31st May 2013 

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Too late    
News and Comment from Roy Lilley

I have always thought being a GP must be fabulous.  What other work could be so satisfying?  Knowing, in intimate ways, you've changed a life, saved a life, been a lifeline in the labyrinth of illness.  What a fabulous job.


The variety, the unparalleled sense of quiet fulfilment.  How good it must be to hear the words; "Thank you doctor" and know they come from a place where only the truth resides.  Being self-employed but unlike lawyers and accountants, never having to look for a customer and in the top 1% pay-bracket.  Does it get any better?


Sadly, I fear the craft of general practice is in a place where doctors are no longer at ease with themselves.  They are touchy, prickly.  They are neither independent, nor contractors; they do what is dumped on them.  They work hard - but not like road diggers.  Long hours - but not like the exhaustion of a factory shift.  They have the weight of responsibility - but not like the police rapid response fire-arms unit.    


Local, living in a community that depends upon them but in other places, a treadmill.  The undeserving treated by the unwilling.  GPs are echinated...   Practices swing between Ikea cool and stuffed-to-the-gunnels, car-boot-sale.  General practice is eclectic...


I never thought I'd say it; I agree with LaLite; it can't go on.  I fear general practitioners may be set to become lamplighters in a digital world.  GPs workload is becoming unmanageable.  There are around 300,000,000 GP consultations, every year... increasing.  The Mystic-Megs of workforce modelling say (Page 4) if recruitment holds up we might struggle through.  They don't inspire me with confidence:


 "...achieving and maintaining 3,250 GP trainees per annum is necessary to address future demand, and should be the top priority... Given the rapidly changing nature of healthcare and the inherent uncertainties about future demand... we... recommend there be periodic reviews... supported by a stronger evidence base."


In other words, they don't really know.  Since 2008 SHAs tried and couldn't manage 800 a year. (Page 8)  Here is something else I agree with: 


"On the demand side, we see some scope for GPs to improve their ways of working over the longer term... (this would)...  help to ensure that any remaining demand-supply gap is closed."


GPs have to get to grips with demand management, work-flow and system-shaping. The days of; ring-up, wait, receptionist, wait, appointment, wait, see the Doc, wait...  ain't gonna crack this.  Look what is happening to the high street.  The same forces are at play here.  As a business model Primary Care needs refreshing. 


Aren't we forced into a new set of assumptions? 


Assumption 1; Doctors should answer the phones in the morning, not a receptionist.  Who better to decide if an appointment is necessary?  And, get used to the idea the first resort for consultations might be by email, Face-Time, Skype, the web and the phone.  A surgery visit, when all else fails.


Assumption 2; Every practice should have a self-care nurse-practitioner, training and coaching patients away from being a cost centre and looking after themselves.


Assumption 3; Where ever possible long-term conditions should not be clogging up waiting rooms.  They will be tele-maintained on the web, self-managed and supervised by regional health and wellness call-centres, funded and run by GP federations. 


Assumption4; The millions needed to bring the primary care estate up to scratch and absorb secondary care services is unfundable.   Forty percent of practices with no more than 4 GPs is a not a goer. (Page 10)  Federating to get to 30+ might make the skills of general practice future-proof?  Bigger is better but with case-holding community nurses working in community centres, Mother-Care and Church Halls.  Satellite GP surgeries in Sainsbury's.   


Assumption 5; Bigger surgeries that redefine the GPs role in the community.  Practices becoming become community centres, drop-in places, child-care schools for young Mums, places where people can go and learn to turn ingredients into healthy meals.  IT teach-ins, health and wellbeing workouts.  Workshops for the new generation of retirees to potter, repair, make and meet without having to play Bingo and sing the songs that made Vera Lyn famous.  Coffee shops, book exchanges.  Social services, CAB, job-centres, physio's and rehab, just down the corridor.


If GPs stand still they are in danger of becoming inundated by the same forces that are destroying the high street.  We need GPs to be where we are now, where our lives are nowadays, in the places we inhabit.  This is not an 8-6 world, this is not a closed at the weekend existence.  This is increasingly an on-line, on-the-phone, on-the-go, converged lifestyle.  New technologies have to be used to create head-room for the practice to see the people they really need to see. 


I want GP practice to survive, not by clinging to the wreckage of the past but by building a new future.  Assumption 6; they may have left it too late.


Have a good weekend.  

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