There are findings to cheer in this month's BJGP, and others to provide a little critical thought. Lets start with two articles from the Netherlands. On page 927 there is a report that shows rates of both COPD and its exacerbations have decreased over a 25-year period. Interpreting such trends is always tricky and the authors are rightly cautious, but they point out that this parallels the decline in smoking among men, and conclude that it represents a genuine fall in the workload for GPs. Mind, there remains a bit of a problem with the spirometry to diagnose COPD (page 921). This study can be summed up as ‘Better than expected, but still room for improvement.’ Here too, care is required in the interpretation. The study seemed to use stringent standards when deciding what was and was not acceptable, so there is a gap between the numbers of ‘acceptable’ and ‘useful’. There's another lesson in interpretation in the study of text messaging from Malaysia (page 916). Contrary to what I half remembered had been reported in the past, text messaging (and phone reminders) helped to reduce the rate of non-attendance; but the non-attendance rate in the control group was 23%. That's certainly higher than we have in my own practice, (where we have already introduced a system for sending text message reminders to patients).
Another study from the Netherlands reports a significant reduction in the rates of tonsillar infections in children (page 901). The authors here try to disentangle the possible reasons for the observation, and conclude that it is not a change in recording, but a change in demand by patients, and there is a suggestion that guidelines, issued to Dutch GPs encouraging less use of antibiotics, may have contributed.
With the knowledge, from both diary studies and the General Household Survey over many years, that GPs only see a tiny minority of the symptoms experienced by patients, we're well aware that small changes in this proportion could potentially have very large effects on GPs' workload. So the existence of walk-in centres has always looked to me like a mechanism for encouraging extra demand, not a means of dealing with a proportion of a finite demand. Bad enough, but who on earth thought up the idea of walk-in centres for commuters, trivialising health concerns to a 10-minute slot on the way to work? In the event these centres didn't seem to attract as many takers as had been intended (page 934). The patients using these centres reported high levels of satisfaction overall, but were less happy with waiting times, despite the centres working below capacity (page 940). But then offering a service on the basis of instant gratification is perhaps a hostage to fortune. They also look very expensive at the price except that, as the editorial on page 893 points out, with the real cost hidden under the invisibility cloak of commercial confidentiality it's impossible to tell. Other recent developments in the NHS in the UK come under the microscope this month. The report on page 897 suggests that liberalising the sale of antibiotic eye drops may undermine efforts to limit their use, and the editorial on page 891 puts this into a wider context that we haven't yet found a way of working effectively with primary care pharmacists. More worrying than that is the emergence of a two-tier career structure among UK GPs. Last year we published a surprising article reporting that salaried status suited some doctors very well; the article on page 908 reports views rather closer to my own expectation. What is emerging is a career structure that restricts the commitment, ambitions, and potential of the very able doctors whom we are training, and we have all connived at its development.
In the UK, the last 10 years have seen substantial sums of money coming into the NHS. Doctors have been blamed for taking too much of it in their personal pay, but the Department of Health has been profligate in its stewardship, with the launch of various meretricious schemes designed as much to look attractive to healthy patients as to address real matters of health concern. With the gathering threats of cutbacks in years to come, it's time to acknowledge the reality, that it is only by supporting good primary care that the NHS can achieve its fundamental task, and the current climate of fragmentation leading to resentment and anxiety will just not do.
- © British Journal of General Practice, 2009.
