I remember several years ago a brief exchange I had with a friend; it was just before the elections where David Cameron was sort of elected (the one where he and Clegg manoeuvred/manipulated their way to power).
My statement had been something along the lines of, ‘Vote for Ed or it will be a disaster for the NHS.’
Well, the rest is history and that brings us to yesterday.
There was lots of media focus on an article from the medical magazine Pulse relating to the – if not collapse, the significant transformation of primary care – that is, for most of us, our local GP practices.
In the past year there have been 138 closures of practices versus 18 in 2013.
Some of the stories described the experiences of doctors struggling to keep going yet failing with the eventual collapse and closure, resulting in untold suffering for the doctors – many of whom experience this as a personal failure and for the patients who experience the loss of a deep patient-doctor relationship they may have maintained their whole lives (and in the cases of practices that are ‘in-the-family’ this could be across generations).
“If I gave up, I think the practice would close because we’ve been trying to recruit doctors for months and nobody’s coming forward. It’s too stressful and the workload is too high,” she said. “We’re doing the work of five or six partners between three of us. Why would anyone come into this mess?”
Excerpt from the Guardian, 31 May 2019
Most of the collapse has resulted in changes first to doctor working patterns – more and more people are, when completing their GP training, opting to either not work full-time or to not join as partners (and with it the responsibility for maintaining the health and wellbeing of the little organisation you call-up when you have a funny rash, notice a lump or are too depressed to go to work).
With this change – the reasons for which are complicated; some to do with the shifting nature of society – moving from Baby Boomers to Generation X, Y and Z and the extension of working life (aka delay in retirement), to the realisation that for some, life is more than being a doctor; doctoring has to some extent drifted from being a vocation to that of an occupation, although clearly there is great variation in how people relate to this.
Perhaps a bigger challenge relates to GPs and often doctors in any branch of medicine (and, I imagine many other well-paid occupations) retiring, sometimes as early as possible.
I have never expected to retire – indeed, from my perspective, I have worked quite hard to craft a situation where I don’t need or want to retire.
The Baby Boom generation who are retiring now – those in their late 50’s and 60’s in the UK at least, if professionals, benefitted from free university education, grants and dramatic increases in house values over the 80’s and 90’s.
Their retirement age seems to be elastic and with this, again a variation, with some people I know opting to work and not stop when the pension arrives.
I appreciate all of this is in the face of a society that is more unequal than at any time, with whole populations living with poverty; this is the milieu.
The reason for my meander into sociology was to explain that much of the reason for the collapse of General Practice is doctors who are physically and mentally able to work, opting to retire.
Work conditions over the past 10 years in the NHS have deteriorated beyond most peoples’ worst imaginings – the A&E trolley waits, nurse, therapy, pharmacy and doctor vacancies or even the recent reduction in life-span in our country are some of the indicators of a problem;
Add to this the introduction a six or seven years ago of Revalidation which every doctor must undergo every five years – now spread to nurses and other care professionals, being a hurdle that acts as a disincentive to carry-on; and, the annual appraisals that although often tick-box in nature are a further burden (I’m not saying appraisal is bad, just, that I wish there was some way of automating the data collection rather than it being an additional burden to tired souls).
The net result of this as well as pressures from taxation (that I do not understand) have led to record numbers of GPs retiring.
The response to some of this has been an attempt to redesign Primary Care – increasing the autonomy of nurses and therapists to see and treat patients without medical intervention; a move away from medical paternalism, which I love, and even Public Health shifts to get people to stop smoking and drink less (the latter of which is less successful as far as I can tell from the data).
Another change has been the development of super-practices that have joined together with 10, 15 or 20 different doctors working alongside nurses, therapists and other members of the team; receptionist, clerks, social prescribers, phlebotomists and so on.
When I was a kid there were two GPs in the practice, a couple of nurses and the odd receptionist, all out of the front room of one a doctor’s house (on Eastwood Mains Road).
Sure, that wasn’t perfect and I suspect the health outcomes were not amazing either, but at least, when you made an appointment or sat and waited, you got to see the same Dr Kerr who knew your mum, dad, grand-dad; saw you the year before and the one before that; someone you didn’t have to relate your life-story to in order for them to know you, or, who didn’t need to skim through your electronic record to get a notion of your ‘problems’.
Those days have gone and, although I miss the toys (my brother used to borrow the odd edition of Time Magazine), the energy and efficiency of modern healthcare is far superior; except for the little thing about continuity.
And this is really the focus for this blog.
It is what is being lost because of all these changes.
Continuity in care, which, in other words means, relationships – human, one person connecting and getting to know another is a fundamental of all health and social care.
Beyond this we could frequently lapse into a form of algorithm; symptom – diagnosis – treatment.
This is fine for straightforward conditions – my favourite ‘UTI’ being an example, but what happens when ‘UTI’ isn’t UTI or, the high blood pressure doesn’t fit with the algorithm because the patient doesn’t want or can’t take or refuses to reveal that they won’t take the medicine, the secret stashers, who order medicines to ensure the doctor thinks they are taking them, but stashes bottles of Ramipril and Amlodipine in the cupboard.
What happens when the raised blood pressure is a sign of something else – dodgy hormones or domestic abuse? Will artificial intelligence be able to cope? I am sure one day the computers will be adequately sophisticated to see through this, but, when we get there, there is the likelihood of such a degradation of human relationship that society will have completely changed.
So, my stance is that humans are best at delivering care – the health and social variety; the meeting of minds, smile, humour, irony and associated emotions all contribute to something special that affects both clinicians and their patients, or in the case of social care, clients, very deeply.
And this can’t be replaced by algorithms and it is damaged if not lost by small GP practices becoming mini-hospitals, where you see a different person every time you are poorly and the computer rather than the human heart is the repository of your relationships.
It is this continuity that is being lost.
It has already more or less vanished from hospitals – changes to working conditions, shifts, rotas, working-time directives have created a workforce that clings to something called ‘handover’ which is the best we have to replace continuity, but which lacks any human bond – this is most commonly experienced by a nurse saying, ‘Sorry, I don’t know Sadie/George/Francis/Mum/Dad as I am just back from 10 days off; I’ll look in the notes.’
This is a frustration shared by countless patients and relatives;
How we regain continuity of care in hospitals is for another day; how we stop it being lost in General Practice is my focus.
Part of my recent shift to work outside of hospitals has been heralded by this situation – the process of hospitalisation not offering me the depth of connection I needed to maintain my passion for care and the realisation that I could do more to maintain this out in the community.
Already I am developing relationships.
I am getting to know patients by their first-names; hearing about their work, their families, the husband who died young or the sister with cancer – the grandson who is at university and the family dog.
All of these add richness to relationship and whilst not essential for me prescribing penicillin are essential to my humanity.