GPs in the dock: case for the defence

It has been an interesting few months for GPs. From headlines decrying family doctors for earning too much and doing too little, to perceived or real threats from the private sector, to the brave new world of polyclinics and a constant focus on access, there is a growing feeling that perhaps in these days of choice it is anti-competitive to stop patients going straight to their preferred specialist.

A while ago in HSJ, Long-Term Conditions Alliance chief executive David Pink spoke of the value of patients holding their own budgets, saying these were potentially valuable in improving access. His reason was simple: at the moment, "costly and time consuming gatekeepers" hamper access to services. I guess that must mean me. After all, I am a GP, I do not appear to be cheap and I function as a gatekeeper.

So wouldn't it be much simpler for patients to access specialist care straight away? Is general practice not an anachronism?

In all the heat and noise around GP contracts, access and out-of-hours care it is easy to forget that nearly 90 per cent of the work of the NHS is carried out by GPs and their teams. Around 1 million patients are seen every day in British general practice, but too many people undervalue the complexity of the generalist's role. It is not just sore throats and sick notes, it is most of the care experienced by most of the population most of the time.

An inconvenient truth

Perhaps this failure to recognise the strength of general practice results from the fact that for most of the time the job does indeed look relatively easy. The majority of patients come into a reasonably warm and comfortable office, tell of their woes, are given advice or a prescription or both and leave. A trained and experienced doctor should look calm and unrushed, whatever torment of anxieties, concerns and pressures may be bubbling beneath the surface.

As a result, when the success of the NHS is judged solely on hospital waiting lists, there are those who wonder if the NHS can afford the luxury of frontline GPs seeing apparently minor illness.

But international research has shown that hospital (yes, hospital) mortality rates are even more closely related to the number of GPs than to the number of hospital doctors. The more GPs, the fewer hospital deaths.

Why should it be that GPs have such a major effect on the nation's health? The simple fact is that keeping patients away from hospital, except when it is essential, is generally good for them. In addition, research shows that doctors who know their patients are less likely to admit or investigate them.

GPs not only see huge numbers of patients but they absorb huge levels of risk and uncertainty. This is similar to the effect of a device found in every computer. Known as a heat sink it appears to do little other than absorb the heat in the system, but if you take it away, the system crashes.

I once described general practice as the risk sink of the NHS because, generally, referral rates to specialists are low. On average, only five patients are referred to secondary care services for every 100 consultations. An experienced GP is likely to know when a headache needs an urgent investigation and when it is a result of disease or unhappiness. No doctor will always get this right but high satisfaction and low complaint rates point to a high level of skill.

Under threat

In a randomised study in the US, men aged 55 and over were directed to primary care either with or without continuity of provider. For those with continuity of provider there were fewer, shorter emergency hospitalisations and greater satisfaction.

And healthcare systems with a strong primary care focus have been shown to have numerous effects, but two stand out. Strong primary care improves health outcomes and reduces health inequalities. Just what else are we trying to achieve in the NHS? No amount of talk about access and gatekeepers and expense can take away from this vital truth. But it is under threat. An entirely reasonable drive for rapid access at any cost means that continuity and individual care may in some practices be threatened. The dream of many healthcare planners would be to have general practice broken down into bitesized chunks, allowing delegation of almost every task to a wide range of professional and semi-professional staff.

Over the past few years there has been an increasing perception that a GP's job can be done by algorithms and numbers. Guidelines, national service frameworks and evidence-based medicine have been sincere and valuable developments but grossly fail to understand the complexity of the GP's task.

There is far more to caring for people than caring for disease, essential though that may be. The skill of general practice should relate to a holistic, whole-person assessment. While there are patients for whom a simple algorithm of care is highly appropriate - an otherwise healthy non-smoker with significantly raised blood pressure might be an example - there are countless more for whom such simplistic reductionism loses some of the most valuable aspects of care.

The sheer complexity of general practice is often overlooked by those who do not understand how we work. Take the example of an elderly, hypertensive, diabetic man with poor vision who has depression (possibly because he is an elderly, hypertensive, diabetic man with poor vision). Can someone please direct me to the exact guideline that tells me the best way to treat him? As most clinical trials are based on patients with single disease entities, it becomes near impossible to determine what evidence can be used. But while the trials can exclude such patients, GPs cannot exclude them from their care.

Last Tuesday I was consulted by nearly 40 patients. I have no idea how I can take on board each and every patient's ideas, concerns and expectations, unravel the cause of their problems, offer the appropriate remedy, advice or referral, explain, discuss, share and simultaneously make sure that I spot the occasional truly urgent life-threatening problem which requires the right diagnosis instantly. But that is what I have to do. That is what every one of Britain's GPs has to do.

Most of what we do in general practice is intensely complex. Even something as simple as a headache is surrounded by uncertainty. Which patients need investigating? Which need reassuring? Which ones need admitting? When there are no guidelines - and there usually aren't - the art of medicine becomes intensely complicated.

As one new GP registrar said to me at the end of his first surgery sitting in with me: "I just don't know how you dare practise like that." Seeing a look of alarm on my face, he quickly rephrased his comments: "I mean it as a compliment. In hospital we wouldn't dare see a headache without arranging an MRI scan. But you knew how to deal with that patient's headache without one."

And he was right. If you were to cut GPs out of the system, the NHS would collapse. Studies show that family doctors working in emergency rooms are significantly less likely to investigate or admit patients compared with junior hospital doctors, a classic example of the risk sink in action again. And look what has happened in areas where fewer GPs are commissioned to work out of hours and more assessment is done by others: admissions have gone up. It is a powerful lesson for every commissioning organisation tempted to cut costs by using fewer doctors: it will cost you.

Personal touch

But there is so much more to the tasks of the GP. We are whole-patient doctors, the doctors of patients with names. We bring a generalist perspective now unique in medical care. A while ago, I received a letter from a man with prostate cancer enclosing two papers from academic journals about the management of his condition. His letter said that he thought I "might like to read them before our next consultation".

When he next came in, I politely pointed out that I probably was not the best person to help him with what sounded as if they would be highly technical questions as I am far from being an expert in prostate cancer. He said he knew that but he was there "because you're an expert on me". The value of personal continuing care has rarely been described more succinctly.

Reducing the doctor's task to building blocks might sound efficient, but even if implemented intelligently such an approach could damage that which so many patients and doctors hold dear.

None of this means there are not problems in general practice that need to be addressed. But there is little doubt that cutting out a layer of "costly and time consuming gatekeepers" would demonstrate once and for all what the word "costly" really means.

For more analysis, see Care Quality Commission: a chance to peep under the primary care carpet