I faced a difficult career decision 28 years ago. I wanted to go into general practice, but should I opt for a rural practice, where biomedicine had a clearer role, or for inner city practice, where needs were greater but medicine seemed less important?
I wanted to go into general practice because of its variety and multiple challenges and because it meant being part of a community with a role, albeit limited, in improving the health and wellbeing of that community. But choosing was tricky: rural practice, where biomedicine had a clearer role, or inner city practice, where needs were greater but where medicine often seemed less important than other health related areas such as housing, education or social services?’
David Widgery in Some Lives expressed vividly the frustrations of an inner city doctor unable to change the lives of his patients – frustrations that undoubtedly had a part in his premature death at 40.
John Sassall, another GP, whose work was described in The Fortunate Man, expressed a similar and deep frustration working in a rural but deprived practice in the Forest of Dean. He said: “Our present society wastes and, by the slow draining process of enforced hypocrisy, empties most of the lives that it does not destroy. A doctor who has surpassed the stage of selling cures is unassessable”. His own feeling of emptiness may well have been a factor in his later suicide.
Both these GPs were committed and compassionate doctors frustrated by the way the system prevented them from making a real difference for their patients.
Fast forward, then, to March 1993, when 40 or so GPs and managers met on a grey day in Telford to vent their deeply held frustrations at being unable to have any effective impact on the health of their patients or the services they received. The GP commissioning movement was born. It originated as a nonconformist movement of GPs and other primary care clinicians and managers. They were fed up with being “told by the centre”, fed up with the primacy of secondary care over primary care and fed up with all the inefficiencies (and then very long waits) that were an accepted part of how the health service worked.
Those commissioning GPs wanted to make a real impact outside as well as inside the consulting room. It was a mission and ethic that quickly fired the imagination of many other GPs, who were ambitious for their patients and that they should get better health and care. Prior to the Labour election victory in 1998, over three quarters of GPs supported the concept of what was then called Locality Commissioning. Thus clinical commissioning and clinical commissioning groups (previously called GP commissioning and GP commissioning groups) belong to a movement that has been championed and progressed by GPs themselves over many years.
Why then are there so many reports in newspapers that GPs are against it all? In part, this may be an expression of understandable cynicism and despair. This inherently logical concept has already been tried out in Locality Commissioning Group Pilots, Primary Care Groups, PCTs and most recently practice based commissioning. In all cases, senior management dominance, an over powerful secondary care sector and centralism have managed to crush the ambitions of those commissioning GPs. Some, who might otherwise support clinical/GP commissioning, feel defeated by the past and are rightfully suspicious that all the usual forces will once again conspire to paralyse any effective voice of frontline clinicians in improving services and the health for their patients.
These are not, however, the most powerful objecting voices. Some simply want to contain their work to the individual consultation because they do not have the time or stamina or the imagination or the ambition to extend beyond those 10 minutes in front of the patient. The problem with this view is that it assumes that we can make a real difference for our patients simply by meeting their demands for face-to-face appointments, visits and telephone calls. It ignores the most needy and excluded as well as those for whom medicine could achieve the most. It also sustains a provider-driven health service model with no perspective on how resources might be better used.
Regardless of what we might want to be, there are some who say GPs can not be individual patient advocate and at the same time advocates for the whole patient population, championing “the greatest good of the greatest number”. A man cannot serve two masters. This frequently quoted argument is an ethical cop out of Pontius Pilate proportions. If we are not prepared to balance the good of the individual versus that of all the local population – then who is? Furthermore, if frontline GPs, clinicians and patients are prepared to roll up their sleeves and plan better coordinated services and how money can be better used then things in the consulting room should also improve.
There should be a better menu of choices available and possibly more resources because there is less waste in the system. The alternative, which some GP colleagues seem to prefer, is to wash our hands of responsibility then bellyache that there is never time in the consultation, that services and health initiatives are failing and continue blaming someone else rather than getting out and doing it ourselves.
Perhaps the fundamental issue is not so much about ethics but about the amount of effort we are prepared to make. The GP working day may be very busy but pay and hours are not bad. So why should we bother take on extra commitments and responsibilities? Have we become the jobsworths that some of the tabloids would make us believe? I hope, and think, not.
Most GPs are genuinely challenged to think how they can really alter local health and services. They would be up for it if only they did know how and if they were given the support and resources to do so. Instead, they are continuously assaulted by all sorts of self-interested parties suggesting that clinical commissioning will make things worse rather than better. How and why should things be worse if decisions taken at the centre by managers with little day-to-day contact with patients are replaced by decisions made by frontline clinicians and patients?
It does seem extraordinary that GPs appear, in all seriousness, to want to turn their back on a leadership role that will not only enable them to make a difference for their patients but will also establish a sustainable future for general practice itself. Of course, there are plenty of vested interests against all this. Centralists, traditionalists, managerialists and recidivists all joining forces with the apathetic, the alienated and anti-everything. Many of them don’t like general practice and think GPs are not up to it. That is par for the course.
What seems unexplainable is why any vocational, committed and compassionate GPs should want to swell their ranks. Because the big question facing us is: “Do GPs want to play an effective role in creating a better and more sustainable NHS or do they want to turn their backs on it and say that is someone else’s job?” It is as simple as that.
There are problems with some of the detail of the Health and Social Care Bill but it is time for GPs to think beyond detail towards the end game and the big game. We need to be a little more ambitious for ourselves and for our patients. To reach beyond the restrictions of the here and now. It is time for general practice to regain a collective conscience. To adopt a “can do” attitude and grasp the means – now uniquely at our disposal – to create a health service that is clinically led.
Admittedly these aren’t the best economic circumstances for us to assert ourselves in this way. Paradoxically, it is because of the economic circumstances that we are so needed and now offered this opportunity. General practice must move forward from learnt helplessness, perceived thinking and seeing every government announcement as a plot against them. GPs and their fellow professionals must move forward to seize power and take control. To make history and make those differences that we always say are important but have all too often failed to achieve.