Where is the Family Doctor?

I went to the surgery in person, expecting it to be full. It was empty. I called out in a loud voice, asking if there was a doctor in the building…

This happened two years ago, before Covid, when I had an infected discharge in my ear. I telephoned my GP surgery, after several attempts, during which I was urged by recorded message to try NHS 111, before eventually being answered by a receptionist.

I was then offered a telephone consultation with the practice nurse three weeks into the future. As a former GP and trainer of GPs, I knew this was inadequate. There was no alternative. Our conversation was polite. I immediately went to the surgery in person expecting it to be full. It was empty and there was no GP in the surgery. One of my ex-trainees came out, looking alarmed. He referred me to an ENT specialist, that afternoon, where I was treated. I had had a penicillin resistant Staphylococcus infection.

If this incident were isolated, it perhaps wouldn’t warrant any further consideration, but it is not. Over the last 10 years, I and other friends of mine around the country have all had similar experiences. There is something seriously amiss with General Practice at the moment and it has happened over the last decade. It is not surprising that so many patients end up in A&E.

Rightly, we all value the NHS. Millions of pounds have recently been donated to it. People go into the street to clap the staff. So what has gone wrong with what should be its first port of call, the family doctor?

Left: 1958 -Family Doctor Bradford Timeline

It started in 1999 with a laudable pilot scheme in East Kent, called Primary Care Clinical Effectiveness (PRICCE).  GPs in East Kent monitored a range of medical conditions, including type 2 diabetes, ischaemic heart disease, hypertension, raised cholesterol and many others. It was a worthwhile voluntary enterprise, but added a considerable workload on all those who participated. Almost all the practices in East Kent came on board.

When the trial period was over, it was suggested it be rolled out nationally. I felt this would be too great a burden and that it would initially be better restricted to just the four aforementioned conditions. If at a later date the profession felt able to take on more it could do so.

GPs exhausted

At the same time there were other increasing demands. GPs were exhausted with having to work a full day and do night calls as well, with no recovery time. To address this, they organised themselves into large cooperatives for out of hours duty. They employed drivers and secretarial staff to man the phones, and funded it themselves. It was an effective arrangement, but it wasn’t cheap and it was a significant administrative burden on those doctors who organised it. When help from the government was sought, they requested a subsidy to help pay for the ancillary staff. It was a modest request.

What happened next shook the foundations of general practice, and was barely believable. GPs were suddenly relieved of their 24 /7 responsibility. In exchange, GPs were asked to adopt a new payment method, attached to items of service and data collection: the idea taken from PRICCE.  Overnight, GPs reduced their hours of work and had a huge increase in their salary. In amazement, a colleague said: “We’re on twice the salary,  four days a week and no nights.” It seemed too good to be true – and it was.

For the next five years General Practice was the favoured occupation within the NHS. Specialists were envious, but it couldn’t last. To correct the blunder, demands were stepped up for more data collection, and tougher target setting. Briefly gamesmanship and even cheating emerged before the authorities got wise to it and clamped down.

Merging practices

Many doctors who entered the profession to practice clinical medicine became increasingly disenchanted. Others, more entrepreneurial, saw the opportunity to make even more money, started to merge failing practices, employing data clerks to ensure hitting targets and recruiting newly trained doctors as assistants to do the clinical work.

Some entrepreneurs earned huge salaries, amounting to £250k per annum, whilst the young doctors they employed were content to take well paid sessional work. They had little incentive to uphold the welfare of the practice. It was just a job. Everything became depersonalised. 

The concept of old Dr Findlay, who knew all his patients through three generations and looked after them day and night, was gone, perhaps for ever.

As for the new young GPs, many no longer want to be partners in practice, to be saddled with a large debt from having to buy in, preferring instead to work the hours they wanted with clinical work and take the money. They could ignore the added burden of data collection and target setting, which they hated anyway. When Covid hit, the situation lent itself easily to remote telephone consultations, scheduled often with a practice nurse, rather than the GP and frequently some weeks ahead. It is a service which saddens many retired GPs.

Ironically, few within the NHS are satisfied with the present service. GPs in their 50s want to retire early and young GPs no longer wish to become partners. A&E departments are fed up with seeing patients who should be with their GPs, and hospitals are fed up with being penalised because their A&E waiting times breach the rules.

Worried patients must now contact the impersonal NHS 111 call centres, who man the phones with nurses, who are better paid than they would be if they worked in hospitals. Not long ago family doctors saved the NHS by acting as an effective filter for more expensive specialist investigation.  Now practices are replaced with large Polyclinics, financed by PFIs with crippling interest charges: much more for much less.

It is no surprise that the Chinese have an ancient proverb: “The flapping of a butterfly’s wings may cause a hurricane on the other side of the world.” Had it not been for a brief lapse in negotiations, this would never have happened. And we are stuck with it.