Ted Willis: Consequences of the “John Wayne” contract (“A GP has to do what a GP has to do”)

Ted WillisWhy is general practice unpopular, with low morale, falling applications for training, and—according to some experts—poor overall performance? I have worked as a GP for over 25 years and it is clear to me that this is an inevitable result of the way we are paid mainly according to capitation, rather than by item of service. This has allowed our managers to add massively to our workload, while workforce capacity has only increased slightly.

Chronic disease management is perhaps the area of our work that has increased the most. For example, the number of patients with diabetes has roughly doubled in the last 15 years, and the management of each patient has become much more complex.

Similarly, the management of atrial fibrillation used to be a pretty simple affair of titrating digoxin dosage, but now requires a complex analysis of a whole variety of options for treatment. If patients are put on warfarin, they then require monthly blood tests, prescribing other medication is tricky and time consuming, and the planning of medical procedures is more complex. There are more older patients who are treated with more drugs, and that all takes more time. In addition, there are far more lab test results to be checked and this also has become a major part of a GP’s workload.

Preventive medicine used largely to be a matter of cervical smears and checking blood pressures. Now we are supposed to “make each consultation count,” and deal with obesity, smoking, alcohol, domestic violence, osteoporosis prevention—as well as advise on breast, prostate, and bowel cancer screening. The guidelines from the National Institute for Health and Care Excellence (NICE), for example, on prevention of cardiovascular disease with statins took no account of their effect on the demand for consultations with GPs.

Administration work has gone up hugely: the Quality and Outcomes Framework (QOF), the Care Quality Commission (CQC), clinical commissioning groups (CCGs), prescribing and referral analysis, applying NICE and other guidelines, and preparing for appraisal and revalidation. Adding up all the time spent by local doctors on the CCG in our area uses up around 2% of the total GP workforce. All of these have been added to our workload in the last 10 to 15 years.

The work involved in liaising with hospitals has also increased vastly. Just dealing with incoming correspondence (still mostly arriving on paper rather than electronically) is now a major burden. The number of hospital doctors has increased far more than GP numbers, and the amount of mail has gone up correspondingly, together with sometimes unreasonable expectations of our ability to carry out their instructions in terms of prescribing and follow-up testing.

There has also been a big increase in the demand from patients arising from well meaning advice from health charities and public health campaigns. We see patients every week who are worried about harmless skin blemishes, as a result of increased awareness of the relatively rare condition of melanoma. Similarly, we regularly see terrified men who are sure that they have testicular cancer, which killed all of 63 men in the UK last year, according to the most recent statistics.

The increasing medicalisation of some aspects of life has also added to the demands placed on GPs. Attention-deficit/hyperactivity disorder (ADHD) and the epidemic of “depression” are the main examples.

The underlying problem is the open ended job description of the GP contract—aptly named the “John Wayne” contract—which basically says, “A GP has to do what a GP has to do.” There has been an obvious temptation for NHS management to exploit this very loose definition of our responsibilities.

We have coped with this to some extent. There has been an increase in the share of our work done by nurses. In some ways, this has been a step forward as they are often more systematic, although patients often complain that they have to attend several different nurse run clinics—one for each of their chronic diseases.

The adverse consequences, however, have been huge. Care has become disease centred (rather than patient centred), polypharmacy is rife, and we manage multimorbidity badly. We do far less home visits, meaning that some of our patients most in need of care are thereby neglected. Continuity of care has plummeted, sometimes leading to a tendency for overworked doctors to shunt problems on to each other, sometimes by arranging needless investigations. Access to GPs has become more difficult for patients, with many practices putting up barriers in the form of complex telephone menu systems and triage nurses.

So when experts accuse GPs of performing badly—citing, for example, the UK’s poor statistics on early diagnosis of cancer—perhaps they should look for the underlying reasons as to why the vital job of sorting the wheat from the chaff, and spotting the patient with a serious disease, has been pushed aside by all the extra work that has been piled onto our plates.

And the next time someone gets the idea that GPs should take on some new function, then the question must be: who will be taking on the job that we will stop doing as a consequence? . . . Because we will have to stop doing something.

Ted Willis is currently a GP in Brigg, North Lincolnshire. He has also worked in Denmark, Scotland, Zambia, South Africa, and New Zealand. He is interested in health economics and the amazing inefficiency of many healthcare systems.

Competing interests: I am a GP partner.