Only later, perhaps even a decade later, as the pandemic of 2020-22 shrinks in our rear-view mirror, may we be able to assess its enduring consequences. So I am only speculating when I suggest that one of these may be the beginning of the slow death of general practice in the United Kingdom.
And, no, this will not be a column attacking Britain’s GPs, whom I think to be mostly dedicated and hard-working men and women whose careers are demanding, whose work is difficult, and who are not paid excessively for the hours and expertise they bring to their vocation. Rather as with the class for which we use the generic term ‘politicians’, public discontent about ‘GPs’ is felt towards the generality. Local doctors whom we really know, like local constituency MPs we know, we tend to respect. Nevertheless, judged in terms of perceived lockdown performance, general practice has had a dreadful war. Such criticism as has surfaced in our news media is only the tip of an iceberg of public disapproval, verging on anger, heard at kitchen tables and private chatter across the land. I don’t wish to repeat or amplify it.
Indeed I’m inclined to question it. The biggest popular gripe has been that a remote consultation is no substitute for a real, face-to-face appointment. But what if the contrary is true: that remote is in many — perhaps most — cases just as good or better than going in to a local surgery and sitting in a waiting room full of sick and possibly infectious people, until one of a large team of doctors who probably doesn’t know you anyway is ready to give you what he or she hopes to be no more than ten minutes’ attention?
What should really worry family doctors and their trade union, the British Medical Association, is that the BMA’s complaint (voiced last month by GP committee chair, Dr Richard Vautrey) is justified. Dr Vautrey was responding to the government’s idiotic knee-jerk response to public disquiet: to try to write in-person patient contact into doctors’ conditions of funding. It was disappointing, Dr Vautrey said, ‘to see that there is no end in sight to the preoccupation with face-to-face appointments’. Dear oh dear. An entirely defensible statement. But has the BMA not considered where it leads?
Many years ago I wrote at some length for the Times about what I argued was the approaching obsolescence of the idea of the family doctor. Judging by the sackful of letters this prompted, many GPs were indignant at my argument. Two letters in particular ended with invitations to sit with the GP correspondents in their surgeries and see for myself the value of personal interface between doctor and patient.
I accepted both invitations, one from my own local surgery in Matlock (a partly rural practice) and one from a busy surgery in an often underprivileged part of east London. In both cases each arriving patient was asked if they minded if a journalist (who promised not to identify any individual) sat in on their consultation. Only one patient did, and I watched and took notes as two excellent, kindly, hardworking GPs made their way through a daunting list of different patients with wildly different complaints, some serious and some minor. Some patients, especially elderly ones, struck me as being just lonely.
This exercise complete, I wrote a second column, trying to summarise what I had learnt. On three counts I felt I’d better understood something of which I’d been only partly aware. First, the occasional usefulness of the personal link between a patient and a doctor who knows them and their history. Second, the reassurance that can come from face-to-face contact — especially for the ‘worried well’. Third (and related), the role of the family doctor in guarding the gateway to specialised medical services, and filtering out patients who did not really need them.
All heart warming. But the problem is this. Even as I wrote, and long before this pandemic, the medical profession itself was weakening the personal link that can generate patient confidence and may (though I’m dubious) improve diagnostic outcomes. Without that confidence and trust, the gatekeeper role is undermined, because a worried–well patient is less likely to be reassured when the doctor is just an anonymous face from a large panel of doctors in one of our increasingly common group practices. Busy people these days don’t often ask to see a particular doctor, known personally to them. Doctors these days rarely make home visits. Remote consultation, the reliance on ‘triaging’ that lockdown has brought, intensifies the weakening of those personal links.
The best justification for having GPs at all lies in harking back to a model of general practice that the medical profession itself has been moving away from for decades. Their long-established direction of travel (only accelerated by lockdown) points logically toward our taking maximum advantage of the possibilities for remote consultation that modern IT is opening up. But this means of consultation and diagnosis calls into question the very role of someone we call ‘my GP’. If I think I may have skin cancer, I want a link to a specialist.
We’ll always need gatekeepers, because health worry will always exceed good cause for health worry, but do gatekeepers really have to be inevitably generalist GPs to whose patient lists you have to sign up, theoretically geographically based in a ‘surgery’ somewhere which you may or may not be allowed to visit? We are moving into a world in which a patient’s first access will be online by video or telephone. The second stage (if need is indicated) will be to a specialist clinic, polyclinic or hospital, with diagnostic equipment on-site. Prescribing can be done online, as is already happening.
The BMA’s problem in reassuring the public that most stuff can be done remotely is not that they are too wrong, but that they are too right.
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