Matthew Parris has managed to stir up debate about UK General Practice. Was this the intention? Was he being deliberately ironic? The timing of his opinion piece on the weekend before the first doctors’ strike since 1975 cannot be a coincidence.
If family doctors had not existed, would we today have found it necessary to invent them?
The second question by Mr Parris is arguably the crux of his essay. The short answer is a resounding “Yes!” I will set aside the false premise that the doctors strike, in Mr Parris’ eyes is solely a GP strike. Perhaps because the bulk of the UK public who seek healthcare on a given day normally see GPs one can excuse this falsehood. All doctors (well, > 70%) will not be doing routine tasks on Thursday 21st June.
So back to the invention of family doctors. Family doctors are the descendents of “apothecaries” and “ship’s suregeons”. The health care professional who was available to the masses for many centuries. The idea that specialists should be available to all is a modern concept, especially in the UK where health care delivered by the National Health Service since 1948 is free at the point of delivery.
You do not need to go too far back in time to see that specialist medical advice was only available to the rich – the ruling classes and merchant class. The medical workforce was concentrated in cities, especially London and Edinburgh (and Dublin). Oxford and Cambridge Universities were for a long time the only recognised centres for training physicians in the UK.
The Public needs medical women and men who are trained in the nuances of first contact healthcare. There is far more to the intitial consultation than simply making a diagnosis of a somatic process. Mr Parris is lucky to need a doctor so rarely. His experience does not, in my opinion, give him the right to pass judgement on what doctors like me do!
Barbara Starfield (1932-2011) wrote some of the best essays on the merits of general practitioners and primary health care. An important conclusion is that mature health care systems must have robust primary health care systems to withstand the constant pressures of medical advances in order to protect citizens from the worst excesses of health seeking behaviour. Economies with strong primary healthcare also spent less on health without compromising outcomes. A selected bibliography in support of this statement is here
Are we investing too much in the citizen’s first port of call, to the detriment of investment in the specialist attention to which, to an increasing degree, surgeries are likely to end up referring the patient?
The next question deserves an explicit answer: “No, Mr Parris, we are not investing too much in the citizen’s first port of call”. If anything, there is too little investment in first contact doctoring because politicians are seduced by the gleaming hospital in their constituency. It is not sexy to spend money on often small and out of the way health centres which are often owned by the doctors. There is no political mileage in giving more money to the hardworking GPs and their staff. We do not spend enough money for your campaign funds. Profits are ploughed back into the practice to maintain services. Unglamourous activities like cervical smears and blood pressure monitoring. There is no obvious soundbite for enhancing the environment 95% citizens visit in any year. Greedy doctors must not be encouraged. On the other hand hospital doctors are gagged – prevented from speaking out because of their contracts. GPs remain independent contractors which is an anathema to the Ruling Class.
Is the work of these expensive and expensively trained men and women best directed to the point at which they’re doing it?
“Yes, Mr Parris”. We are the cheapest healthcare professional available to determine whether the first sneeze is the beginnings of a serious illness or just a virus. Making that decision requires confidence, high level of training, and a feel for pattern failure that almost any other healthcare professional cannot do. Nurses are generally hopeless at detecting pattern failure. Secondary care doctors are trained to investigate; general practitioners are trained to reassure. Certainly, we would love to investigate more given the chance (witness the explosion of near patient testing), but there is little evidence that such behaviour improves outcomes. It may reduce the doctor’s stress levels, but that is not a good reason to inflict tests on patients “just because it seems a good idea”.
“Referral rates” — the proportion of GP consultations that lead to a consultation with a specialist — are rising fast
Whose fault is this, Mr Parris? Media campaigns pandering to the worried well concerning the latest medical scare do not help manage demand for secondary care opinions. Two week rules for suspected cancer, demands for early diagnosis of dementia, advances in cardiovascular and respiratory medicine, better endoscopy techniques, imaging techniques denied to GP access by NHS rules, barriers for experienced GPs which prevent in house treatment, and a culture of defensive medicine engendered by people like Mr Parris who insist on certainty in an uncertain world all conspire to increase referrals. This is not of our doing. This protocol driven medicine is the undoing of decades of responsible use of scarce resources.
Perhaps, if the Royal Family could be persuaded to employ a Royal general practictioner, there would be a sea-change in the respect GPs should receive.
Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results.
Mr Parris should do better research. Nurse-led primary care does not work! 30 minute appointments, protocol-driven working, limited formulary, lack of experience, deference to a GP when things go awry, and catastrophic errors do not support this blithe assertion. Rhona Knight (2008) points out that it would be backward step. If you cannot read the whole article, you will find it here. Nurses are anxious not to fight GPs for primary care; we must collaborate and play to each other’s strengths. Nurse-led clinics can improve health, for example in secondary prevention of heart disease (see Campbell et al 1998) but this is not the same as nurse led general practice.
Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.
The day this arrives, Mr Parris, will be a very sad day indeed for the healthcare of this once proud Nation. At the one and the same time you express such strident opinion, countries around the globe are struggling to implement primary health care modelled on the very system you seem so intent on dismantling: Quatar, India, Poland, Slovenia, USA to name a few. How can such an erudite fellow as Mr Parris get it so wrong?
It feels good to make this effort to dismantle Mr Parris’ thesis. I do hope it is now clear why General Practice and the GP are a fantastic resource for the UK. By the way, the Royal College of General Practitioners is the guardian of the high standards of practice expected in the UK. Its new building in Euston which opens later in 2012 is a testament to the endurance of primary health care and GPs. GPs are here to stay and we will fight hard to protect the most vulnerable in our society from the excesses of the Ruling Classes who share Mr Parris’ views.