Tuesday, 29 June 2010

I cannot ever get to see my GP, it always takes weeks to get an appointment. Some thoughts. The basics 001.

At ND Central this title has over the last few weeks has been a common opening gambit to a consultation from patients for both doctors and nurses. The implication being that as a result the patient has suffered and it is OUR fault.

The fact that it is often followed by a two minute monologue on the state of the NHS and, what if I was ill?, immediately tells a health care professional there is very little actually wrong with the patient.

You learn to develop a thick skin in general practice in the UK. You also know that if a patient is blue, unconscious, pulseless and not breathing rather than moaning on about appointments they might be actually ill as opposed to being pathetically well and whinging.

Let us have a think about not being able to get an appointment (the instant I want one). Lets start with some basic questions like why can you not get an appointment (the instant you want one)?

If it doesn’t cost anything and has some worth to a consumer, the patient, guess what?

Everyone wants it.

Our medical students from many nations overseas all say the same thing. "The NHS is brilliant, we can see a doctor and it costs us nothing unlike at home where it will cost . . . ".

Their idealism changes rapidly after they start seeing patients themselves and by the end of their time with us they keep asking why people are coming to see us with things they wouldn't bother a doctor with. Remember this is the hugely affluent and over educated Northernshire where we practise.

So if there is no economic check on the provision of healthcare to the consumer (patient), combined with potentially limitless demand for healthcare, which is pitched against a finite provision of healthcare then something has to give. Have you worked out what that might be yet?

Perhaps a shortage of appointments because there is no disincentive to use the service?

Would a charge for appointments make it easier to get an appointment?

Perhaps a sliding scale say £ 10 for a routine appointment, £ 25 for an “urgent” one? What about home visits at £100 a time?

We bet the “I can’t afford a taxi” argument would disappear overnight as a self preservation (health) argument and it is free argument would rapidly give way to a “how do I save money?” (economic) one and guess which usually wins?

Lots of time is spent talking about “markets” in the NHS but most peoples experience of real markets means that if you want something you have to pay for it. If you want it NOW you pay more or you wait your turn.

People are used to using markets and those who want things a bit quicker usually take advantage of private medicine.

Unfortunately this “market” option is unlikely to happen until patients have to pay so possibly the easiest way of “creating” more appointments, by managing demand, is not likely to be a political option so you will have to wait and continue to moan.

Let us now think about the diseases we see in general practice and whether most of them actually merit an appointment.

All of us here at ND Central have been through different General Practice Vocational Training Schemes. All of us know, and have been taught, that most illnesses we see in General Practice are self limiting.

In other words most illness gets better on its own. This is nothing new but is highly unpopular with Joe Public who since the advent of penicillin think there is a “pill for every ill”.

This means that if you have a cold, a sore throat, a case of diarrhoea and vomiting the vast majority of these will get better on their own. More often than not we talk to patients, examine them, tell them what they have got and give them nothing.

A good use of medical time?

Or pandering to the pathetic who just came for a “check” or for the name of a disease to tell their employer that they need sometime off? We think if you are completely well and want a check go to a bank they will probably charge you for something. Doctors are trained to treat illness, not wellness.

A lot of the diseases we see have been around for centuries and people have survived them even before the NHS was invented. This is nothing new and those of us in the UK who know who our parents are and who their parents were as well had such knowledge passed down to us.

Where grandparents paid for healthcare there was a pool of knowledge built up whereby simple diseases like chickenpox were recognized and diagnosed by the family rather than involving an expensive trip to see the GP.

The changes in the family structure in the UK means that such self obvious diagnosis now means a trip to see the GP.

Let us summarize our humble argument thus far.

At this point we have a “market” led healthcare system.

This market, where demand is not regulated by cost to the consumer, and, its demand is potentially infinite, is delivered by finite resources.

The vast majority of users of this “market” have diseases that are self limiting and will get better without treatment.

And people feel aggrieved they cannot get an appointment?

Praise be to the Party that created illness the vast majority of which gets better on its own. And then created the NHS to deal with this “problem”.


GrumpyRN said...

Hear, Hear! Brother! Preaching to the choir.
People value things by what they pay for it and as NHS is 'free' then value is zero.

Real heartsink moment in triage - "I am just here to get it checked out".

My dad, born 1933, talks of 'half a crown' (2 shillings and 6 pence or 12and a half pence today) to see a doctor.

Unfortunately, if you institute payment then A&E will have a massive increase in attendances - 4 hour target out the window. Plus, in the A&E I work in we do not do GP things, patients are sent back to their GP.

Anonymous said...

Dear N Dr
We have cultural iatrogenesis. Health clubs needing a letter from the doc re fitness to exercise.
Schools insisting on doc's letter re child's absence from school.
Hospital OH insisting on vaccinating you for childhood illness already had. I fought that one but had to have a blood test to confirm immunity.

Prisoner of Hope said...

A consultation exercise that I carried out 20 years ago at a busy general hospital OPD asked how out patient clinics could be improved. One of the proposals (which came from patients who were involved - alongside clinical staff) ,suggested charging £10 for evening appointments. This was one of 30 actions that respondents were later asked to prioritise. The results were then subjected to cluster analysis and compared to related biographical data. To my surprise a significant group of respondents scored this proposal very high compared to everyone else. On closer analysis this turned out to be not the contented majority of "worried well", but - by and large - manual workers who would otherwise lose half a day's pay to attend the clinic.

Like many challenges to pre-conceived ideas it was - of course - blindingly self obvious in retrospect. So I think the idea of Northernshire's masses paying to see the doctor (at a time that is most convenient to the patient - i.e. "when they want to be seen") may not meet with as much resistance as you think.

On the whole I agree that there is much scope for "up front" payments which - like the French system - could then be claimed back 6 months or so later from either personal or national insurance depending on circumstances.