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What value do GPs offer?

Hard-wired GP

Luke Koupparis

Thursday, 25 August 2016

question mark_shutterstock_95623480.jpgI have recently been thinking as to the value I offer as a GP to the NHS. There are many negative stories in the press (usually the Daily Mail) about GPs who missed a diagnosis, failed to refer or about patients who couldn’t even get to see a GP for their condition.

So would the NHS be better without GPs? Let’s consider the scenario that does exist in other health economies: a patient gets a symptom, decides what area they feel it relates to and makes a beeline for the nearest specialist they can find who deals with that. So that cuts out the need for the GP as any kind of gatekeeper and also cuts out a whole load of appointments, in which the underlying reason is to get a referral. It is well known that in countries where this system exists, the costs are much higher for delivering healthcare and the outcomes are no better, so many countries have adopted a primary care system. But it might remove the blame game that currently exists where the GP takes the flack for missing the diagnosis - if the patient opted to go to ENT for their symptom, then can you blame the specialist for missing a diagnosis relevant to another speciality? Perhaps not…

So if we turn this situation around and consider that part of the role of the GP is to assess a patient, make an appropriate differential diagnosis and then evaluate whether they can be managed in primary care or need specialist input; I would probably say that GPs are, in the main, pretty good at doing this. Patient surveys consistently show high satisfaction rates with GP services and patients with chronic health conditions value continuity of care with a known doctor. In addition, the Five Year Forward View puts GPs at the centre of integrated models of care delivered by a number of different health and social care disciplines. But as the workforce crisis is rapidly evolving, despite pledges to address it, is this merely lip service to create a new NHS structure based around fewer and fewer GPs?

Consider the variety of cases that comes into the surgery. There is a lot of white noise that presents on a daily basis and many conditions are self-limiting, resolving with time and patience, along with a good dose of homely remedies. So, most coughs that come in are not lung cancer, urine infections are not an impending sepsis, nor tinnitus the first presentation of an acoustic neuroma.

However, in order to sleep at night when they get home, GPs need to live with a reasonable dose of uncertainty along with the security they have given the patient clear safety nets. But despite best efforts, sometimes a diagnosis may present just too early to turn a nagging doubt into action, and a GP may inadvertently miss something or refer it slightly later than at the first presentation. If we want GPs to provide the gatekeeper role in the NHS, then living with this uncertainty is just part of the job and this risk of a missed diagnosis may be a factor in the spiralling rise in indemnity costs.

So, on one hand we are saying we want GPs to be the gatekeepers of the NHS, but on the other hand we hang them out to dry in a media trial when something goes wrong. Sometimes, hospital clinicians do not help when telling a patient on admission that the GP should have spotted that diagnosis earlier. Don’t get me wrong, if there is clearly a presentation or situation that should not have been missed, then there is clearly at least a learning need there for the doctor. But the result is that GPs may no longer want to take any risks and hence have a much lower threshold for referral, fearful of the blame culture or trial by media. This could partly explain the exponential rise in secondary care referrals.

So if that is the case, what does that leave the GP as? Do we just become an administrative conduit to get to the hospital, based on any potential nasty symptom with only a whiff of clinical input? Or are we key to the Forward View of the NHS, working as the lynchpin at the centre of integrated community teams, thereby keeping patients out of hospital?

Thankfully, we are not yet at a place where GPs are simply the administrative assistants and record keepers of the NHS and patients still value what they get from their “specialist generalist” GP.

However, for a Government and population to value what GPs offer they have to truly understand the complexities and demands of working in an out-of-hospital environment. I wonder if this intrinsic understanding does exist in our NHS leadership…

Jeremy Hunt: I take my children to A&E because GP wait takes too long

Author's Image

Luke Koupparis

Luke is a general practitioner in the Bristol area with interests in men's health, child health, minor surgery, online education and medical information technology. He is the IT lead for Bristol clinical commissioning group, LMC representative and chair of the locality provider group. He also works as the medical editor to OnMedica helping to deliver high quality, peer reviewed information to the wider medical community. In his spare time he is a keen road cyclist and likes to ski with his children.
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