What can GPs do? In last month's focus column I ended by quoting the words of one participant in a research study whose mother had felt that doctors were very overrated. But there is always the tension between what we feel we could do, what we have time to do, and all the extra tasks we are being asked to take on.
Take childhood accidents. They remain a common phenomenon, responsible for 9% of all new health problems in Dutch children (page 630). Prevention of accidental injuries to children has been a priority for several years, with a target set to reduce death rates from accidents by 20% by 2010 (page 579). It is difficult to imagine how this can be made to happen, other than by preventing all the faintly risky outdoor activity that many of us would consider to be an important bit of childhood, both to learn about risk taking and all the other benefits. But as Yvonne Carter points out, success in this field will depend on coordinating numerous different agencies, rather than simply seeing it as a problem for primary care to sort out. Even so, a report this month shows enormous success for an educational programme (administered in this case by midwives and health visitors) designed to discourage the use of baby walkers (page 582). Interesting to speculate why this programme should have succeeded when so many others have not; one reason could be that it was a simple intervention addressing a very specific area.
Then there is the suggestion that has been around for so long, that we should be able to alter the behaviour of the patients. The study on page 603 charts the reduction in rates of antibiotic prescribing and infectious illness over several years. It considers the possibility that the two are linked, so that doctors prescribing less have succeeded in encouraging patients to consult less. The study looking at patterns of various illnesses on page 589 concludes simply that there has been a reduction in the prevalence of diseases caused by infection, together with an increase in the prevalence of degenerative conditions. The shifts of illness are indeed mysterious. We have worried for so long about the ever increasing numbers of children with asthma (one of life's innocent pleasures was attending the departure of a school trip, when the teacher asked all children with inhalers to come forward and there was a stampede of travellers clutching their inhalers), but asthma may now be on the wane among children, even while the prevalence of wheezing continues to rise in adults (page 596).
There is never enough time. As we try harder to identify slightly hidden mental health problems, or to identify and treat the psychological element of physical problems, we shall find the consultations taking longer (page 609). Even that was not enough for the GPs who felt that they needed even more time to deal with these more complex problems. Besides, time is only one of the resources we have to ration. On page 639 Alec Logan fulminates over the way that the pharmaceutical industry (again) distorts the priorities of care for patients with dementia. GPs are always faced with rationing decisions and a study to explore how GPs make these is on page 620. Not surprisingly the GPs did try to make decisions by explicit reference to ethical principles, but that didn't always resolve the problem, so they adopted other approaches, sometimes using their knowledge of patients and their lives, sometimes passing the responsibility back to hospital doctors. The authors remind us that ‘Within general practice, there exist tensions between the role of GPs as the gatekeepers of NHS resources and their role as advocates for their patients’.
- © British Journal of General Practice, 2005.