June's free article
Is change in general practice good?
Like many GPs I dread the psychiatric consultation that requires
an immediate specialist assessment. The referral is disputed by
suggesting the patient is not in their catchment area. Once this
hurdle is overcome the next obstruction arrives like a bullet as
inevitably the patient is aged 17 years or less, or 60 years or
more and that falls in the remit of ‘the other service’. A phone
call to that ‘other service’ says ‘No, no, the service you just
rang has informed you incorrectly’. Eventually, after a reluctant
agreement that the patient needs to be seen, now exasperated, you
are then asked, ‘Can it wait until tomorrow?’.
Access to acute NHS services is indeed complex. There is an
urgent need for change, but should more services currently based in
secondary care, now be run from primary care? In the case of
psychiatry, should waiting times for patients with severe
depression be reduced together with increasing access to the much
hailed, but difficult to get, CBT? Health service change can be
good, and practice-based commissioning (PBC) and empowering primary
care organisations also have positive points in achieving this aim
of improved access, despite some GPs’ frequent criticism.
For years there have been, and still are, certain hospital
departments that are recurrently reluctant to see patients quickly.
One of our many roles as GPs is as patient advocates, and we try to
expedite an investigation or treatment, but it is a stressful area
as hospital department doors are often closed to our requests.
Consider the scenario where a person injures their knee, has
pain and swelling, and cannot work. An avenue for referral is the
hospital fracture clinic as routine orthopaedic appointments are
lengthy. However, you quickly ascertain that a definite date cannot
be allocated and they request you send the person to A&E. It
was a revelation to me that our new PBC-initiated local
intermediate orthopaedic triage clinic could see a patient,
initiate physiotherapy, and obtain an MRI, all in a few days. This
can be accessed as the choice of priority through the often
maligned enhanced service ‘Choose and Book’ and is, therefore, the
best option.
Through PBC diagnostic and treatment centres can be set up
independent of hospitals. Perhaps this is a good thing. Why is it
that when you need an urgent radiological investigation, for
example, an X-ray or ultrasound, following several phone calls you
finally speak to a radiologist and you feel as if you are being
granted a special favour? Normally you fax in a request, the
patient has to wait for an appointment and 2 weeks after their
appointment, the report arrives. It is delayed as it has to be
dictated and signed. If ‘Choose and Book’ and the NHSnet can
overcome these issues, then let’s all use them. Perhaps the time
has come to outsource requests to diagnostic and treatment centres
independent of hospitals and move away from this archaic
system-centred approach.
These are good examples of how PBC-commissioned services can be
used to triage and organise quick and efficient services which,
using ‘politician speak’, provide good access, choice, and are
patient-centred. Through these, primary care has responded and
changed where secondary care has not, and inevitably there is a
risk that such secondary care services will lose funding as the
franchise moves into the community. A catalyst for this has been
the advance in the use of computers to drive the process and the
failure of secondary care to engage quickly enough and work towards
a common electronic record.
Change is not all bad and I would dispute the claim by some that
general practice is inflexible. Rather, it is leading the way and
not least with funding through PBC where secondary care has failed
to develop. Let’s hope we can achieve similar advances in patient
care for specialities like psychiatry and for laboratory services,
which some regions of the UK have already achieved.
There are two areas of change where our leaders need to exert
caution; and these concern GP-led health centres which may threaten
continuity of patient-centred care by a personal doctor. Second,
destabilising the GP as a gatekeeper and patient advocate where a
franchised private primary care provider, who does not know the
patient, may unnecessarily refer. This has implications for patient
stress through unnecessary investigations and their associated
expense to the NHS. Any improved outcomes from the above changes in
relation to patient care have yet to be measured scientifically.
Fragmentation of primary care is potentially a threat to the jewel
in the crown of the NHS, now in its 60th year.
Rodger Charlton
DOI: 10.3399/bjgp09X421076
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