low bone density, obesity, pre-diabetes and smoking to name but a few. No-one can deny the benefits of reducing such risks. However, the lifestyle advice given to those with these risk factors is no different to the advice applicable to anyone else.
For all of the risk factors listed above, there is now drug treatment available. Some may see this as a breakthrough in medical science. Some may worry that this absolves individuals of responsibility to live healthily. Others may suggest that architects, town planners and government have a far greater potential for impact by influencing living conditions.
What is not in doubt for a growing number of these conditions is that drug treatment, as analysed by cost per QALY, is cost-effective. Indeed, the National Institute for Health and Care Excellence (NICE) has recently decided that an additional 4 million people should take cholesterol-lowering medication. As the Royal College of GPs have pointed out, significant additional investment in general practice would be required to deliver this objective.
Such a recommendation obliges large numbers of people with no physical illness to consult their GP regularly as if they already had a chronic disease. The only illness these people have is the fear of illness manufactured by drug companies, special interest groups, journalists, health economists and politicians who fail to make available to general practice the resources needed to undertake this massive extra work.
There is little doubt that GPs have the skills and position within their communities to fulfil a variety of different functions. As costs rise, society must consider how it wants to use and pay for such a scarce resource. Remember the three parameters of the Project Management Triangle: if the cost of healthcare is to be controlled, society must choose between speed of access and quality; we cannot have all three!
Refusing to make choices will result in the ill (group 1 above) having to compete for resources - Margaret McCartney's Patient Paradox. For the four options I have presented, serious consideration should be given to whether 9 years of medical training is really needed in every case, or whether individuals and communities could reasonably be expected to shoulder more risk and responsibility.
This blog was originally published on John's personal blog, and can be read in full here