The future of the Primary Care?

Its been a few weeks since I've had time to update this blog, but now exams are finished - and almost returned to us 6 weeks after we marked the lottery card that is an MCQ answer sheet - and the next module has started in earnest, I think I need to comment on the current stories surrounding General Practice in the UK; After all, HMG want me to become a GP when I qualify, don't they?

The Furore has long standing roots, with the Governement's previous, accepted, contract proposal finally agreeing payment for the hours that a GP actually works, and limiting the hours too - making a life as a GP more enticing to my colleagues in the medical school system, and making general practice a valid career choice for the future. Sadly, the Government decided that they have given too much away, and now are negotiating with the GPs in a bind - asking for 3 extra hours of service, but suggesting a £1.something per patient payment. The reason - if there is one - is to allow patients to access a GP during current closed time and is a decent goal, in theory. The problem exists when you consider the problems that it would cause.

Longer opening hours means that a GP practice could be open from 0730-2100, increased from 0730-1800. In reality, normal hours run on longer than 1800 anyway - with doctors rightly ignoring the "10 minute consultation" guideline when the case guides them, causing overrunning of the apoointments. On my GP placement last week, the GP was billed to finish at 1730, and I left the building before the last patient went in, at 1830.

The point is to allow follow up appointments when a patient can easily access the surgery, at a time that suits them. If we take hospital outpatients, we do not hear the clamour of "you get paid too much for too little!" - though that, surely, is the next step in this overspinned political farce. Nor do we hear complaints that a patient with a chronic condition had to miss work to have a follow up appointment.

Last time I checked, a Out Patient Department (OPD) employed consultants and juniors; and some of the conditions could be well-managed in the GP practice. Why, then, does the country expect so much leeway from GPs? They see a more senior doctor, more often, than in OPD (where its feasible to see junior doctors (SHOs and SpR) for years before consultant review). How dare the general physician even contemplate having normal working hours for himself?

The danger is that GPs will be forced into this new contract, and find themselves needing to sub-contract the work out to non-specialist, non medically trained pharmacists and nurse practioners working from rigid protocols, and this has already caused problems in patient care.

As a medical student I have had numerous placements in "GP-land" as its lovingly called, and I have seen for myself the dangers of Pharmacists being involved in a clincal decision making capacity.

The incident involved a telephone consultation during a face to face with a different patient (good practice, or just normal? Sadly I think it was incompetent.). The pharmacist then prescribed a dose of benzo's without access to notes or previous prescriptions, leading to a 10x increase of the dose in a weening addict. Two years of work undone by bad clinical practice, right there.

From my portfolio, "Critical incident"

The sad future of medicine is that Medical students are constanty being palmed off onto "associate specialist consultants" - be they nurses, physios, OT, midwives, pharmacists - and not getting the clinical exposure that we need to be able to function on day one as a houseman.

I've seen some medical students speak out against GPs and the current workload - suggesting that GPs do not work for their money - but I heartily disagree, especially when on placement I see doctors working 0800-1800 without pause for lunch or dinner, seeing 20 patients in morning surgery, 5 house visits and conducting the ward round in the local community hospital, followed by a full evening surgery.

In 4 different GP placements I have yet to see a GP resting on his laurels, counting his cash. Instead I have constantly seen professional doctors working tirelessly for their patients, spending as much time as they can with each and every one in a vain effort to convince them that they are not just another person on a conveyor belt in General Practice.