Dr Do Little – an urban myth!

The last time I went to see my GP was November 2020. The practice had contacted me to get a flu jab. It was a brilliant experience. I had been asked to arrive no more than 5 minutes before my specified time, and had to be masked and social distance. I have to admit that I was sceptical about having a precise appointment slot, but when my time arrived, I got my flu jab bang on time. Due to my age, I was also given a mini health MOT. My medication was reviewed and there was a chance to talk for a few minutes with two earnest medical students. Fortunately, I have not had to go back since that time.

My Covid19 vaccinations were done at a hospital vaccination hub, and my repeat prescriptions have been switched to a 22 week rolling prescription, which I get filled at my local chemist when the tablets run out. I can get help online, and I can use our urgent care centre if ever there was a need to. Fingers crossed I won’t need their help. I’m content, but clearly others aren’t.

It would be impossible to have missed the stories of anger and abuse many GPs have been subjected to in the last few months. It’s been said such behaviour is the result of patient frustration at not being able to get an appointment or to see their GP in person. Last week there were media reports of some GP practices receiving bomb threats, having their premises covered with offensive graffiti and many practices seeing a rise in threatening behaviour and violence towards staff, both in person and through social media. Such threats have resulted in many staff going on sick leave, and for others, leaving their jobs. It’s not a good place for many GPs and others working in primary and community care right now.

The public frustration appears to be fuelled in part by the perception that GPs are no longer offering face-to-face appointments, and where they do, getting an appointment is almost impossible. The situation appears to be a legacy from the early days of the pandemic when many practices were shut to the public and consultations went mainly online or over the phone, and an unprecedented, and what has been an exponential rise, in demand for health care. It’s an urban myth that GPs have ever stopped seeing patients in person. All the way through the pandemic, if someone needed to be seen, they were. GPs and their primary care colleagues have continued to work throughout, and indeed, they have played a major part in ensuring the UK vaccination programme was so successful.  

For some folk being able to access a GP virtually has been a real bonus. My parents, both now elderly, live on their own in Cardiff (a round trip of some 470 miles for me). Recently I have been trying to sort out some health and mobility issues on behalf of my mother. Trying to resolve these problems would have been nearly impossible without being able to communicate online. Actually, it was an advanced nurse practitioner that proved to be the ‘gatekeeper’ able to open the door to getting my mother the help she needs – a thought I will come back to in a moment.  

Now regular readers of this blog will know I try and steer clear of politics, but I could not write a blog about what is going on in GP land without saying something about our current health secretary, Sajid Javid. Last week he was urging GPs to see their patients face-to-face. The thinking being such an approach would increase their effectiveness as ‘gatekeepers’ to diagnostic services and specialist services, and so reduce the waiting lists. On Tuesday he told his fellow MPs that the Government ‘intends to do a lot more’ to ensure in-person consultations go ahead. He didn’t actually say what this doing a lot more might actually entail. Now I quite like Sajid Javid. Despite being a solid Thatcherite, he is a man of integrity, a pragmatist and has a well-defined moral compass – think back to his resignation as Chancellor of the Exchequer when DC ordered that all his Treasury aides be sacked. He is also a very astute and intelligent man and supported J during her election campaign. He has held all the major Secretary of State roles during his time as a MP. 

Having said all that, I think he has got it wrong this time in his thinking about GPs. Increasing the number of face-to-face consultations won’t increase their ability to act as ‘gatekeepers’ to specialist services; in the main they can do most consultations virtually, and have done so successfully for the last 18 months, but that rather misses the point. If we keep seeing them as the ‘gatekeepers’ we will never achieve the transformation necessary to seize the opportunities presented by place-based health care. Today, the single ‘gatekeeper’ notion is an almost Kafkaesque concept (‘Before the Law’), and no longer helpful. It creates an image of the ‘real’ health service being somewhere else, perhaps in one of the PMs 40 shiny new hospitals? The reality is that much of the ‘real’ health care should and could be done in primary and community care services. The reasons we currently have such a high waiting list problem is complex, but it’s not a consequence of GPs doing little during the pandemic.

Alongside thinking differently about population health, I think we need to re-think who is involved and/or takes responsibility for signposting patients to specialist services. As well as expert clinicians and practitioners, we need GPs and other health care professionals to become leaders, navigators, and interpreters of patient need. Only then will the opportunities of place-based approaches to population health be realised in reducing the ever increasing demand upon acute services. In an age of advanced practitioners, rapid uptake of digital health technologies, and algorithm driven decision making processes, there are many alternatives to the notion of the GP as being the only ‘gatekeeper’ in town. We might have to think differently about how we pay people, how and where they work and so on, but that is part of that transformational thinking that needs to happen. Change in primary care is possible, it’s exciting and, in many places, that transformational thinking is already bringing about better ways of enhancing the health and wellbeing of folk.

Ps – nearly all the patients we have in our ICU are people who have chosen to not take up the offer of a Covid vaccination. A poignant example of how our thinking on population health needs developing.