The Social Care Act has now passed into law and one of the key ideas revolves around patients’ involvement with the concept of “no decision about me without me”.
Dr Nadim Fazlani, a GP and the leader of a Clinical Commissioning Group in Liverpool, said:
“The new structure of the NHS will give me and my colleagues much more freedom and control to design care around our patients. ‘No decision about me without me’ is a key concept – my colleagues and I will be working directly with patients, giving them a wider choice of where, when and how they receive their healthcare.” 1
Health services have already evolved to meet patients’ expectations, which doctors almost unanimously recognised have increased over the past five years, according to our recent survey of 740 doctors.
More than 80 per cent of GPs have increased their number of telephone consultations and 79 per cent the length of surgeries to cope with demand. Nearly 60 per cent of doctors agree that access to GP appointments has improved compared to five years ago and almost the same proportion have a member of staff who monitors the demand and number of appointments required each day.
But this raises a number of questions: can services keep meeting increasing demand? Is this sustainable? And, perhaps more importantly, is it desirable to nurture a constant rise in patients’ expectations?
OnMedica has asked doctors to give their views on the subject and here are the key findings.
Click here to read the detailed report.
A staggering 94 per cent of GPs agreed that patients’ expectations have risen over the past five years. A large proportion of GPs (73 per cent) have noticed that patients are less able to manage self-limiting illness, almost the same number (71 per cent) have seen more requests from patients to be referred to a specialist for conditions that could be managed in primary care.
Many GPs noted that patients now expect to have multiple problems dealt with at one attendance, which can prove difficult to accommodate during a 10 minute consultation. Patients are seen to take little responsibility for their own health and expect that doctors can “do more to ‘cure’ them”. Some respondents also pointed out that patients go the surgery for other reasons than medical issues such as “problems with benefits, dispute with neighbours, relationship and work issues”.
There is a view from GPs that “patients expect [doctors] to be like a 24 hour supermarket, where they can drop in any time and pick up what they want off the shelf.”
Higher pressure on doctors
90% of doctors feel constantly or frequently pressured to increase the level of care they provide in order to satisfy their patients.
Almost 60 per cent of GPs constantly feel pressured to increase the level of care they provide in order to satisfy their patients. And another 31 per cent say they frequently experience pressure.
Not only does this come directly from patients’ increased expectations, but also from the healthcare system as a whole, particularly through the constant changes in QOF targets (mentioned by 74 per cent of respondents), the obligation to use particular referral pathways (72 per cent) and top-down governmental policies in general (65 per cent). Pressure from Clinical Commissioning Groups has also been noticeably quoted by 40 per cent of respondents.
Potential further challenges for budget holding GPs
Doctors have an equally split view about the effect GPs holding the budget will have on patients’ satisfaction. While half of doctors think that the level of satisfaction will drop, 44 per cent think that it will not be affected.
Doctors’ main concerns are:
- Managing conflict of interest:
- “GP's will be seen as someone you have to fight with to get what you want/need.”
- “GPs will have to defend the choices made by their own commissioning groups and this may limit patient choice. We may be compromised when a patient asks us to take on a patient advocacy role.
- Managing conflicting messages:
- “Inevitably rationing decisions will have to be made. Unfortunately politicians continue to give the impression that the NHS can provide everything to everyone. In the new world GPs will have to make rationing decisions based on local consortia budgets. If consortia are unable to afford certain services GPs will be seen as refusing access to services that patients are ‘entitled to’ which will have a negative impact on GP patient relationships.”
- Possible loss of expertise:
- “The only reason GPs are best placed to know what is best for their patients is because we work with them day in and day out, taking GPs away from the coal face will lose that perspective.”
A system testing its limits with no evidence of better health
70% of doctors believe patients are not using out-of-hours care appropriately.
Despite 65 per cent of doctors acknowledging that the out-of-hours service is working well in their area, 70 per cent said that patients are not using out-of-hours care appropriately with only a quarter saying that patients make adequate use of the service for emergencies only.
Many GPs are calling for better patient education as to what needs urgent treatment and what can wait.
51 per cent of doctors recognise that increasing the number of doctors working out-of-hours to cope with demand would improve patient’s satisfaction with the service. However there are concerns with encouraging local GPs to work as one doctor commented: they are “so burnt out after a week at work, doing weekend and evenings are no longer attractive. GPs would self-combust if out-of-hour provision was given back to them.”
Many GPs are calling for better patient education as to what needs urgent treatment and what can wait. Meanwhile, some respondents suggest that patients should receive “less encouragement from the government to demand immediate treatment at any time for non-urgent problems.”
When asked whether increased access to health services has improved patients’ health, the majority of doctors clearly disagree. (See table 1)
Table 1: Do you agree that increasing GP surgery opening times and provision of 24 hour access has improved the overall health of patients?
When particularly asked about the impact of private clinics offering almost around the clock care in areas such as retail centres, doctors said, at best, that these do not affect patients’ health and, at worst, that they have a negative impact on health (42 and 48 per cent of responses respectively).
Among the few believing that such clinics can have a positive impact on health, positive outcomes included that it is a simple and quick way for patients to have minor conditions checked (78 per cent) and that it is increasing patients’ choice (65 per cent).
66% of GPs who foresee a negative impact from round-the-clock care services believe that it is putting pressure on the NHS which will struggle financially to maintain this level of service.
But at what expense? 86 per cent of those who think that this type of setting has a negative impact on health said that it is hindering continuity of care, 84 per cent that it is increasing patients’ expectations unnecessarily and 66 per cent that it is damaging the GP/patient relationship.
Other doctors raise additional concerns, such as a referral back to their own GP which will “increase the burden on registered GPs to try and explain what was said in the ‘market’ clinic”, and encourage dependency as per the following comment:
“Most health issues require continuity of care, from the patients point of view in the short term they may perceive a positive result to be seen round the clock, however the negative side of this is instant gratification and a reduced capacity to cope with even minor ailments or symptoms this learnt behaviour then reflects on future demand. The health benefit of general practice 24 hours a day will have no impact other than encourage dependency.”
Finally, 66 per cent of GPs who foresee a negative impact from those round-the-clock care services believe that it is putting pressure on the NHS which will struggle financially to maintain this level of service.
So if putting patient first is a laudable aim, it seems that the system should not foster unrealistic expectations of what problems the health services can resolve. Patient satisfaction does not necessarily mean better patient health. Empowering patients to better manage simple conditions without them feeling the need to always involve a doctor is essential. If expectation and demand continues to rise at its current rate, many practices will struggle to cope. However, if “public awareness is a must”, are GPs really best placed to announce the “bad news”?
- Department of Health, 27/03/2012