Richard Smith: Time for GPs to be leaders not victims

richard_smith_2014General practitioners are overworked, underappreciated, and perhaps underpaid. Politicians are unsympathetic to their plight and expecting more of them. Hospital doctors dump work on them. Nurses are after their jobs. Patients are demanding and ungrateful. Bureaucrats and regulators are making their professional lives a misery. General practitioners have replaced farmers as the profession that complains the most.

I have no sympathy for them. I want them to stop being victims and become leaders, people who solve problems rather than complain about them and expect others to solve them. I’ve preached this message to meetings of GPs several times in the past, which has not made me popular, but the current orgy of moaning has urged me to put finger to iPad.

My first argument is that even if you are a victim you gain nothing by thinking of yourself as such. Indeed, you lose. The world simply doesn’t care when you unfairly miss your train, are passed over for promotion, or even die. You may see yourself as a victim, but the world won’t. I know of a billionaire who thought himself unfairly sacked and for years saw himself as a victim. It was unedifying, and it was him who suffered not anybody else.

When I was editor of The BMJ I seemed always to be reading studies of stress in doctors. Why, I wondered, were there so many studies of stress among doctors but few among single mothers, the unemployed, schoolteachers in rough areas, aid workers, rickshaw drivers, asylum seekers, or the billions living on less than $1.25 a day?

General practitioners know through their daily work that the world is full of people with much more difficult lives than them. And here’s the most crucial difference: unlike the others in my list general practitioners have the space and resources to change their lives. They are mostly independent contractors. They have the status, education, money, and power to do things differently, and lead the way to a better future. Indeed, I suggest that they have more power to change and lead than anybody else in the health and social care system, including hospital consultants who are salaried and working in a large system that is more difficult to change. Indeed, through clinical commissioning groups GPs are literally the leaders of most of the system, and should be innovating and experimenting not moaning.

It must be obvious to GPs that the current model of general practice has to change. Instead of calling for 30 000 more GPs and much more money, neither of which is going to happen, GPs should be experimenting with new models. Geoffrey Marsh, a famous GP researcher, argued 25 years ago that each GP should have 3500 patients not 1400. This was the case in his practice: he concentrated on what only he could do, keeping up his clinical skills through seeing a wide range of patients, while others (nurses, counsellors, physiotherapists, social workers) did work more suited to them.

In much of the world doctors are simply not available, so people have devised alternative ways of delivering care using nurses, physician assistants, or community health workers with guidelines and training. North America has 2% of the global health burden and 25% of health workers; Africa has 25% of the health burden and 2% of the health workers. Western Europe is as privileged as North America. British GPs surely don’t want to worsen that extreme inequality.

Other models might use technology much more. There is evidence that a half to two thirds of consultations don’t need to be face to face, but can be successfully managed by telephone, email, or online consultation. Computers can be used to take histories and encourage self care. Various modes of demand management can reduce demand. Encourage patients to take polypills rather than come frequently for unnecessary check ups and tests.

I’m not trying to enumerate every possible new model, I’m simply suggesting that there are many of them. Most businesses have to reinvent themselves every 25 years or they go out of business, overtaken by competitors who have found better, cheaper, or both better and cheaper ways of achieving the same outputs as the old businesses. General practices, most of which are small businesses, could reinvent themselves, and I know that there are practices doing exactly that.

Yet somehow we hear much more moaning that ideas on reinvention from GPs, and I urge them to change that. I suggest a moratorium on moaning and a festival of ideas for reinventing general practice.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

  • Mary McCarthy

    Many GPs would like, as Richard Smith suggests, to be leaders and limit their workload but GPs are preselected to be kind people who put the needs of thier patients first and who find difficulty in saying “No” to patients. They therefore continue to accept work from secondary care “Go and see your GP” that secondary care could well do and continue to deal with problems that are not medical.
    GPs are free to patients and are often the first port of call for problems about relationship breakdown, work worries, truanting children or housing needs even though these are are covered in medical training and there are others who do this better, albeit at some financial cost.
    GP consultations have increased by 50-60 million in the last five years due partly to an ageing population with increase levels of chronic and complex disease. This is against a background of reduced funding and a diminishing workforce. Young doctors are not choosing UK general practice as a career and instead opt for working in Australia, Canada and New Zealand.
    In Europe there are more doctors and more hospital beds per 100.000 population and patients get longer consultation times with their GP.
    A system that is continually under stress is a system where mistakes may happen which is why hospital doctors have the EU Working Time Directive which does not apply to GPs. Until GPs are treated on a par with hospital doctors there is a risk that older GPs will look to retire as soon as they can and young doctors will not consider general practice a viable career.

  • Grange

    I agree.
    You describe by the way the reality of French GPs.
    General practice is inhabited by professional mourners in UK and France as well. Hopefully in BMJ we read Des Spence, Margaret McCartney and Richard Lehman, they are lights in the darkness. GPs must understand that the world is changing and instead of regreting oldies but goldies, they should propose a new GP paradigm mixing evidence based medicine, share decision making, therapeutic education, patient empowerment and refusal of corruption. Is there a good beginning ?

  • Nick Mann

    You think we should stop waving and just drown? The multiple ongoing NHS campaigns are not about ourselves; it is the primed media who choose to portray us that way. The message is that the service for NHS patients is being strangled and cannot continue without compromise to safety and quality. The facts are published. Less is spent on primary care in UK than almost any G7 or European country, and quality in NHS is better. The NHS has always run at or near capacity, largely sustained by the goodwill of its workforce. That capacity has now been exceeded.

    Neither has the world-leading primary care model in UK suddenly become “unfit for the 21st Century”.
    Your deckchair proposals for ‘new models’ have been tried, tested and found wanting: GP telephone triage increased contact rates by 33-48%; remote monitoring for chronic diseases was not effective; GP lists of 3500 patients would be unsafe in deprived areas, which have double the consultation rates of affluent areas.
    General Practice has indeed changed and developed many new skills and pathways to manage changing need.

    Polypills and health-tagging for all are clearly not the answer to a sustainable or satisfactory, let alone an excellent, health system.
    Useful IT developments should be adopted when and where they prove to be truly beneficial. A basic integrated NHS IT system would have made a huge difference to integrated working, but the Blair govt blew the £9bn for nothing.

    I think your comments are ill-informed and denigratory, redolent of journalism more suited to The Telegraph than the BMJ.

    The NHS GP model needs to be built on, not undermined.

  • Prof. Azeem Majeed

    If Richard Smith was to visit some of the online forums used by GPs, he would find many ideas being put forward to address the problems being faced by GPs in the UK. One of the more common suggestions is that the current GP contract should be modified so that GPs can charge their patients for medical services (in the same way that NHS Trusts already can for private medical care). Linked to this would be the introduction of charges for using GP services.

    People like Richard and I might regard these as regressive developments but they would certainly unleash the wave of innovation that Richard is calling for – if you can afford to pay to benefit from all the new services that would be on offer – such as flexible appointment times, and longer and more thorough consultations.

    On viewing the online forums, Richard would also find a growing divide between GPs in the higher echelons of bodies such as the BMA and RCGP (who are largely opposed to charging patients) and grassroots GPs (many of whom are in favour of charging patients).