A Crisis in General Practice?…don’t blame the patients

Written by: Dr Graham Kramer, GP and National Clinical Lead for Self Management and Health Literacy, Scottish Government

Published: 15/04/2015

Despite the challenges in General Practice, don't blame the patients says Graham.

They say that if you want to know how the war is going ask a soldier on the front line. If you want to know how healthcare is going ask a GP. It’s not a happy picture with over 70% saying their workload is unmanageable and unsustainable. There’s a perfect storm of rising workload being tackled by a depleting workforce. Nearly one in 5 practices in Scotland have a vacancy and practices are beginning to face closure as those practitioners left can no longer manage the demands and expectations of patient care whilst maintaining safety and quality for the health of their patients and indeed their own health. With 40% of GPs set to retire in the next 10 years, with 40% of women leaving General Practice by the age of 40, it’s hard to be optimistic. GPs are burning out at an alarming rate. If General Practice fails, the consequences will be catastrophic.

GPs are not work shy. They were also the hard working, goal-orientated pupils, students and junior doctors that have striven to get into medical school and taken on countless undergraduate and postgraduate exams. They’ve not been seduced by glamorous specialism that restricts itself to narrowly defined disease and certainty, but roll up their sleeves to take on the totality of holistic generalism, helping people make sense of illness, whether physical, emotional or social from cradle to grave.

I’ve been a GP for over 20 years. In my early days I worked full time, worked out of hours, provided first response to our local casualty unit. I provided antenatal care and attended women in labour at our local maternity unit. I usually used to get a lunch break and managed to get out of the surgery soon after the doors closed at 6pm. So why am I working 12 hour days, cramming in a sandwich over my desk or whilst driving between home visits? Why with all those years of experience am I arriving home long after family meal time emotionally and physically drained? There’s no simple answer but surprisingly I don’t subscribe to the view of some of my colleagues that it is due to increasingly demanding patients with overly unrealistic expectations. Yes they exist but they’ve always been there, balanced by equally stoical people who successfully self manage or patiently wait until they can get an appointment. It’s just become harder to cater for them against a background of our rising responsibilities. General Practice has become the art of the impossible.

Why has it got so hard? Certainly demographics have changed, a growing population, rising frail elderly with complex needs. Our social fabric has also changed which creates different demands that might not be apparent to some. Many practices now serve multicultural populations where language, health beliefs and familiarity with other health systems challenge our ability to help in a 10 minute appointment. Family fragmentation mean sons, daughters, parents, grandparents live in different communities and can’t support each other. Lack of social connection creates greater reliance on health services. Secularism means people turn less to a minister or faith group and more to their GP for a trusted ear and guidance. Prosperity has seen the rise of lifestyle diseases and Medicine has taken responsibility for the consequences of an increasingly unfit and out of shape population manifesting itself as obesity, hypertension, diabetes. Austerity has bought welfare reform. Poverty, coupled with social and family fragmentation translates into mental health problems, alcohol and substance misuse. Illness and disability may be someone’s only ticket to support and benefits in their already irreparably damaged lives.

These demographics are significant but mostly I “blame” Medicine itself, with its changes and advances, some good, some dubious, that have increased my workload. Evidence-based medicine gathered from narrow sub groups of the population have been translated into guidelines, and applied to wider populations by linkage to financial inducement. This is potentially creating a state of “Pharmageddon“. The safe prescribing and monitoring of this polypharmacy has resulted in spiraling and disruptive medical complexity. Guidelines are touted without any pragmatic regard for the capacity to implement them. Every time I prescribe a long term medication the implications for repeat prescribing, monitoring, dose changes and appointments for perceived or actual side effects cumulate. Long term treatments with high risk disease-modifying drugs need complex monitoring as do the ever widening prescribing of statins and anticoagulants. Medicalisation has created new demand for treatments for fungal nail infections, sexual dysfunction, sadness, stress, personality disorders. There has also been a huge shift towards disease prevention where our responsibility extends not just to people with illness but the asymptomatic population through widening screening and immunisation programs, prescribing for risk factors along with health promoting brief interventions for smoking, alcohol and physical activity. It sometimes seems well people command as much of my time as the sick.

Another massive workload responsibility has been caused by the reduction of inpatient beds in hospitals. Long term infirm elderly people previously looked after by hospitals are now in community nursing homes where their medical needs are met by GPs. The same for previously institutionalised people with severe mental health problems and learning difficulties now living in supported community settings. Pressures on beds coupled with delayed discharges mean people acutely ill are discharged back home as soon as they are stabilised often without a diagnosis, pending out-patient investigations and ongoing management. This increasingly defaults to the GP, acting as a community house officer, to coordinate this intermediate care. The rise of specialism has led to the demise of the hospital general physician, a role that has now defaulted to GPs. I trained as a General Physician before I entered General Practice and find that I’m faced with people of greater medical complexity than I did in hospital clinics but trying to manage in a 10 minute/patient community setting, without in- house diagnostics, house officers and clinic nurses. Even when I refer for a specialist opinion it is usually proceeded by being on a “pathway” of endoscopies and scans and people exist as X-rays and lab results, what Cecil Helman, described as “paper patients”. People repeatedly return to see me with ongoing symptoms and seeking their results because they are still not yet “under” a specialist. Specialism can also lead to “rejectionism”. If someone’s problems don’t neatly fit within a speciality, or spans several specialties there is a reduction in interest and responsibility which usually defaults to the GP.

This rising workload in General Practice has largely gone under the radar alongside the focus on the relatively greater budgetary needs of secondary care, and meeting targets of A&E and out-patient waiting times. General Practice with its independent status has largely had to fend for itself managing the tsunami of workload transfer with diminishing resources. All this against a backdrop of increasing regulation and contractural micromanagement, documentation, annual appraisal and revalidation. Our professional responsibilities to keep abreast of best practice, teach undergraduate students, train tomorrow’s GPs and participate in research is becoming too much. In addition we also have to run our practices, and be employers to increasing numbers of pressured staff.

It’s difficult to think of solutions that will provide any easing in the short term. It will take time to train, retain and recruit GPs. I think the public need to be aware of the pressures GPs and their teams are under and why it’s so hard to get an appointment. We all need to be prepared to accept a wider range of healthcare professionals to turn to such as pharmacists, nurse practitioners and maybe trained community health/ links workers. Serious efforts need to be made to make General Practice attractive again, not by financial inducements but by creating time, according to need, for GPs to care and plan support with their patients. Transformational change to a more sustainable model of primary healthcare will require supported clinical leadership. This will be hard as GPs are so overwhelmed by service delivery they have limited capacity to embrace service improvement. Their mouths are not so much choked with gold, as Bevan put it, but choked by workload. They have lost their ability to speak up at a time when they most need to be heard.

If GPs are to meet the changing demands and expectations of society and medicine they will need more training, support, parity of resources and helping hands from across health and social care, third and voluntary sector and their communities. Importantly people and communities will need be seen as resourceful and contributing to the solution rather than being blamed for being part of the problem.

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