Grey matter

Despite the confident claim by (Bournemouth-based) the Echo that its Christchurch borough has ‘the highest population of over 85s in the UK’,¹ I can’t shake the feeling that my practice patch is in the running on this one. As the young continue their flight to the cities, it is predominantly retirees moving out in the opposite direction. No matter though that most might be fit and active when they come, time takes its toll.

Life expectancy may have stalled² in the UK in recent years but a recent study shows that the number of tests ordered in primary care continues to rise.³ Between 2000 and 2015, the average rate of increase was 8.5% apparently. The hallowed ‘test of time’ would appear to be fading from view.

An accompanying editorial⁴ to the tests study focuses on over-testing and over-medicalisation despite noting that the data itself say nothing about what is driving the rise. Though written by GPs (albeit Irish academics so not working in the NHS), their article does not mention the idea of shifting roles. This is a mistake.

My own perception is that, though I am sure plenty of test ordering goes beyond what is strictly necessary in all medical disciplines, this century has already seen a significant further shift in the role of the GP towards being physician generalists.

Some examples of what I mean: with long-stay geriatric beds closed, the patients who once occupied them are now cared for beyond the ken of hospital medicine; the rise and rise of day-case surgery means that most of the post-operative problems that arise do so in primary care, not on the hospital ward; and primary care has had its own flowering in the form of chronic disease management and toxic drug monitoring.

To focus too hard on the idea that most testing is needless is to risk missing this point of how much is appropriate to the role as it now is.

A target that Northumberland practices were asked to meet this year is to reduce antibiotic prescribing levels to the mean for England 5 years ago, in 2013–2014. At first hearing, it might seem it ought not to be too difficult to revert to a pattern of behaviour only so recently the norm. Yet with most of the year gone, it appears that virtually no practice will meet this target. So why are we all failing on that?

The truth is that the context always changes. This applies to me personally: I am not the same doctor I was, and the experiences and influences of the past 5 years will necessarily have made a difference. It is also true for each of my patients: they too are constantly changing. Crucially, though, the medicine I practise on them is also constantly evolving — I am investigating and managing illness more actively than I have ever done.

Grudgingly, I might perhaps concede that more is going on in hospitals too, though only to highlight that their customers mostly return not cured but with something new added to their problem list.

The future does not look like the past, even the recent past. Trust the Echo on this.

• © British Journal of General Practice 2019