The government has attempted to ease some of the burden of general practitioners by the introduction of NHS Direct and is said to be about to make doctors available at “stations” for direct and immediate(?) consultation. Meanwhile many GPs have organised themselves to provide out-of-hours cover by arranging that a nurse on the end of a telephone, many, miles away, will conduct triage on their behalf and contact a duty doctor, who may also be many miles away, if she thinks it necessary; it does not appear to be considered vital that either of these should have access to the patient’s records.
At the same time pharmacists and nurses seem to be clamouring for the right to prescribe and treat patients without reference to fully qualified opinion. That these actions are bound to fail to ease the load on the GP can be logically demonstrated
A day in a good GP’s life could consist of say, four hours of consultation in his surgery, probably divided into a morning and an evening session, two hours or so of visiting patients in their homes and, an hour or possibly more in writing letters to, and reading letters from professional colleagues, and from path labs, x-ray departments &c., communicating with social and other services and filling in reports. Some time would also be required for administration of his practice and keeping up to date.
Assuming a rate of six consultations an hour in the surgery, which allows for a session of half an hour for those who need it, balanced by those who can be satisfactorily dispatched in a minute or two, and three patients an hour in visiting for five days a week, that brings the total doctor/patient contacts to 30 per day or 150 per week if the doctor limits himself to a five day week.
The rate at which new reasons for seeking medical advice arise has been shown to be roughly five or six per thousand patients per day. A practice of 2 000 patients, therefore, would, on average, give 84 patients per week seeking advice for a new problem i.e. one which has just arisen as opposed to a recurrence or follow up of an old trouble.
At this point I wish to introduce a new concept which I will call a “Unit of Medical Service” (UMS) and define as:
The time and services provided to a patient between his first decision to see his doctor with a problem and the time the patient can fairly say “Thank you, problem solved.”
How many doctor/patient contacts each UMS requires determines how busy the doctor or group of doctors will be and can be considered as a measure of their efficiency. Thus a doctor with a practice of two thousand patients who can deal with each UMS in an average of two patent contacts will have to give one hundred and sixty-eight consultations a week, which could be managed in “A GP’s day” as described above.
By contrast, a doctor who needs four contacts per UMS would probably be unable to give the 336 consultations per week required by a 2 000 patient practice and could only give a reasonable service to 1 000 patients.
It follows that, to keep up a good standard of efficiency in General Practice, it is important that as much work as possible is done towards diagnosis and prognosis at the first consultation. If tests or X-rays are required, it will usually be necessary to see the patient once more to give further definition of diagnosis or advice. If the primary diagnosis proves correct, then two consultations will conclude the UMS and thus the more astute doctor, who gets it right first time, will keep his work load under control.
Thus the first consultation for a new item of service must be conducted by the most experienced doctor. Any attempt to interpose a nurse or pharmacist or triage by anyone else will increase the number of consultations per UMS and this diminish the efficiency of the practice, although it may be helpful to employ ancillaries in some cases for follow-up when no decision making is involved. It should be clearly understood that all actions by other members of the ‘team’ arte under the direct control of the doctor and are his responsibility. In a team working in harmony, no difficulty should arise, but in the event of disagreement, all members must accept the doctor as the leader of the team and comply with his direction.
For brevity let a doctor who can work at an average of two consultations per UMS be designated UMS2. It is possible that some may achieve UMS<2. This would be possible only with a knowledge of the patient and his background and an ability to appreciate the importance of nuances in the patient’s words and expression. It is improbable than anything less than UMS3 could be achieved by a doctor new to the practice. In the sort of multiple-doctor practice, too common today, where there is a long waiting list and patients rarely see the same doctor twice, rarely will it be possible to achieve better than UMS5 and the quality of consultations will diminish under the pressure of patient demand, thus producing a snowball effect of increasing demand and a downward trend in the standard of care.
This is concerned with the essential and desirable features required in the detailed coordination of the large and complex operations of the health serviced with particular reference to primary care. Consideration of how a good standard of primary care could be achieved in today’s health service, one is tempted to roll out the old cliché “I wouldn’t start from here”, but faced with the reality, one can only set out long term aims to be worked towards gradually and persistently.
In the light of the above argument, a standard of UMS<2 must be the aim. This can only be achieved by a return to the personal doctor who sees his own patients every time they attend. This has been shown to give clearly the best quality of care. He will probably work in collaboration with two or three like-minded colleagues, each with his own list of patients, who give cover to each other for half days or weekends and possibly for holidays is no locum is available. They will deal with any immediate problems and report to the personal doctor immediately on his return. Such a small group must know and trust each other and observe a strict rule that a patient seen on behalf of another member of that group is “privileged” and will on no account be taken on to the list of the acting doctor. This is the ideal group practice , as opposed to partnership.
The qualities required by a personal doctor should include not only a sound basis of knowledge and experience of all branches of medicine and surgery, but also the effect of social and financial factors. A good standard of Honour, Duty and Responsibility are required but almost impossible to teach, as are the virtues of empathy, integrity, honesty, compassion, charity and humility. These may come fairly naturally to those fortunate individuals brought up with a caring profession background, but those brought up in an old fashioned trade union type culture where nobody does anything unless they are paid for it, nor exceeds set hours without overtime pay, will need special nurture to adopt the standards of a noble profession, which standards ought to be jealously guarded by senior members of that profession.
Given the quality of entrants to general practice, the motivation to first class practice will come from within the individual and cannot be helped by dictation from the Ministry or the setting of targets or standards by the sort of doctor who opts out, wholly or partly, from clinical work to work in the Ministry or who pushed himself forward to be the appointed to organizations such as NICE, many of whom may have opted out of clinical work because they could not stand the hard work and dedication required. It is accepted that in a government-run service, politicians may give broad direction as to objectives, but much of the Ministry output today is seen as irrelevant to targets &c. as counterproductive and to take general practice uninviting.
A totally reconstructed GMC may be necessary to set and impose standards. Ideally the new GMC would be dominated by senior members of the profession, nominated by their colleagues, after at least twenty years full time work, such as Fellows of the BMA retiring fro practice at ages 60 to serve on the GMC for five years.
[Partnerships, especially large ones, have a built-in problem in relation to quality practice. Every practice has its minority of discontented patients; when a new partner appears, he will be tried out by these malcontents, who will ask for medicines or certificates to which they are not entitled and which none of the others will give him. IF the new partner gives in, patients will approve and the established partners may accept him as popular with the patients, whereas, if he takes a strong ethical line, the malcontents will change their doctor, to the horror of the partners, who may consider him unworthy to join them.]
Real General Practice still exists in rural communities and in the Highlands and Islands, but is being replaced in many urban districts by a combination of large multi-doctor practices without responsibility for out-of-hours service and with little continuity of care. Attempts to bolster this up with nurse-triage, NHS Direct &c. are proving to be an expensive waster of time and money and many out-of-hours problems are ending up in A&E being seen by doctors with inadequate experience.
Before the health service was inaugurated in1948, every large hospital had an Outpatient Physician who took the responsibility of primary care of those who arrived without reference, acting in fact as the GP to those who were neither casualties nor emergencies, and with access to the facilities of the hospital as appropriate.
A modern extension of such a service would seem to be the logical way forward in the primary care services. For two generations at least, Consultants in charge of A&E have complained of the “misuse” of their facilities by patients who should, in their pinion, have been seen in general practice. Now that there is a demand for out-of-hours work to be optional or eliminated from regular general practice, a new arrangement is desirable. Such an out-of-hours service could be run in parallel with A&E in hospital and would have to be manned by those with good experience of general practice working in shifts round the clock or such hours as are necessary. This out-of-hours service could be funded from by deduction of an appropriate proportion of pay for full time responsibility.
GPs not accepting out-of-hours work would miss many of the crises on their patients’ lives, there by knowing them less well, diminishing the enjoyment of satisfaction in their work, lessening their value to the community and incidentally increasing their UMS score.
The quality of General Practice can be assessed by the average number of consultations required to complete a task. General Practice can be improved by loyal support. Dilution, direction, interference and attempts by government to control are generally counter-productive.
The GP who wishes to take full responsibility 24 hours per day and seven days per week, making his own arrangements for time off with a few trusted colleagues is giving the best service to patients, may be working at UMS2; his value to the community is at least double that of his UMS4 colleague and he should be rewarded accordingly.
The government should stop trying to control and dictate the details of a General Practitioner’s work and promote an assist in every way his independent Contractor status and his service as guide and philosopher to his patients.
The ideas here expressed originated when taking part in and helping to analyse the first morbidity study and have been developed in a medical lifetime, mainly in general practice:
Studies on Medical and Population Subjects No 14:
Morbidity Statistics from General Practice. London, HMSO, 1962.
Details of qualification and experience of the author can be found in: www.simongrant.org/father/lifestory.html
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