Old Lad

So what do you think about GPs these days. That’s a question I am constantly asked seeing I was in the business for quite a long time. Despite the fact that I have not practised for 10 years I still get stopped in the street or the supermarket for a quick ad hoc consultation. In a way its quite flattering that people still recognise me. But here’s a question. Do you know who your GP is and would you recognise them in the street. My hunch is that the answer may well be No and No. Ten years ago just before I hung up the stethoscope I suggested to a colleague that UK General Practice would not last more than a decade. My opinion now is that I was right and it is steadily being reinforced as I enter the world of being a patient – it happens to all us Old Lads!

Why did I become a GP? I started my career wanting to be a Specialist – Rheumatology as it happened – but the thing about being a specialist is that you end up seeing the same conditions over and over again. I liked variety and the challenge of making a diagnosis from first principles. I also was influenced as a boy by watching Dr Finlay’s Casebook and was in thrall to Andrew Cruickshank’s portrayal of Dr Cameron. There was something attractive about being part of a community. And so it was when I joined my first practice. Because we did our own nights on call it was a condition to live in the practice area. My children went to the local schools, we shopped amongst our practice population and gradually over time I developed a deep knowledge of families and their relationships, the places they worked and got used to being recognised and consulted informally. In the 1970s and 80’s general practice training and education came of age and as I moved into teaching in practice we began to emphasise the benefit of this community approach. We also taught the skills of face to face consultation which involved not only a wide knowledge of medicine but the skills which are demonstrated in the Sherlock Holmes stories- the value of observation and the “Non Verbals” as we called it. The workload was heavy and at times arduous but the satisfaction of a “good” consultation with the correct diagnosis and a satisfied customer kept the enthusiasm going. Computerisation came and brought enormous improvements in record keeping but the trick was to not let the screen dominate the conversation.

So when and why did what I perceive as the slow death of general practice start. Its difficult to put a precise date on it but several factors seem to have come together. First there has been a demographic shift with more and more talented women entering general practice but bringing a desire for part time working. The latest figures suggest that 80% of GPs now work part time. The removal of the requirement to be on call at night meant that doctors no longer needed to live in the practice area so could commute, and the community identity began to be lost. Continuity of care began to decline before the pandemic. When I retired from active practice I worked as a medical adviser in the Tribunal Service and we often had to request a print out of a person’s medical record. These almost universally showed a pattern of multiple consultations with a multiple number of people and no clear plans for follow up, the onus being on the patient to arrange a further consultation. The pandemic necessitated a dramatic reduction in face to face consultations and greater use of telephone doctoring, and this has never recovered. There is now great dissatisfaction amongst the population about the difficulty in getting to see a GP. In mitigation of my colleagues they have actually been encouraged by the NHS to adopt methods which make the process of seeing a GP less straightforward. The old mythical “Dragon at the Gate” (Receptionist) has been replaced by the internet! The practice I am now a patient with ( which happens to be my old practice) has adopted the model called Total Triage. So if I want to start the process of a consultation I first have to fill in an online form stating my case. were I not computer literate and resorted to the old fashioned method of ringing the surgery or calling in, a receptionist would fill the on line form in for me! This on line form then goes to a triage centre where a decision is taken as to who I will see – not necessarily a doctor – rather than who I want to see. If a consultation is deemed necessary there is a 50:50 chance it will be by telephone. And quite probably with somebody I have never met!

These new ways of working are said to be extra efficient and as the jargon has it “Make the best use of resources”. Perhaps in these days of social media, WhatsApp, the next generation will be quite happy. But we have lost the personal touch. GPs have become anonymous figures working in episodic medicine rather than forming any relationship with patients. Worryingly face to face consultation skills and the ability to elicit physical signs of disease may well decline and telephone consultation is high risk. The knowledge of a patient’s circumstances that I used to get on home visits has all but gone – in fact many practices have a home visiting team of nurses or paramedics

Does any of this matter. I leave it to you to judge but sadly my style of general practice aint coming back. Which makes me sad because looking back on a deeply fulfilling career I have had to admit that I would not like to be a GP now.