A and E [Casualty dept] waits are at an all-time high and the pressure is likely to increase during the winter when illnesses increase. David Cameron has promised that he will take a personal interest in the coming months. The Health Minister, Jeremy Hunt has complained that the 2004 GP contract deserves much of the blame and the press has complained of ‘lazy GPs’. Unlike most other countries 90% of all consultations in the NHS are done in Primary Care. In the UK very few children will ever see a paediatrician, very few women ever see a gynaecologist in their life times and hardly any elderly see a geriatrician. The vast majority of patients with chronic illnesses such as asthma and type 2 diabetes receive their entire care by GPs in Primary Care. GPs are known as ‘gate keepers’ in the NHS. The only way you could be seen at a hospital was that you were referred by your GP or has a serious accident or emergency. The majority of people coming to hospitals had been vetted and referred by their GP who knew them. Hence GPs are known as gate keepers. GPs were able to keep a lid on demand because they are best at deciding who is really ill and needs to go to hospital and pre the 2004 GP contract they were responsible for providing emergency out of hours care for all their patients – at night and at weekends. The 2004 GP contract enabled GPs to give this work up and this was replaced by ‘out of hours primary care services’ and ‘walk in centres’. Some GPs do still work on rotation out-of-hours, caring for patients in their area but there are indications that patients have lost confidence in out-of-hours primary care services. Even when GP surgeries are open, the wait to see a doctor can be a week or more. A survey by business analytics company SAS suggested one in 10 people now has a “hospital-only” mentality. This means they go to A&E even for trivial problems because they are not prepared to wait for a GP appointment. The NHS 111 helpline was supposed to ease the pressure, but its launch was so shambolic it has just made the problems worse. The number of people attending A and E has gone up by 50% in the last decade however the number of appointments offered by GPs has also gone up by 50% in the last decade. There are still not enough GP appointments to keep up with demand; it is not GPs being lazy.
General Practice has changed. Pre 2004 each patient would have a named GP; practices such as mine operated personal lists which meant that patients could only see their named doctor unless that doctor was away. The upside to this was that the doctor patient relationship was strong. The doctor knew the patient and their families well. They were able to control their out of hours calls and visits to patients appropriately because they knew them. Holistic, family orientated General Practice with continuity of care was greatly valued. Nowadays patients do not have a named GP that they belong to. They may see different doctors within the Practice at different times and may not know them and trust them. Can we turn the clock back? Can GPs be made to be responsible for out of hours work and A and E attendances again? GPs ‘day work’ has got harder. Most GP surgeries open from 7.30- 8.00pm; more work has moved out of hospitals and done in Primary Care. ‘Commuter clinics’ early in the morning and evening are provided to satisfy those who do not want to take time off work, GPs have been encouraged to specialise and see patients not just within their practice but those of other practices who would otherwise be referred to hospitals and they have also been landed with the job of Commissioning and spending the bulk of the £100 billion NHS budget.
To add to this there has been a massive demographic change. In the past a GP would normally be a man with a supportive wife taking calls and an active role in the community and helping her husband. When I started work my Practice had two part time women and 6 full time male partners. Now the majority of GPs are women who don’t have a spouse to help out and want to spend some time with their children. Turning the clock back would be extremely difficult; patients expectations have soared and many now attend for trivial reasons or for reassurance. Work has also moved from hospitals to General Practice and there are just not enough GPs to do it.