I was introduced to practice visits 25 years ago under the auspices of the ‘What Sort of Doctor’ scheme (colloquially ‘Whatsod’). These were peer-to-peer visits to practices and at their heart was a friendly but challenging discussion about what practices were actually doing to deliver good care, and how they might do it better. Their strength was that they were carried out by fellow GPs who knew that general practice is a difficult balance between efficiency and personal patient care.
In the 1990s I visited each of 51 practices in and around St Helens in north west England. My central question was, ‘Would I want them to care for my mother?’ Some failed. But as I waited in some scruffy waiting rooms I frequently saw rather muddled patients coming to reception desks to be greeted by name. They were then helped to navigate systems that had confused them, whether it be a repeat prescription, a flu jab, or how to get stitches removed. Some were clearly very well known and had major mental health issues.
Every practice has a fair number of such patients and when we raise the barriers to access, such as impersonal telephone systems, the inevitable happens and they simply go and wait in A&E departments. Doubtless unconscious triage was occurring with experienced staff, usually women with families of their own, able to spot when people were actually quite ill and in need of urgent attention.
As usual I got much more out of practice visits than I put in. I returned inspired with fresh determination to try harder and look for, as Jesus pithily said, the plank in my own eye having sought the splinter in others. Unless the practice was less than mediocre I found ideas we could adopt. Occasionally these were major: a practice in Morpeth introduced me to ‘birthday reviews’, where annual blood tests, medication, and other review areas are aligned in the month of the patient’s birthday.1 These have enabled us to have systems for chronic disease review that are clear to patients, families and carers, pharmacists, our staff, and ourselves. This quintuple-winner alone has saved me much more time than I have spent on all the visits I have done throughout Britain.
Why did practice visits pass away so peacefully with no attempt at resuscitation? We completely failed to recognise their unique value and ability to teach us things nothing else could. It is tempting to blame QOF and appraisal, whose rise to prominence coincided with their demise. Externally generated agendas have now become the only agenda. As our nerve failed we failed to say that much that is of value in general practice can be described but not quantified. Over a decade ago we took the financial lifeline of QOF and abandoned professionally led standard-setting. Optimism initially rose, and then fell into the doldrums.
In my opinion low morale is our greatest problem. We are waiting for a government to step in, but it is unlikely that we will ever become a high enough priority for a lifeline to be thrown. Practice visits could be part of the solution and we could rediscover that much good care is still being given beyond the narrow confines of QOF and guidelines. We could affirm, encourage, and appreciate each other.
General practice is at its best when we blend technical medicine with the needs of our most vulnerable patients. A child dying of a brain tumour and a man with terminal Parkinson’s disease are currently stretching my experience of a lifetime in practice, and we inevitably struggle. They and their families need excellent, continuing, accessible, responsive care from us, the best people to deliver it. The danger is that eroded confidence might lead us to abrogate their fate solely to secondary and tertiary care.
But we could become self-confident again and the drive and optimism that a host of College role models gave me could return. The key phrase is professionally led. We have learnt that this can be remarkably easily lost once financial incentives and the demands of appraisal are involved. So why not rebel and exclude practice visits from their stranglehold? There is no one whose permission we need, indeed nothing stopping us from visiting each other again.
It would be a breath of fresh air.
- © British Journal of General Practice 2018
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