Brief notes before the Battle of Ideas 2011 debate,
Radical surgery for the NHS: what is a GP’s role today?
The answer depends on who is defining the role.
The answer (as always) should not come from GPs, (or those pesky meddlers the Kings Fund, or the Dept of Health) but patients.
And not the pushy, entitled, ‘fix my sore throat before I interview Sir David’ journalists, that cannot understand why GPs don’t keep the same opening hours as Tescos (do they think Tescos could afford 24hour opening if it took 10 years of training to operate a checkout?)
Nor the people who run think-tanks who write long papers about what they would want from a GP if they were a patient, only they’re not actually chronically sick or worried half to death that they might be; these are healthy people, not patients.
No, the answer is that GPs are defined by our patients: moulded, stretched, pummelled, weighed down and held up, worked over, leant on, wept on, bled and spewed over and even pissed on by the youngest ones. Our patients spend years beating us into shape.
Studies have shown that at the start of medical school, GPs are in fact normal people, capable of blending in at any social occasion. After 5 or 6 years we are turned out of the sausage machine that passes for a medical education, unable to speak the same language as our parents; after a few years in hospital we are a different species entirely, harder to understand than the average teenager. Entering General Practice we soften a little, but being unused to conversing with conscious patients who ask difficult questions, we’re like pubescent Dr Spocks trying to cope with the emotional turmoil that our patients, (yes, our-own patients) lay on us. After painful years, we unlearn most of what we have learned and replace it with what our patients have taught us. How to interpret stories and relate them back, how to recognise unspoken signals, appreciate hidden strengths, uncover silent symptoms, and be a part of the narrative of our patients’ lives.
The commonest question my patients ask me is, “Will you be my doctor?”
How can we say no? In spite of decades of incentives to make us all attachment-free, autonomous consumers, to be somebody’s GP is to make a committment, a committment in many respects like that of a marriage. To stand firm in sickness and in health, to be consistent and honest at all times, to take abuse and shoulder blame without judging, to bear witness to suffering and personal tragedy and always maintain confidentiality. To be fair and compassionate, professsional and competent no matter how we ourselves are feeling.
The commonest reason for visiting a GP is ‘fear’.
Fear that the lump is cancer, that the chest pain is another heart attack, the headache a stroke, like the one that tragically disabled Maureen. Fear that I may die before my children grow up, fear that I may lose my sight, my balance or my mind. Fear that I cannot cope, that I am a failure or that I will be judged unfairly and blamed for my suffering. To be a patient is to be unfamiliar with oneself, to inhabit an unfamiliar shell, barely in control and in need of help. The world and our relationships are radically altered when we are patients.
What an extraordinary job we do. Grounded in a therapeutic relationship, everything we do depends on trust. What an extraordinary responsiblity to be charged with caring for people when they are at their most vulnerable and most easily exploited.
Because of this it is absolutely vital that we are not led into temptation. Just as monks and nuns need to be protected from the distractions of the world so that they can dedicate themselves to God, so we need to be protected from mammon and the perverse incentives of the market-place, so that we can dedicate ourselves to our vocation and our patients, and be the doctor that they need, not the doctor the market makes us.
Amen to that
What a wonderful, insightful post!
This to me says it all: “What an extraordinary job we do. Grounded in a therapeutic relationship, everything we do depends on trust. What an extraordinary responsibility to be charged with caring for people when they are at their most vulnerable and most easily exploited.”
Thank you for being you and to all GPs like you.
Thank you. Really powerful and important.
The problem is how can we get most if not all GPs like you. Moreover, the current proposals will make this less likely. But yes, thank you.
The perennial battle between GPs and specialists was once addressed by a GP friend. He said: “But I am a specialist: I am a specialist in general medicine!” This is more profound than it appears on first sight. As a patient I expect my GP to know enough about *everything* that could possibly be wrong with me. What I want is the care, and that starts with the diagnosis. So my GP needs to have a wide knowledge and experience and be able to piece together what my condition is from a wide range of information and evidence. But it is more than that, my GP should be able to diagnose my condition, not just from what I say, but also from what I *don’t* say. I am not a medic, I don’t know what is relevant, so my GP must know what is, and be able – from asking the right questions – to get me to tell her what is relevant. That is a true skill, a real talent.
I want my GP to ensure that my condition is treated, and not necessarily treat it herself. That brings me to the next thing that I think GPs should do, (and I am afraid they don’t do well at the moment – mostly because the internal market has made it hard for them to do it): project management. My GP should not treat referral as simply handing off care to someone else. My GP should be managing the treatment insofar as having the overall role of co-ordinating care. This means that if I get lost in the system, my GP should be the first point of call, and the person will ensure that I get the care. If my care is substandard, then my GP should be the person who ensures that the service is improved.
I don’t think this happens at the moment, I think that there is no overall co-ordination and that everyone involved (hospital, community services, GPs) regard themselves as individual “contractors” in the project with no-one really taking responsibility. My GP should be that co-ordinator.
What I don’t want is to be seen as a “business opportunity”. I want my GP to realise the limit of her skills and be able to refer me to someone who has better skills, even if that means transferring the “business” to someone else. (That does not say that I don’t want my GP to treat me, since clearly it is “closer to home” for me to be treated by my GP.) This is why I think fundholding was a failure – thrusting GP doctorpreneurs took it as an opportunity to specialise and hence be something they are not. A specialist GP by definition means that they are no longer a generalist, so why would I want to go to that GP unless I have a condition they specialise in?
My sister, professionally-qualified, at 52 recently had an NHS breast cancer scan and is now in the midst of decision-making about cancer treatment. What she would have liked is a GP who would go through the options with her. What she would have liked is properly knowing about breast self-examination, breast awareness is not enough. What she would have liked is an earlier mammogram, being called at a younger age and not in surgery turn. What she has is in her area is the choice of a NHS lumpectomy, leaving her deformed and radiation, known to be harmful and a private mastectomy on her medical insurance with reconstruction, possibly not covered by the insurance or a private lumpectomy. The private guys are ruminating about the additional therapies to stave off recurrence yet she does not want to be a guinea pig.. As time marches on, she is becoming terrified and the positive approach she had is being worn down. This is the nub of it, she doesn’t ant to lose her nerve. The reality of illness is not something that markets can cope with. She would have liked a GP who said to her, these are your choices, these are the risks with each: this is what I think will best , knowing you as I do, how do you feel about it? What she would have liked beforehand is knowing the risks of lifestyle choices, how much exercise to take, the details of good foods, whether you can drink alcohol and coffee at all. She would have liked the facts earlier. What she would like now is for someone to wave a magic wand and take it all away. Some GPs have that extraordinary ability to lift the burden patients’ shoulders and some are totally hopeless. We must continue to cultivate an environment which fosters the former and in which the former are appreciated. Patients want to be healed. They need support. That old-fashioned word “Character” is something that GPs need in order to provide this. It is a special requirement.
What is GP’s role today?” wrote:
“What an extraordinary responsiblity to be charged with caring for people when they are at their most vulnerable and most easily exploited.
Because of this it is absolutely vital that we are not led into temptation. Just as monks and nuns need to be protected from the distractions of the world so that they can dedicate themselves to God, so we need to be protected from mammon and the perverse incentives of the market-place, so that we can dedicate ourselves to our vocation and our patients, and be the doctor that they need, not the doctor the market makes us.”
I am not a GP, but a non-medical member of the general public. I have respect and admiration for all the medical professionals I have ever encountered. The health and Social care Bill, however, has in my view great dangers.
Consider the following factors:
1. Medcal practitioners are increasingly deperately in debt when they start work, and this will get worse. See, for example: http://www.bma.org.uk/press_centre/presstuitionfees.jsp
2. It is not at all clear top what extent “commercial confidentiality” will be used to hide financial transaction of Clinical Commissioning Groups (CCGs) with external providers from public scrutiny and freedom of informatuion legislation. The bill does not appear to say anything about that subject. (I note, for example, that a person can be member of a CCG and an external provider at the same time).
3. Only one obscure sub-clause of the bill appears to recognise that there could be conflicts of interests and collusion (sub-clause 71((3)(b)) and it states that regulations MAY be made in this respect.
I think that it would be utterly irresponsible, and it would do the medcal profession a great disservice, if those sections of the bill which set up the system of CCGs were to be enacted before these regulations are made, and furthermore, that these regulations are so sensitive and have to be so detailed that they will require very extensive consultation first.
As it stands, the bill creates the potential of a layer of institutionalised corruption in the NHS.