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.