🎵 “Where have all the GPs gone?
Gone to leafy suburbs every one” 🎶
(with apologies to Pete Seeger)
No subject prompts more heated discussions around the dinner tables, the pubs, the bus queues, the talking shops the length and breadth of the land than the future of our beloved NHS. Whenever the subject is raised, there are those in our midst, having experienced positive, even life-saving, contact with our system of health care, who swear undying devotion and absolute support for the NHS. And why not? At its best, for those patients in extremis, the expertise, the experience, the cutting-edge technology and the devoted care and attention of doctors, nurses and support staff, are truly humbling. On the other hand, there are an equal number of vociferous critics who bemoan a paucity of available GPs, long waiting lists, inefficient bureaucracy, misdiagnoses, poor nursing care and shoddy infrastructure. And don’t get them on hospital parking fees for patients and visitors.
Clearly, opinions widely diverge. In order to clarify things in my own mind, it would be helpful if I were able to compare at first hand the NHS with the system of health care in other countries. On a recent holiday in France, my wife had need of a course of tablets which she had inadvertently left at home. Neither her GP surgery nor the sister pharmacy in England were prepared to send out a replacement prescription, so she organised a visit to the local doctors’ surgery. She received an appointment on the same day, (immediate answer on the phone – no long wait after being placed 24th in a queue), she was seen by a doctor, who took down all the relevant information, wrote out a prescription, pointed her to the pharmacist next door and - Bob’s Your Uncle - my wifepopped the necessary pill that very evening. Simples! There was of course a fee to be paid up front, but it was not much,and, in any case, who would not be willing to fork out a few euros for such prompt service?
Simple but probably a little arbitrary. It was after all one isolated case, not a fair sample of the French system of medical care. I’m sure the French have their own problems, difficulties and critics. Nothing is ever perfect. The grass always seems greener on the other side of the hill. Let me, therefore, concentrate on the problems confronting our own system.
I had always believed that the Indian Railways employed thelargest workforce in the world, closely followed by the Chinese Army, with our NHS trailing in third place. In fact, research tells me I was mistaken. In first place is the US Defense Department, followed by the People’s Liberation Army of China, then Walmart, then McDonald’s, then the Chinese National Petroleum Company, with the NHS coming in at sixth place. Those behemoths knocking our NHS down the table serve whole continents, let us not forget. Furthermore, Walmart and McDonald’s are global brands. By contrast, the NHS operates only in this country with a comparatively small population of 62 million. So, proportionally, the NHS is a mighty beast – no doubt about it.
I have no knowledge and little understanding of macroeconomics, nor even microeconomics. I couldn’t even balance the books of the boys’ pocket money when I was a housemaster so asking me to comment on how much the NHS costs and how it could be better spent is a bit like asking Donald Trump to define ‘self-deprecation’. Thus, I shall leave the broad brush of political and socio-economic analysis in other, better qualified hands than mine.
Let me therefore confine myself to one arm of the NHS with which most of us have had contact at one time or another. We all have a GP. At least, I thought that was the case. We are told there is a shortage of GPs. Or rather, they are unevenly distributed. In some parts of the country, you can get to see one relatively easily whereas in other areas, they are as infrequently spotted as red squirrels. Why is this? For an answer, I sought the opinion of my son, who is, as it happens, a GP himself.
Well, it’s complicated…..
The unequal distribution can be put down to demographics. In the more wealthy and middle-class parts of the country, in the leafy shires, GP surgeries serve their patients efficiently and well. In the poorer, inner-city areas, GP surgeries struggle with over-subscribed numbers and all the attendant problems of a deprived and run-down neighbourhood. Consequently, GPs in in these areas are becoming disenchanted and are moving to the suburbs, thus leaving fewer doctors with higher workloads and patient satisfaction inevitably diminishes. The old guard are retiring early (changes to pension rules and uncertainty about the future). Furthermore, a large contingency of the GP workforce is female (flexible, child-friendly hours), which puts more pressure on the system. Recruitment of new GPs is stagnating. Who would want to become a GP when there is so much uncertainty around?
The government is aware of the problem, Dr Joe assures me, and wants to address it. Their plan – one they would like to put into action but cannot, for reasons he later explained – is to develop large hubs, super surgeries, if you like - 1,500 has been the number bandied about in political circles - near the larger conurbations, with scores of doctors on duty around the clock. These GPs would be paid by the government – a fair wage, obviously – but they would lose the independence that they currently enjoy in owning their own practice. So, patients would have to travel into the city to be seen but at least they could be assured of an immediate appointment.
There are two, insurmountable obstacles in the way of this plan. First, we are by nature conservative, especially when it comes to health care. We don’t, as a general rule, like change, especially those of us beyond a certain age, the ones most likely to need to see a doctor, and who don’t want to travel some distance to see a doctor they have never met. This cohort of elderly patients likes the family feeling of a local surgery and would be resistant to any upheaval in the status quo.
Then there are the doctors themselves. GPs who are partners in a practice - where they enjoy autonomy - know their patients, know what works and what doesn’t, feel that they already provide an efficient and compassionate service and relish working in a friendly environment where everybody, from cleaner, to receptionist, to nurse, to doctor operates as a team. There is also a pecuniary aspect here. GPs who own their own practice are unlikely to relinquish control of a business they have sedulously built up over the years and in which they have a considerable financial stake. Turkeys don’t vote for Christmas, not with a signed and watertight contract lying in their desk drawer, they don’t.
Nonetheless, the government (of whatever shade) will want change because the political pressure to ‘fix’ the NHS is swelling and the ‘superhub’ project is the only logical way forward. The plan envisages some 35,000 to 40,000 patients attached to these superhubs, with everything done on a larger scale, incorporating doctors, pharmacists, physiotherapists and other health care workers under one, very large roof. The 7,500 GP surgeries countrywide would be pared down to 1,500 superhubs.
But large numbers of GPs and patients regard the ‘superhub’ solution as no solution at all. Big is not always better. Will patients really believe that these extreme changes are in their best interest? A compromise that is being kicked around in committee rooms and think tanks within the NHS might be that several GP surgeries merge within their neighbourhood, under the proviso that the GPs maintain their autonomy to decide what is best for them and their patients. With an ageing population, most people agree that change must come, but it must not be done precipitously.
To fight off this unwelcome government initiative whilst at the same time discussing and planning what is best for their patients has meant a great deal of politicking which takes a doctor, my son included, away from his surgery and into those stifling committee rooms, something he does not welcome.
So, where does that leave us all? Dr Joe throws his hands in the air. He did not spend all those years training to be a doctorto take on the role of a politician. What is certain, he believes, is that uncertainty will abide for some time yet.