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Identity crisis

Still practising

Chris Preece

Monday, 23 May 2016

doctor and question mark_shutterstock_123840544.jpgGeneral Practice has a problem.

Now, obviously, General Practice has lots of problems right now – the increased workload, the relative lack of funding, issues with recruitment, unrealistic demands, and the ever growing population of complex patients. Let’s just accept all that as a given for a moment, because the problem I’m concerning myself with today is more abstract. 

It’s one of identity.

What is it, exactly that we do? What do we expect, and what do others expect of us?  What, fundamentally, is our worth?

I know this may sound ridiculous, but I would maintain that, increasingly, as a profession we’re no longer sure of the answers to those questions.

This used to be easy. The role of a GP was fairly firmly defined in the popular consciousness – a “family doctor”, part of the community, someone who would be known to multiple generations of a family, playing a part in the narrative of their lives from cradle to grave. Your GP made visits when you were sick, knew a bit about everything (but not necessarily a lot about any of it) and was prepared to double up as a secular clergyman when necessary. You knew their name, and they invariably knew yours.

This was, to some degree, what GPs signed up for - but over time it became almost impossible to deliver. All those problems I listed in the opening paragraph tore at the edges of this idyll, and practices, each independent from the other, found their own solutions. Practices merged into bigger, less personal but more cost efficient businesses. Others started to bring in alternative staff to doctors, or found ways to reduce their visiting to practically zero. For their own sanity doctors reduced their individual hours, or abandoned partnership altogether. Some establishments developed a forensic focus on what would get them paid, turning into well oiled QOF machines. Others clung to the old vision no matter what. Some simply ceased to exist.

All of these changes came about through necessity and expediency – but with no sense of consensus, and no public discussion. As a result, “General Practice” varies wildly from one surgery to another, whilst our patients, still clinging to an unsustainable model, perceive us as failing in our duties.

As the screws have continued to tighten on the profession, so the differences have become more painful and acute. It has, frankly, started to get a bit unpleasant, as each proponent of their own solution to the dilemma becomes infuriated by those who disagree. Those who argue charging would be unethical seemingly exasperate those who see no solution but to do just that. The camp who believe visits should be outsourced to someone else barely tolerate those who regard continuity as king. In the great Venn diagram of dysfunction however, the groups which seem most disparate of all are those who believe salvation lies in negotiation with Government, and those who believe the only way to achieve change is through protest.  

This was gloriously illustrated by the LMC Conference – which voted in favour of a motion stating the General Practice Forward View was so inadequate they advocated mass resignations unless something was done, just a couple of days after Maureen Baker of the Royal College of GPs sent an email to all members wholeheartedly endorsing the Forward View.

It is, simply put, something of a farce.

The problem is, that this matters. It matters because all of those pressures on General Practice aren’t going to go away. It matters because, whilst I might find the Forward View hilariously wishy-washy, I still don’t know what vision for General Practice the LMCs feel I’m supposed to be resigning for. The General Practitioner’s Committee seem no more coherent than the RCGP, just a bit angrier.

It matters because others are already stepping into this mess of indecision to start saying things for us. From the Forward View itself, to newspaper headlines like that carried in The Telegraph on 19th May: “GPs to vote on strike action as they say patients should trouble them less”. It sums up the current mess that when I first encountered this headline I genuinely had no idea whether this was something that had been proposed or not – because really, who knows what we’re coming up with this week?

It matters, because this uncertainty doesn’t extend to our political masters. The future of General Practice is fairly clearly mapped out. The narrative has been pretty explicit for some time, but for those who are yet to understand it, let me rehearse it once more– it goes like this:

Small practices are to be absorbed into larger ones. Practices are to group together into Federations, and start to provide additional services in the community – many of which are traditionally associated with secondary care. GP numbers will be supplemented by a variety of other job descriptions – physicians’ assistants, pharmacists, physiotherapists, care co-ordinators etc. Federations will provide seven-day booked appointments in addition to emergency care. (These appointments will not necessarily be “local”, unless you happen to live near the allocated hub.) The GP will increasingly be a peripheral specialist opinion, rather than a central part of care. Partnerships will diminish with most GPs salaried employees of the larger (private) employing organisation.

That’s the identity that’s planned for us.

Now there’s stuff in there I like, and there’s stuff I definitely don’t. Your mileage may vary. In the case of The Royal College, they’ve fairly clearly hitched themselves to that wagon. In their defence, their reasons for doing so are clear – if this is what’s going to happen then it’s better to be on board to get the best deal possible. I suspect their enthusiasm is based on a sense of inevitability. They’ve already accepted the narrative they were given because we, as a profession, have singularly failed to come up with a better one – or even attach any worth to the one we already had. 

We have utterly failed to articulate why that old model might have been worth keeping. We’ve failed to adequately warn people that it’s likely to be lost forever. Indeed we’ve become so casually accepting of the pressures heaped on General Practice that it seems that the questions we’ve asked for some time have been “what can we stop doing?” rather than “how do we ensure we get what we need to carry on?”

Of course – I’m not sure I have a solution. I didn’t get the impression that the GPC were proposing we voted to support a return to the good old days, though beyond “more money” I’m not sure what they were calling for. Besides, it feels a little as if we’ve gone too far, too fast, to readily paddle back. Which is a shame, because much of why I’m doing the job can be encapsulated in that “old model” – and I don’t think it’s coincidental that turning our backs on it corresponds with a retention crisis. Equally it’s something we know our patients will miss – even as they inadvertently help bring it to its knees.

Part of me feels like mounting my own one-man protest, setting up some ridiculous Campaign for Traditional General Practice. But in reality, my skin’s too thin to cope with the inevitable abuse, and besides, the last thing we need is yet another idiot proclaiming that they speak on behalf of everyone else. 

What we need now is not more voices. It’s to all be speaking as one. 

It’s time, long past time, that General Practice found some consensus. I’m yet to find a single GP that can even tell me what, exactly, our core services actually are. We’ve clung, rightly, to our status as independent practitioners, but somehow we’ve lost sight of what it is that we practice and why.

We have lost our identity, and unless we do something to address it soon – others will define it for us.

Author's Image

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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