The Essence of General Practice
Dr Jonathon Tomlinson
On December 29th 2007 Lord Darzi, in an interview in the Guardian gave an example of a patient with abdominal pain who required a scan for diagnosis and an operation for a cure.
The essential problem with the NHS, Darzi argues, is not a lack of funding or expertise, but the way different parts connect. Patients in search of treatment must navigate a maze – and may not end up at the door of those best equipped to treat them. “Take the example of a patient in London who develops abdominal pains in the evening,” he says. “They tolerate the pain overnight, then they go to see their GP, who says they need to see a consultant…” What follows is a time-consuming and costly back-and-forth: to the consultant, to the hospital for an ultrasound scan, to the consultant to discuss the results, to the hospital for a surgery pre-assessment, to the hospital again for an operation, back to the GP with a wound problem. “I mean, if you did your shopping this way… If Tesco provided you with that service, you wouldn’t go there. If you booked your flights that way you’d be all over the place.”
He then went on to explain that he was going to change primary care services to reflect the needs of patients like this. I responded with a letter to the Guardian because it was immediately obvious to me as a GP that this wasn’t remotely typical of general practice. I see several patients with abdominal pain every week, but in nine years only a tiny minority have needed a scan and even fewer an operation. None of these have had an unnecessary delay. Just as everything looks like a nail to a man with a hammer, only a surgeon would advocate the reorganization of primary care on the basis of patients that need operations. And yet it was with that in mind that his plans were conceived.
More typical of general practice was a 50yr old man who came to see me with abdominal pain 2 weeks ago.
He was accompanied by a friend who said she was there to help him because he never came to doctors and he was really anxious. He looked anxious; he was also very overweight, slightly tremulous and pale. His friend explained that he’d been worrying about stomach cancer ever since his father died from stomach cancer last year. He wanted a scan to see if he was alright. He confirmed that this was the case. I spent a few minutes reassuring him and asking a few general questions about his health. Soon it was clear that he didn’t have any symptoms suspicious of stomach cancer. I examined his stomach and checked his weight and blood pressure.
His blood pressure was 224/124, extremely high, though not altogether surprising.
I checked a urine sample which revealed glucose, (probable diabetes) and signs of kidney failure (associated with high blood pressure and diabetes)
I asked him about his smoking (40 a day for 30 years) and family history of heart disease (his father also had a heart attack) He’d been experiencing pain in his arm on walking upstairs for the last few months, but had put it down to sleeping awkwardly.
He was beginning to relax because, I suspect, the level of attention and concern he was getting was more than he was used to, and because I hadn’t yet broke the news about the significance of what I’d already discovered.
He asked his friend to leave and asked me if he could have some Viagra. Unsurprising really that someone with diabetes, hypertension and kidney disease should have impotence.
He asked if he could also have some sleeping tablets.
Not really surprising then, that he also admitted that he was depressed
Up to 50% of people with chronic illness are depressed and insomnia is a common symptom of depression
Not surprising either when he admitted that he was drinking excessively.
Perhaps he might have something wrong with his stomach after all, an ulcer? Pancreatitis? Or even cancer
One by one I talked through his problems with him.
What he wanted when he came in was a stomach scan, some Viagra and some sleeping tablets
What he needed was looking after. He needed a doctor who was prepared to take responsibility for his care.
For this he needs continuity, a doctor who he could see regularly and develop a relationship of confidence, trust and understanding
He also needs a comprehensive service. With so many associated problems he needs to be seen by a doctor willing and able to manage all his different conditions.
What the changes proposed for primary care offer is the opportunity for people to be seen in a range of places other than their usual GP including walk-in centers, urgent care centers, and GP led health centers. What is lost by this is the opportunity for them to be seen by one GP who is able to take responsibility for them and offer continuity.
The unbundling of primary care services offers patients a choice of providers to provide care for each of their conditions. What is lost is the possibility for one doctor to provide comprehensive, holistic care in one place.
The changes to primary care are ideally suited to young people who occasionally get sick, whose wants are closely allied to their needs and for whom prompt convenient care is more important than continuity or comprehensive care.
The people for whom the NHS is most important are those who are much less able to identify their actual needs, people who need not so much choice, as looking after.
The Lawson Practice
June 8th 2009
“The NHS is the greatest expression of social solidarity found anywhere in the world: it is as much a social movement as it is a health system. It is not just that we stand together but what we stand for: fairness, empathy and compassion. It is for these reasons that we all care so deeply about its future; and it is why I stand ready to contribute to ongoing efforts to invest in and improve the NHS, in any way I can.”
Professor the Lord Darzi of Denham KBE; resignation letter to Gordon Brown. July 13th 2009