When I first started work as a doctor 30 years ago, 7-and-a-half-minute appointments were the norm. But this very much depended on where you worked. For a few years I worked at 6-minute intervals. People ask: how did you do it? The answer is, we just did. We also took our own bloods, did house calls in the middle of the day, referrals, acutes, and all the rest. We didn’t write much and the history and examination structure I had been taught at university was binned. Most of my undergraduate education was just plain wrong because illness never seemed to present in the way I was taught. We were obliged to work nights and weekends too.
Our practice meetings took place weekly at 7.30 am. It was all paper and no computers. I first saw a PC in a practice in 1995! This isn’t macho posturing, but the reality of six doctors managing 15 000 patients. Many practices didn’t even have practice nurses. In the 1990s, general practice was in severe crisis. General practice was the Cinderella service. The hospital sector devoured 90%-plus of the resources but offered outpatient appointments with a 6-month waiting list. General practice was effective, but not always safe, and GPs were burnt out to cinders. The government had to act and we were offered a new contract and investment.
Today, history is repeating itself. We still receive pitiful tokenistic resources compared with hospitals that continue to offer utterly woeful access. If only the government had the foresight to recognise primary medical care unicorns, worthy of investment with huge potential to deliver access and quality! Hospitals are wanton, poorly managed, and with no idea about time management.
Get, for example, all those hospital pharmacists out of hospitals and into primary care because this is where prescribing happens. Put mental health services into primary care. Our general practice CPN has reduced referral rates by 80% but, more importantly, reduced our reliance on medication. Why are dermatologists and paediatricians based in hospitals? I could go on!
Resourcing primary care is a complete no-brainer. We need more time. GPs are increasingly refusing to work to 10-minute consultations, citing pressure of work, complexity, and medicolegal concerns. And they are right. I took some persuading, being a hardened hack, but 15 minutes a patient should be the norm.
But how can this be delivered in these straitened times? It can’t without root-and-branch change. Something has to give. There is plenty of resource in the NHS but it simply has to be better managed. Stop clogging the system with the needless bringing back of patients for return appointments, call and text reviews, centralise paperwork, and introduce on-call systems. Most importantly, broaden the base of clinicians with the promotion of all forms of advanced practitioners.
There is unacceptable variation in clinical practice and a need for new standardisation. A lot more resources for primary care, a lot more for social care, and a lot less for hospitals is the way forward.
There is a broader debate; is it time we nationalise general practice to stop history repeating itself?
- © British Journal of General Practice 2019
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