Last time I invited responses to two questions: how to choose a GP and why bother now that direct access services are so good?
First off, John Toby wrote to say he is disappointed that I used this column 'to question the benefits of general practice' and insists 'the role of gatekeeper for which your successors as finance directors should be grateful will also be needed on a long-term basis'.
And Brian Balmer finds it surprising 'that a former finance director should appear to recommend such an inefficient use of limited NHS resources'. Not guilty, m'lud. I was merely asking a question and wondering why new arrivals in Britain seem to choose direct access.
HSJ readers' suggested reasons for bothering to register range from pragmatic self-interest to civic duty. For GP Peter Ward the alternatives - walk-in centres and accident and emergency departments - are great 'if you don't mind lengthy check-in procedures, long waits, junior doctors two years out of medical school who order tons of tests and protocol-driven nurse-led care; go with a sore finger and they'll check your blood pressure and take a urine sample. I don't think many A&E departments or walk-in centres do house calls either.'
Quite so, though neither do many GPs since the new contract came in. GP Steve plays the fear card. 'Hospitals are best avoided; over-investigation and over-treatment are dangerous.'
Several contributors point out that not having a GP may be fine when you are well. John Chisholm wrote: 'Those with long-term conditions, personal distress or terminal illness are far more aware of the benefits of a continuous relationship with a GP.'
Royal College of GPs chair Professor Steve Field cites a study that found interpersonal continuity was important to 63-75 per cent [of patients], particularly those with poor health. 'The majority wanted to consult someone who was familiar with their clinical history. One of the reasons for a general dissatisfaction with the NHS might be insufficient attention paid to values like continuity of care.'
Mark Pittman, emergency nurse practitioner at a minor injuries unit, proposes a practical self-triage tool. 'If it's believed to be life threatening or involves chest or abdominal pain of any sort, ring 999. If it's chronic, long-standing and slowly getting worse or unresolved, see a GP. Anything else, depending on severity, go to an A&E unit, an MIU or a walk-in centre.'
But if you do want a GP how to choose one? Well, let's start with how not to choose one. GP Steve advises being wary of anyone 'with onerous outside responsibilities (professional executive committee members are never around when patients need them) and anyone who offers homeopathy'. And Rory O'Conor tantalisingly observes that 'one of the few people who could advise you as to which practice not to sign up with would be the primary care trust medical director'.
Professor Field advocates the NHS Choices website, using sensible criteria such as the qualifications of individual doctors and the existence of patient partnership groups.
But how real is choice? Mr Pittman maintains it is determined by availability and postcode. And in the absence of objective data, what other metrics might be useful? Suggestions were:
Proximity and quality Select a practice within easy distance - in a town, walking distance - which should limit you to five, then pick one with three or more partners and a quality and outcomes framework score in the top 25 per cent;
Knowledge, wisdom and negotiating skills Good gambits are 'Do you think I should have the blood test for prostate cancer?' and 'Could I have a prescription for some sleeping pills?';
Prescribing 'You should apparently be on one pill for every decade over the age of 10' (says Steve, who is 55 and on four);
Quality benchmarks 'Not all GPs are the same. Our practice is one of the 2 per cent that is in receipt of the quality practice award,' says Charles Alessi.
There is always personal recommendation, but where to obtain one? Easy, says Arthur Hibble, if you have a young family. Ask the opinion of the ready-made focus group at the school gates.
Steve reminds us that the clergy are a good source of advice; 'educated, networked into the community, conduits for local gossip, see a lot of the sad, the old and the ill (as GPs do - and as you will one day be)'. Thanks for that cheery memento mori.
Thanks also to Michael Taylor, for whom my picture, 'which I imagine is two years out of date, suggests that you should have a fasting blood sugar with your cardiovascular MOT'.
Finally, here is the experience of County Durham health service manager Mr E: 'On my first few visits to a local practice I received a consistent standard of care; consistently greeted with sour-faced stressed receptionists, who felt waiting times were patients' problems not the practice's. There were two doctors you could always get appointments with reasonably easily. One referred every patient in the hospital's direction and the other, our orthopaedic surgeons warned me, was one never to cross swords with.
'One day I had a consultation with the latter and shared with him my thoughts about the practice's front-of-house chaos. It was the best consultation ever. "Listen", he said, "we have 12,000 patients registered here and five doctors. Most of them have crap lifestyles and they use us a lot. Can you just piss off [said in a firm but light-hearted way] around to those lucky buggers at Surgery X. 8,000 patients listed there, all of them posh and five doctors."
'This was the best bit of evidence-based GP selection ever. I was greeted with a fantastic practice, at the forefront of advocating protected learning time. What a difference it made.'