Workload in general practice has become unmanageable. Dr Zoe Norris and others have made this point persuasively. GPs work long into the evening and at weekends making referrals, writing reports, checking letters and test results, issuing prescriptions and managing their practice. General practice has been working beyond capacity for years. This was tolerable to a degree when pay was reasonable. However, the demand from society for GPs to do ever more work for ever less pay (and even less understanding) has brought the profession almost to its knees. Furthermore, there has been no investment in premises for a decade, so that many GPs are now working in wholly inadequate accommodation.
It should come as no surprise, therefore, that the existing shortage of GPs is due to become extreme. Many already close to retirement age are deciding to retire early. Others are emigrating, for example to the Middle East and Australia. Saddest of all, practices are closing altogether as they become unviable.
Clearly, significant investment in general practice is urgently needed simply to keep the service going. However, if the service is to be fit for the medical needs of the 21st century - such as improved access and longer consultations - society must choose what it wants GPs to provide.
Most of a GP's work can be divided into four groups. I shall consider the first two in this post.
1. Management of those who need, or who believe themselves to need, medical treatment
This is central to general practice. GPs are contracted for "management of [those] who are, or believe themselves to be, ill ... [where] 'management' includes ... such treatment ... as is necessary and appropriate" (Standard General Medical Services Contract para 8.1.2-3).
What we must treat and how has changed immeasurably since the inception of the NHS. The range of conditions we can treat and the complexity of the treatments delivered within primary care now is extraordinary. Tragically, resources have not kept pace.
On the other hand, our healthier population is, happily, less likely to succumb to bacterial infections and their complications. The tools of evidence-based medicine (including the ability to compare the value of different treatments using cost per QALYs (quality-adjusted life years) have helped to expose many treatments as either unnecessary or inappropriate.
Paid to care for a population of patients, it has been in the interests of responsible GPs to reassure their patients about which symptoms and conditions do not require medical treatment. Unfortunately, GPs have now been completely robbed of this ability. The ability of stories of health misfortune and non evidence-based miracle treatments to sell newspapers by the million has been irresistible to journalists. They care nothing for the ill health in the form of anxiety that they provoke, and there is no shortage of special interest groups to ensure that such stories reach the press.
Consequently, appropriate reassurance and the traditional low cost (low financial cost to NHS and low risk of harm to the patient from medical tests and treatments) wait and see stock-in-trade of general practice is becoming increasingly less acceptable.
2. Treatments of limited value
The cost per QALY mentioned above provides a helpful tool here. Particularly if GP time is factored in, the cost per QALY for providing treatments for self-limiting conditions (such as the vast majority of acute respiratory infections, gastroenteritis, viral skin infections and even muscular injuries) would be exorbitant. Not only that, but the urgency to see a doctor before the condition resolves puts the system under immense pressure. Where drug treatments have a role, they should be equally readily available to all patients. Perverse incentives to consult GPs such as free prescriptions for medication available over the counter should be very carefully examined.
Cosmetic treatments - from minor surgery, to treating fungal nail infections and arguably even acne vulgaris - are also associated with high cost per QALYs. Most CCGs prohibit hospitals from even seeing patients seeking cosmetic treatment but GPs do not have that luxury. Indeed, although we are discouraged from treating such conditions, it can be next to impossible not to whilst maintaining an effective doctor-patient relationship.
As it is so very difficult for GPs to just say no, and increasingly so in this age of inflationary demand, society must choose between allowing the NHS to pick up this enormous bill and finding new ways to fund it. Given that GPs no longer have any influence on demand, they should be paid according to a tariff for the work they undertake like just about any other service provider. To what degree patients pick up this tab and how is a matter for government.
To be continued ...
In part two, I shall consider two other roles currently fulfilled by GPs and suggest a solution.