Bad practice

GP services are being undermined by a blind faith in 'market solutions', writes Dr Louise Irvine

April 22, 2009 · 5 min read

I have been a GP in an inner city practice for 15 years. The PCT (primary care trust) is about to tender for a new ‘GP-led health centre’ to be sited in the same building where our practice and three others are located. Private companies are winning bids to run these centres. I fear that profit-driven commercial companies running GP practices are bringing in a new ‘industrial’ model of care in contrast to the person-centred care that we and many other GP practices provide.

In the commercial GP practices that I know of doctors are expected to see more patients more quickly to increase through-put and reduce overall costs. I think this will undermine quality and safety.

In general practice patients often have complex problems involving a mix of the physical, social and psychological, which need time, thought, teamwork and contextual knowledge. There are many examples I could cite: the pregnant 14-year-old girl who reveals she was raped; the depressed man who has lost his job and developed chest pain; the teenager with an eating disorder; the elderly woman with a breast lump who was too afraid to tell anyone. Typically such problems do not present in predictable ways, neatly fitting into 10-minute consultations. In a practice like ours we are able to provide the extra time and care that patients need because our values are professional and not commercial. While we do have to manage our resources wisely, our working practices are not constrained by the need to maximise profits.

Undermining the bedrock

The vital doctor-patient relationship is being undermined in the new model of care. The ‘GP-led health centres’ and polyclinics will provide ‘routine’ care to patients who are not registered, thus ending the principle of the registered list. This is the bedrock of British general practice and has been demonstrated by international studies to support the comprehensiveness, co-ordination and continuity that are essential for effective, good quality primary care.

The new commercial GP practices are relying on salaried doctors, many on worse pay and conditions than in traditional practices. There is high staff turnover and reliance on locums. I know newly qualified GPs who have been interviewed for these jobs. They are expected to work anti-social rotas that are not family friendly, often with no other GPs on site during extended hours. Many are denied membership of the NHS pension scheme.

They may also be moved between the different practices owned by the company. There are no incentives for long term professional commitment to an area. For patients the chances of ever seeing the same doctor twice or one that has known them over many years are significantly reduced.

The health secretary Alan Johnson says he does not care which doctor he sees but he is out of touch with what most patients value, especially those with the greatest health needs. They value continuity of care and it’s not hard to see why. The knowledge that develops over a series of interactions over time is of a more profound nature than can ever be captured in a medical record; patients don’t have to keep telling their story to different people; trust and confidence can develop; and patients can be understood in their total context, leading to more appropriate care.

Continuity of care

Recently a woman consulted me with palpitations. She was worried there was something wrong with her heart. I had seen her and her son many times over the years. I knew her son was seriously ill. I examined her and listened as she expressed her feelings about her son. She was happy with my opinion that the palpitations were due to her emotional state and said she felt much better having talked to me. Had I been a doctor who did not know her, I might have sent her for unnecessary investigations or she might not have trusted my judgement.

As 40 per cent of problems in general practice do not have a medical explanation, our job as GPs is not just to detect and treat disease but to protect our patients from unnecessary tests or treatments, all of which carry risks. Research shows that continuity of care enables a more judicious use of resources, better patient satisfaction and better outcomes and is of most benefit to those with the greatest health needs.

The government claims the new ‘super-surgeries’ will improve quality and access. But inexperienced, poorly supported doctors working in the conditions described above, where care is fragmented, are not likely to improve quality. As for access, patient surveys show that 84 per cent are satisfied with existing hours and the rest would like some evening and Saturday morning surgeries. Many practices, including ours, are now providing these extended hours.

We wanted to do more but our PCT told us there was no funding to do so. They have thousands to spend on an unnecessary ‘GP-led health centre’ but are not allowed to use those resources to improve existing services. Instead good general practice is being undermined and replaced with an untested, risky, poor quality and wasteful model, because of a blind faith in ‘market solutions’.

Dr Louise Irvine, GP works at the Amersham Vale Training Practice, Waldron Health Centre, Lewisham


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