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The incredible invisible bed crisis

Still practising

Chris Preece

Tuesday, 24 January 2017

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overbooked_shutterstock_456275623.jpgMuch has been written about the “winter bed crisis”, not least on this site – the 23 hospitals that have declared a “black alert”, patients left to die on trolleys in corridors, and Theresa May hurling a dead cat on the table by randomly attributing the whole crisis to the lack of GPs offering to look at your bunion on a weekend.  (I may be paraphrasing a little, but not by much.)

As our Prime Minister enjoys a brief moment of respite, thanks to the world’s media looking across the Atlantic at the bizarre reality TV show that is the Trump presidency, perhaps now is a good moment to remember the other bed crisis. The one no-one talks about, the ‘Invisible One’, the one which, admittedly, doesn’t actually involve any beds as such…

Here’s the problem. When a hospital is full, it’s full. They can open “overflow beds”, they can cancel operations, but there is, nonetheless, a really clear physical problem; one which makes for great headlines, and which is largely inescapable for managers and politicians alike. But, for GPs, social workers, district nurses and all the rest of us who care for those who aren’t necessarily bound to a bed owned by the NHS, there is no such equivalent.

If, as a GP, I declare that we have no more appointments, I am seen as failing my patients. There is no inherent recognition that, like beds, my time and attention, may be finite. We are expected to provide. Indeed, thanks to Mrs May’s desperate manoeuvring, and some well-established existing rhetoric from Mr Hunt, we are somehow expected to provide more.

Part of the reason for this is that we haven’t yet identified a way of communicating our busyness to the outside world. Yes, there are intermittent headlines stating that GPs feel under greater pressure than ever before, but without something tangible nobody really cares. The whole crisis is filed under “whinging GPs”, someone mutters darkly about our salaries or makes a joke about golf, and they move on.

So, let’s start. First of all, we need to agree a level of activity that’s not compatible with being able to do our jobs safely. Now, this isn’t an easy thing to do, not least because traditionally records of general practice activity are negligible if not non-existent. There’s been very little measurement of what, exactly, we do, and as a result it’s all too easy for other people to suggest that it’s not enough.

Still, some work’s been done. A quick Google search tells me that The King’s Fund reckons we’re doing 4.9 consultations per patient per year, whilst The Lancet had it pegged at 5.16. Now, to me it already feels like we’re over-doing things (that latter Lancet study suggests activity has increased by 10.5% from 2008 until 2014) and I’m a fan of round numbers, so for the sake of this debate I’m going to say we call “black alert” at 5.

Next, we work out the number of appointments we need to make available to stay within that target. That’s our “bed count”. The minute there’s a single patient wanting an appointment beyond it, we’re on “alert”. We let the local radio stations know we’re “full”. We send letters to our local hospitals telling them that we’re aware how busy they are, but we’d be very grateful if they could avoid sending anyone home unless they’re absolutely certain that it’s safe and appropriate to do so. We notify CCGs that the local primary care system is not viable without urgent additional funding and support.

I’m old fashioned. I don’t believe that we should stop seeing our patients. I don’t think we should stop doing visits, or start refusing to do basic services. We do, however, need to communicate loudly and more urgently not just how much we actually do, but also when it is no longer possible to do it. We need to find a way to frame the message, and our language, to make it clear that no part of the system is currently sustainable, including general practice.

I’m just a single random doctor scribbling a blog in the hope that a few people out there read it. We need a clear drive from GP leaders to quantify and express the sheer workload and, let’s be frank, suffering, that is taking place. It needs to be every bit as clear to the public that there are very real, very tangible risks resulting from over-stretching GP services, as the risk from people waiting on trolleys.

The failure by general practice to express the severity of pressures upon our own service is not just the weak link in demonstrating how the entire NHS is failing, it has also, ironically, allowed us to be portrayed as the cause.

There will be another “bed crisis”, and I fear we won’t have to wait until next winter to see it. Let’s make sure that next time primary care is the first to give the warnings, rather than the first to carry the blame. Let’s ensure our metaphorical beds are as visible as those in the hospital.

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Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.
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