GP or Social worker? A historical perspective

Guest post by Bastiaan Kole

My father and grandfather were both country GPs (from 1924 to 1996). They knew patients and their extended families very well, had supported them through major life events, palliated them and delivered three generations of their babies.

People had no sense of entitlement and were not unreasonably demanding. In that setting (in a far less complicated world), they sometimes found reason to support people in all facets of their lives. They were taken seriously, respected and even had some success on the odd occasion when they did.

I, as any other GP or indeed any decent human being, listen with empathy and try to support people going through difficult life events, but never give them the illusion that we should by the first port of call or indeed can really help.

I have seen a lot of unhealthy co-dependency that started with “compassionate listening”. One often wonders who gets more out of it: the patient or the self-congratulatory doctor with a sense of purpose. It is invariably very time consuming as these problems can never be discussed in ten minutes and there is clearly some self-delusion, as what can be achieved is in reality very little. It does, however, take resources away from other patients and places an additional burden on colleagues.

In the seventies, GPs’ medical abilities were often ridiculed by specialists. GP training was in its infancy: requirement of completion of vocational training for general practice before a doctor could become a GP principal was only fully implemented in 1982¹. The extent of what could actually medically be done outside a hospital setting was much more limited. This, combined with the Zeitgeist of sociology, shifted emphasis in General Practice (as promulgated by the fledgling RCGP) to focussing on psychosocial causation of illness. The pendulum has defied gravity ever since.

Trying to make up in the consultation room for hefty social care and welfare cuts is exactly what David Cameron intended with his flawed 'Big Society' agenda². Health is directly related to income and living standards³, which a healthcare service cannot influence. To take on the responsibility as a profession for fixing government failings is, to say the least, unrealistic or worse: a waste of time and resources, leading to medicalisation of unhappiness.

It will not end there, because it never does. Why indeed not police illegal migrants for the greater good⁴? Why not monitor radicalisation to possibly save countless lives⁵? Why not provide relationship counselling⁶? Why not monitor gambling habits⁷? Why not offer financial advice⁸? And what about making up for failings caused by underfunding of secondary care? The list is endless.

Idealism can lead to positive changes but often lacks realistic goals and pragmatism. Doctors who have clear views on the limits of their profession, will use resources responsibly, so that care for all their patients can be backed up by evidence-based healthcare interventions. Repeatedly accusing these doctors of “lacking compassion” is never going to lead to better care or better outcomes.

Such idealism will cause people, more and more, to regard their GP as a “life coach”, a role for which we are not trained, funded or equipped. I am sure the majority of GP's did not envisage such a role when they chose the profession.

It is neither viable nor responsible for GPs to act as social worker and life coach, nor to replace traditional support networks, in times of steeply rising demand and decrease in funding. The time has come for the BMA and RCGP to help the profession survive, by clearly redefining our roles as medical doctors and not pander to politicians’ continuous demands and point scoring.

References

¹ Field S. The story of general practice postgraduate training and education. In: Lakhani M, editor. A celebration of general practice. Radcliffe Medical Press; 2003: p120↩

² Conservative Party Manifesto 2010: Invitation to join the government of Britain↩

³Marmot MG, Bell R. Action on health disparities in the United States: commission on social determinants of health. JAMA 2009;301:1169–71. doi:10.1001/jama.2009.363↩

⁴ Lind S. GPs to police access to NHS care under plans for new registration system for migrants. Pulse Today 1 July 2013↩

⁵ NHS England. Prevent Letter for Commissioner Organisations. 18 Sept 2013.↩

⁶ Swinford S. Midwives, GPs and registrars to help tackle family breakdown. The Daily Telegraph 23 March 2014↩

⁷ Sanju G, Gerada C. Problem gamblers in primary care: can GPs do more? Br J Gen Pract 2011;61:248–9. doi:10.3399/bjgp11X567027↩

⁸ Graham, G. Patients should get financial advice at GP surgery, watchdog says The Daily Telegraph. 28 April 2014↩

GP Funding

As part of the national process to be elected as RCGP Council representative, I was invited to answer two questions. The second, from Lincoln GP Ian Lacy, was:

What plans should the College be developing to meet the impending financial crisis in the NHS, which will provoke political pressure to new methods of funding – including perhaps partial payment and the growth of health insurance?

 This was my answer:

The interim report of the Commission on the Future of Health and Social Care in England (set up by The King's Fund may provide a useful starting point, suggesting, as Dr Lacy does, user charges and other private funding streams.

Optimise value
The first priority, however, within the context of finite resources, is for GPs to focus on that which they uniquely can add the most value. We should start, therefore, by being explicit about those conditions which absolutely require medical intervention, in contrast to those which are self-limiting or which can effectively be managed without medical skills by other sections of society.

Quality assurance
Given that additional funding is likely nevertheless to be necessary, College should have an important role in anticipating the effect of any new funding model on quality GP care. The test for any new funding model should include whether it will:

• improve access for those whose needs can only be met by medical treatment
• not disadvantage the less affluent
• result in better health outcomes
• not be too costly to administer

Any new model must be compared against projections of how the current system will operate in the face of growing demand, at risk of failing the first three criteria above.

Charges
I am not aware of any good evidence that flat access charges meet any of these criteria. In terms of charges, College should seek evidence of benefit of means-tested charges for:

• GP appointments
• GP home visits
• GP services (including referrals)

and prescription charges for:

• medication available over the counter for the normally well
• non-drug items
• medication agreed to be low-priority for commissioning

Careful consideration should be given to the possible benefits of such charges on sharing responsibility for conserving NHS resources not only with patients but also families, communities, employers and schools, third sector organisations, local authorities and other statutory bodies.

Charges relating to the management of chronic disease are likely to be counter-productive.

Partial payment and health insurance
Health insurance has traditionally been seen as a way to relieve pressure on NHS services. However, primary care in the UK generally receives no fees from the insured and often has to do additional work, as referral thresholds are lower. Furthermore, although additional funding sources are welcome, private patients still call upon the same finite pool of medical staff. Last - but not least - we see in the US a salutary lesson of the inflationary effect of health insurance on demand for healthcare.

College may therefore have a role in assessing and planning ways to mitigate the opportunity costs of such systems so that the less privileged with medical needs are not disadvantaged.

Negotiation
Most but not all RCGP members currently choose to work within the NHS, offering services free at the point of use. College must, however, support all of its members and work in partnership with GPC without the prejudice of party political ideology to develop options to improve funding and working conditions in general practice in order to maintain the quality of the care, thus strengthening the hand of those who negotiate on our behalf.

Members can  vote at www.votebyinternet.com/rcgpelections2014 by noon on Friday 30 May 2014. My original election statement can be found here.

Seven day GP opening

As part of the national process to be elected as RCGP Council representative, I was invited to answer two questions. The first, from Bristol GP +Terry Kemple, was:

Should the RCGP “Put Patients First” by encouraging its members to provide a seven-days–a-week service of face-to-face appointments with a GP for non-urgent problems?  In summary, should the RCGP promote Saturday and Sunday opening of GP surgeries?

 This was my answer:

On the face of it, seven-day-a-week opening could benefit general practice by enabling us to make maximal use of our premises while improving access for patients.

Firstly, however, we need to be certain that such a service is used by those with medical needs for whom attending during the working day is difficult. The partly-booked Saturday morning surgery attended by those not in regular employment will be familiar to many members. We also need to take care that such a service does not result in the diversion of resources from those with greatest needs.

The next sticking point will be the identification of staff willing to work at the weekend, mindful of the potential impact on their families. It is becoming harder to recruit GPs in hours, let alone at the weekend.

Having said all this, the Department of Health currently seems determined to introduce seven day working. After making the risks clear, College should therefore work with the Department of Health and other stakeholders to minimise the harms to colleagues and vulnerable patients.

Members can  vote at www.votebyinternet.com/rcgpelections2014 by noon on Friday 30 May 2014. My original election statement can be found here.

Acute respiratory infections

(latest update 14 May 2014)
GPs must meet the healthcare needs of a population of patients, not just those who currently succeed in making contact. It is therefore vital that we give colleagues, patients, carers and policy makers the right advice to ensure that those likely to benefit from medical treatment can and do consult us in a timely fashion.

A significant burden of illness in the community is self-limiting, for which treatment by doctors adds little and risks harm.

Epidemiology

Acute respiratory infections are extremely common. For example, adults have up to 2-4 colds per year and children up to 12¹. If every one of a GP’s 2,000 patients attended just 3 times per year with an acute respiratory infection, 6,000 appointments would be needed. This alone would fully occupy a full time GP, who would have to offer 26 appointments per day (assuming 230 working days per year). This would deny anyone the opportunity to consult their GP about any medical concerns for which medical treatment is actually likely to be necessary. Consultation rates are already rising again from a low of 50.2 visits per 1000 person-years in 2004².

Furthermore, 15-30% of patients consult more than once during each acute respiratory infection². Anecdotally, the first presentation may be within hours of the onset of symptoms and they may additionally consult other healthcare providers such as walk-in centres and Accident and Emergency departments. The urgency and frequency of this demand places the healthcare system under enormous pressure.

Antibiotic prescribing

Presenting to a doctor with a self-limiting acute respiratory infection increases the risk of prescription of antibiotics (often requested by patients when the doctor is unable to reassure them), probably more than any other factor³. This poses risk to the individual patient, who is more likely to experience side effects than benefit, and to the population by encouraging antibiotic resistance.

Overtreatment and illness behaviour

In addition, each prescription for antibiotics encourages friends and family members to attend, and earlier, more frequent attendance in future. Some doctors perceive writing a prescription for an antibiotic to be time-saving: nothing could be further from the truth. For example, of ten people who are prescribed antibiotics for a sore throat, one of them will return within a year with a subsequent sore throat, when they otherwise would not have.⁴

Even being prepared to negotiate can be dangerous: the gambling industry is testament to the fact that an unpredictable reward can reinforce behaviour more strongly than anything (variable reinforcement operant conditioning)^5 6. Furthermore, the clinician who has appropriately resisted prescribing antibiotics risks a complaint when another clinician is subsequently consulted and acquiesces.

Indeed, if we did have an effective treatment for these illnesses, there would by no means be capacity for GPs to deliver it. This was demonstrated during the 2009 “Swine Flu” pandemic, in which Tamiflu (oseltamivir) was made available in the UK through a national telephone helpline. It has since transpired that the benefits of Tamiflu do not outweigh its risks^7 8. Elaborate isolation measures were also put in place, which, at best, only slowed spread. 

Treatable acute respiratory infections

The number of acute respiratory infections for which medical treatment is essential to avert long term disability or death is small and includes pneumonia, epiglottitis and complications such as quinsy, mastoiditis⁹, dehydration and sepsis.

Unfortunately, published literature does not yet support the reliable prediction of pneumonia¹⁰ and complications of sore throat¹¹ by symptoms and signs alone. We must therefore advise patients to watch out for symptoms suggestive of more severe illness rather than presenting earlier with less specific symptoms (“safety-netting”¹²).

Symptoms which would merit immediate assessment (“red flag” symptoms) would therefore include:

• reduced consciousness
• cold peripheries
• mottled skin
• cyanosis
• anuria

Symptoms strongly suggestive of a need for intervention (“amber flag” symptoms) would include:

• breathlessness
• haemoptysis
• pleuritic chest pain

Less urgent assessment should be considered for symptoms that do not resolve within a timeframe normal for viral illnesses (“green flag” symptoms):

• cough for more than four weeks
• earache for more than eight days
• sore throat for more than seven days¹³
• fever for more than five days¹⁴

Those that are at highest risk of such complications are the least affluent with the most unmet social needs. This group seem to present readily¹⁵. However, if they present without symptoms of the above serious conditions, those that are seriously unwell will be lost amongst the majority with self-limiting illness. Tragically, these will be the first to die.

In reality, the intervention that will have the biggest impact on improving life expectancy, especially in this group, is improving their living conditions. This responsibility must be placed firmly where it belongs: with society and the government.

The remainder of uncomplicated conditions (including acute otitis media, conjunctivitis^16 17, pharyngitis, tonsillitis, laryngitis, rhinitis, sinusitis, tracheitis and acute bronchitis¹⁸), will resolve spontaneously with no long term sequelae.

This has to be set against the number of medical conditions which are likely to benefit from treatment, such as cancer, heart disease, diabetes mellitus and thyroid disease to name just a few, for which timely access to healthcare professionals is vital: too soon and the symptoms will be too non-specific for targeted investigation; too late and long term complications or reduced life expectancy may be unavoidable.

Access

Desires to improve various health outcomes, whether it be earlier diagnosis of cancer and therefore improved survival or reduce unplanned admission or even reduce infant mortality have been used to justify blanket measures to speed access to healthcare. Unfortunately, these have been implemented without any evidence that they will actually benefit the groups in question, or whether it will actually be even harder for them to compete with those with self-limiting illnesses.

Workforce planning

As the number of GPs is more likely to reduce than increase due to retirement, emigration and insufficient training, it is therefore imperative that patients and their carers (particularly professional carers such as in childcare settings) are confident in diagnosing and managing common acute respiratory infections, with the assistance of community pharmacists.

Health literacy

GPs could support this by setting up training programmes (Ofsted would be well placed to make this obligatory for schools and nurseries). Community volunteers (“Health Champions”¹⁹) could help to cascade and support this training. Minor ailments schemes should be commissioned to enable pharmacists to dispense over-the-counter medication for the relief of symptoms free of charge to those exempt from prescription charges.

With these measures in place, consulting healthcare professionals with symptoms of uncomplicated acute respiratory tract infections should be discouraged. Anything which encourages such behaviour, such as prescribing for acute respiratory tract infections should also be discouraged.

Opportunity gain

If we can significantly reduce attendance for acute respiratory tract infections, the opportunity gain will be immense, allowing patients with medical conditions which are likely to benefit from medical treatment much better access to their doctors.

Actions

Further work

• Systematic review of the literature focussing on predictive value of symptoms
• Evidence to guide safety netting

For Local Authorities

• Community Health Champion schemes
• Housing

For National government

• Accept responsibility for life expectancy (a societal/economic, not a healthcare issue)
• Understand that access to healthcare must be targeted to exclude self-limiting illnesses

For RCGP

• Endorse this document
• Accredit training in diagnosing and managing common self-limiting illness for nursery and school staff

For Ofsted

• Ensure one member of staff with self-limiting illness training at each nursery and school is on duty at all times

For CCGs

• Commission minor ailments schemes

For GPs and other healthcare professionals

• Address prescribing for self-limiting illness - possible audit area.

Symptom summary

Red flags

(consider urgent assessment for immediate treatment or admission)

• reduced consciousness
• cold peripheries
• mottled skin
• cyanosis
• anuria

Amber flags

(consider assessment for treatment; urgency depends upon severity)

• more difficulty breathing than usual
• haemoptysis
• pleuritic chest pain

Green flags

(symptoms typical of self-limiting respiratory infections; consider assessment for treatment if last longer than normal)

• cough for up to four weeks
• earache for up to eight days
• sore throat for up to seven days
• fever for up to one week

Yellow flags

(factors known to increase consultation and therefore antibiotic treatment for self-limiting respiratory infections)

• previous treatment of patient for respiratory infection
• treatment of contact for respiratory infection

Black flags

(features not covered by this review)

• Any symptom not mentioned here
• COPD
• Bronchiectasis

References

¹Colin Tidy (2012). Upper Respiratory Infections - Coryza | Doctor | Patient.co.uk. Retrieved April 6, 2014, from

http://www.patient.co.uk/doctor/upper-respiratory-infections-coryza↩
²Stanton N, Francis NA, Butler CC. Reducing uncertainty in managing respiratory tract infections in primary care. Br J Gen Pract 2010;60:e466–75. doi:10.3399/bjgp10X544104↩
³Fleming DM, Ross AM, Cross KW, et al. The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing. Br J Gen Pract 2003;53:778–83↩
⁴Marshall T. Reducing unnecessary consultation - a case of NNNT? Bandolier 1997;44-4↩
⁵Kendall SB. Preference for intermittent reinforcement. J Exp Anal Behav 1974;21:463–73. doi:10.1901/jeab.1974.21-463↩
⁶Sparkman RB. The Art of Manipulation. Knopf Doubleday Publishing Group 1979↩
⁷Michiels B, Van Puyenbroeck K, Verhoeven V, et al. The value of neuraminidase inhibitors for the prevention and treatment of seasonal influenza: a systematic review of systematic reviews. PLoS One 2013;8:e60348. doi:10.1371/journal.pone.0060348↩
⁸Jefferson T, Jones MA, Doshi P, et al. Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children. 2014. http://summaries.cochrane.org/CD008965/regulatory-information-on-trials-of-oseltamivir-tamiflu-and-zanamivir-relenza-for-influenza-in-adults-and-children (accessed 11 Apr 2014)↩
⁹NICE. CG69 Respiratory tract infections: NICE guideline. 2008↩
¹⁰Stanton N, Francis NA, Butler CC. Reducing uncertainty in managing respiratory tract infections in primary care. Br J Gen Pract 2010;60:e466–75. doi:10.3399/bjgp10X544104↩
¹¹Little P, Stuart B, Hobbs FDR, et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ 2013;347:f6867. doi:10.1136/bmj.f6867↩
¹²Neighbour R. The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style. Radcliffe Publishing 2005↩
¹³Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f7027. doi:10.1136/bmj.f7027↩
¹⁴NICE. CG160 Feverish illness in children: NICE guideline. 2013↩
¹⁵Carr-Hill RA, Rice N, Roland M. Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices. BMJ 1996;312:1008–12. doi:10.1136/bmj.312.7037.1008↩
¹⁶Rose P. Management strategies for acute infective conjunctivitis in primary care: a systematic review. Expert Opin Pharmacother 2007;8:1903–21. doi:10.1517/14656566.8.12.1903↩
¹⁷Sheikh A, Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane database Syst Rev 2006;:CD001211. doi:10.1002/14651858.CD001211.pub2↩
¹⁸Little P, Stuart B, Moore M, et al. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis 2013;13:123–9. doi:10.1016/S1473-3099(12)70300-6↩
¹⁹Altogether Better. Health Champions. 2014. (accessed 6 Apr 2014)↩

“Four problems”—a typical day for a GP

Judging from the expectations people often have of their appointment with a GP, there seem to be many misconceptions:

1. Time is no object. Unfortunately, like anyone, GPs are paid per year for their own time, that of their staff and of their buildings and other expenses to meet the medical needs of a group of patients. In order meet these costs, they must have on their books perhaps 2000 patients. After setting aside time to visit the small number who are too frail safely to attend the surgery and further time for administration (writing referral letters, acting on test results and reports and managing repeat prescriptions), the vast majority of GPs find they must offer appointments in the surgery at 10 minute intervals. This has traditionally been sufficient for matters of average complexity, one at a time. Clearly, some patients will require a little longer; others should not feel short-changed if, having simpler medical needs, they get a little less time.
2. Appointments are 10 minutes long. 10 minutes sounds short enough. However, 10 minutes is all your GP has to quickly familiarise himself with the history in your records, wait for you to reach his room and sit down and to make notes after the consultation. In reality, there will probably be no more than 7 minutes of face to face time.
   
3. A caring GP runs late. Leaving aside for one moment whether it is right that your GP spends less time with his family if your appointment over-runs, the people that really pay are his other patients. If your appointment has ever started 30 minutes late, you will already have borne the cost of others' appointments lasting more than 7 minutes. Have you ever had a referral or report delayed? More examples of what public health physicians call "opportunity cost".
   
4. Your GP has unlimited time outside of the consultation. If your GP had spare time, there is nothing most of them would like more than to offer longer and/or more appointments. The time between surgeries is barely enough for visits and administration, let alone attending meetings, writing "doctor's notes", undertaking email consultations or anything else, as we tried to explain to Health Minister Norman Lamb.
   
5. The GP consultation is an ideal opportunity for new work. Because of a large proportion of the population pass through our doors, our consultations are seen by every special interest group as a unique opportunity to focus on what they consider to be most important for population health. As such, the Quality and Outcomes Framework of our 2004 contract made much of our pay dependent upon such additional activity, much of which would have been perceived by patients as detracting from that which they had actually made the appointment for. GPs are very well placed to do all manner of work, but it needs to be properly resourced, bearing in mind that some activity might be more appropriate for other sections.
   
6. GPs are overpaid. It may surprise some to know that to become a GP one has to undertake a 5-6 year unpaid degree course and then a further 5 years of postgraduate training. The work is of an intensity which most cannot sustain for more than 4 days per week and is significantly stressful. As such, GPs are right to expect to be well remunerated. Clearly, it is largely a vocation and certainly it is a great privilege to share some of the more challenging moments of our patients' lives. However, with the current working conditions, many are tempted out of clinical medicine altogether or to work abroad.
   It could be argued that GPs could spend more time with each patient by having fewer patients on their list and therefore earn less. However, there are barely enough GPs for the current ratio; with expected retirements outstripping the training of whole-time equivalent GPs, GPs are likely to become even scarcer.

Medical need, Jonathon and Charlotte and #PutPatientsFirst

Admittedly, GPs are frequently consulted about matters for which medical treatments confer little or no benefit. However, in his BMJ blog this week,  describes the case of Charlotte, a woman with real and pressing medical needs, all of which he felt obliged to address during one appointment. It makes for compelling reading and illustrates many of the points I have made above. Note, for example, the effect of over-running on his subsequent patients.

Let us do some simple arithmetic. As established above, Charlotte and Jonathon had 7 minutes time scheduled together. Each one of Charlotte's problems could easily have done justice to a separate 7 minutes (taking up 40 minutes  - 4 x 10min of GP time). She needed a blood test (5 min) and a referral (5 min) and interpretation of the outcomes of these (5 min). So, for an appointment scheduled for 10 minutes, Charlotte took 35 minutes of Jonathon's time, when she really need an hour.

Charlotte's case illustrates very well how GPs scarcely have the time or resources to look after their patients at present. We are painfully aware that demand is rising (people are consulting us sooner in each illness, more often and for a wider range of conditions), we are being asked to do ever more work previously done by specialists, and politicians seem to think that all we need is more work. Couple that with the recruitment and retention crisis and we have a perfect storm in the making.

As the  campaign by the Royal College of General Practitioners asserts, General Practice urgently needs more resources to manage the status quo, let alone what is around the corner.