Sunday 20 July 2014

It's make your mind up time: what do you want GPs to do?

Workload in general practice has become unmanageable. 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.

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 [Cosgrove, 2014], 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.

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? (2014)", 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 just decided that an additional 4 million people should take cholesterol-lowering medication (2014). As +RCGP headquarters have pointed out, significant additional investment in general practice would be required (Baker, 2014) 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.

Project Management Triangle


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 (, 2014) or Weale's Inconsistent Triad of Healthcare (1998): if the price of healthcare is to be controlled, society must choose between speed/access/convenience and scope/quality; we cannot have all three!

Refusing to make choices will result in the ill (group 1 above) having to compete for resources - the so-called Patient Paradox (McCartney, 2012). For the options presented above, 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.

Friday 18 July 2014

2004 UK GP contract

The last time morale in general practice hit a low point was prior to the 2004 contract, which served to turn the profession around.

What were the two main planks of the 2004 contract?

  1. Out of hours cover
    GPs were given the option to relinquish responsibility for treating their patients after 6.30pm, before 8am and at weekends. For the almost 70% of the week that falls outside of these hours, GPs had each been paid £6,000 per year.
    Bizarrely, society was surprised that attempts to provide an alternative out of hours service for the same price resulted either in overspend or a less satisfactory service. Too late, the value of a service that had been taken for granted was understood.
  2. Performance-related pay
    In a massive experiment, a large proportion of GP pay was tied to successful surrogate treatment outcomes, widely agreed then to represent good Medicine. As promised, the bean counters made this tougher and tougher, adding as they did so more and more controversial measures (such as inflicting questionnaires on people suffering nervous breakdown, interrogating many about their memory and men about their erections).
    GPs persuaded government that new money would be required to employ staff to carry out this extra work. In the event, many GPs chose to work harder rather than take on so many extra staff.
    The vast majority of GPs rose to the challenge, hit the new targets and were rewarded as promised. We should be proud that to make this happen, some GPs chose to work harder and achieve better income.
The 2004 deal has since been described as generous, but it encouraged a generation of doctors to stay in UK general practice.

As general practice faces another crisis, how can we learn from 2004 to find solutions?
  1. Value appropriately those services best delivered by general practice before accepting less satisfactory substitutes
  2. Resource primary care adequately for the work required of it, without imposing arbitrary restrictions on how that work is delivered. Or, conversely, employ all primary care staff centrally and set their salaries directly (and accept the consequent increase in costs and reduction in productivity).