Peter Bailey: Galley slaves, rebel!

Jeremy Hunt’s speech to the King’s Fund on 23 May made me wonder if someone in the Department of Health had had an “Oh my God!” moment. A gut clenching, awful realisation that a catastrophic mistake has been made. A mistake that spells misery, shame, and horrible consequence. The sort of feeling you get when you realise that you have removed the healthy kidney, not the one with the tumour. His speech seemed to suggest a dawning understanding that those working in the front line of medicine in general practice, the out of hours service, and emergency departments are the good guys, not the enemy. Slagging them off, starving them of funds, setting impossible targets, and beating them about the head with lurid stories of failure has not, after all, improved the NHS. The effect has instead been an erosion of morale, a steady increase in morbid cynicism, and a haemorrhage of talent away from the beleaguered work places. Small wonder that emergency medicine vacancies cannot be filled and 50% of trainees leave the speciality. Who is surprised that GPs over 50 are eyeing up the prospects for early retirement?

So, with this dreadful awakening to reality, what is Jeremy Hunt actually saying? Is he proposing a significant increase in the workforce in primary care and emergency medicine? Is he calling for longer appointments in general practice? Is he recognising that the case mix and complexity of 21st century medicine is different from the avuncular care of Drs Cameron and Finlay in pre-NHS rural practice?  Does he realise that Janet McPherson doesn’t answer the phone to anxious villagers at Arden House any more?  (Younger readers of this blog will have to ask their parents to explain this reference.)

No. Once again, the Department of Health is asking for the impossible. Hunt said that “Every patient is the only patient.” Is the man mad? My first patient in my morning surgery yesterday had complex visual symptoms that did not fit into any textbook description of eye disease. I had to tease out a clear description of her difficulty, that had already baffled her optician. She needed a careful eye examination and a full neurological examination, and then a referral for a secondary care opinion. By the time I had achieved this, I was already 25 minutes late for my next appointment despite having started five minutes early. Her Patient Satisfaction Questionnaire indicated that she was very happy with what I had done for her. Two more patients like this in the course of the morning meant that I was nearly an hour late for my last patient who made a formal complaint about me to the practice manager. It is no longer possible to practice good medicine in ten minute slots. The “quick” patients are now seen by nurses, making the case complexity of the people who consult the doctors much greater. Hunt makes the point that,

One in four of the population has a long term condition—many of them older people. Within the next few years, three million people will have not one, not two, but three long term conditions. By 2020, the number of people with dementia alone will exceed one million.”

Does he think that such patients can be cared for appropriately given the current pressures on primary care physicians in general practice, out of hours services, and emergency departments?

He says that there has been a betrayal of general practice ideals. The effrontery of this is breathtaking. Is he trying to make us feel guilty? Who exactly has committed this betrayal? Who forced general practitioners to give up in-house out of hours care by imposing regulations that made it impossible for individuals to meet targets designed for corporate care providers? Who was it who said that front line staff are “coasting.” Who erodes practice income year on year while imposing ever more onerous targets, slicing chunks off resources, and expecting us to run faster to stay in the same place? We already feel like galley slaves chained to the rowing bench, out in all weathers, unable to attend to bodily functions, whipped by the slave master, and working endlessly to the beat of a merciless target drum.

General practice has established itself as a speciality with its own royal college, a core curriculum, and a higher qualification. GPs now enter the profession with more idealism and enthusiasm for delivering holistic, scientific, and compassionate care than at any time in the history of medicine, but the grinding inadequacy of provision of the basic raw material of time to spend with patients erodes the spirit, wears out the mind, and exhausts the body.

It is in this context that Hunt expects general practitioners to leap enthusiastically into the breach of out of hours care. No Mr Hunt. We are already working at our limit. You cannot have more for less.

So here is my advice to Mr Hunt: fund the front line. Give us your support to give patients more time. Reduce our case load. Honour the work we do and trumpet our value. Exhort the populations we serve to recognise the true cost of seeing the doctor and encourage them to care better for themselves. Charge people for missed appointments. Pass better laws to limit greed in banking and in globalised tax avoidance in order to help pay for the NHS. Shake off your seedy relationships with purveyors of tobacco and sugar and alcohol. Stop the ceaseless reorganisations of the NHS and stop the endless counting of widgets of activity. What we really want to do, Mr Hunt, is to listen to the dying, the sick, and the frightened and meet their needs. And we want to be left alone to get on with it.

Peter Bailey is a freelance general practitioner, Cambridge.

Patient consent obtained.