Monday 16 June 2014

The fatal moment that divided doctors from patients

“It’s a very frequent saying and a true and honest thought; /That, if you become a teacher, by your pupils you’ll be taught." So says Oscar Hammerstein in the lyrics for The King and I. I certainly found this to be so. In fact, I spent a fascinating few days last week talking to doctors about co-production and learned a great deal myself.

I won’t say what city I was in, in case I betray confidences, but what was interesting is how enraged they are about how they are increasingly taking the flak from politicians for the pressure on A&E departments.

Whether there is really more pressure on A&E departments, I don’t know. I haven’t seen any evidence and rather doubt it, but there is certainly pressure. There always has been.

What seems to me to be undeniable is that:
  • There is an attempt by Conservatives to blame the perceived A&E crisis on the short hours that some GP surgeries work.
  • It is certainly difficult getting an appointment at some surgeries in the morning, as you would expect from the rising pressure there.
  • There is an issue about weekend coverage in the NHS – and clearly no extra resources to solve it.
But there is something else which is hard to pin down, as I learned from the various patients in the room. It may not be the fault of GPs individually, or even collectively, but the fatal decision to commission separate services to run their out-of-hours service in 2003 has tended to poison the relationship between doctors and the public.  Not between individual patients and doctors, but collectively.

This may have been a wheeze dreamed up by the Labour regime at the Department of Health, but it is still perceived as GPs opting out of the trusting relationship with patients. Leaving them at the mercy of the miserable contractors who run these services.

Many of the doctors I talked to were convinced that the contracted out-of-hours service was more expensive than the previous co-operative coverage by GPs on duty which it replaced. I know from experience in Croydon that the standards of the out-of-hours service the only time I ever had to use it was pretty shocking – a huge room full of white faced patients, some of them collapsing, processed very slowly by three nurses through the night (no doctors to be seen).

The real tragedy is that, as a by-product of the 2003 decision, there is no going back. The weight of demand on the new out-of-hours services is out of all proportion to what it was before. Under the old system, people used to think twice before forcing their GP out of bed – even if their was actually taking a turn at night duty – but have no compunction about doing it when it is a private contractor.

The other problem is the extra £5,000 or so that every GP is required by insurers to cover them if they so much as try a hand at out-of-hours. Someone will have to cover that, if we were to are to go back in any way to first principles.

One of the positive developments of the health reforms by the coalition has been that GPs have been taking some responsibility – in a way that was taken from them by the great bureaucratic monoliths that were the PCTs (yes, I know, the PCTs are also being recreated at great expense, but we are not there yet in most places).

But they are taking responsibility for a situation that they did not create, in a vastly more difficult environment. The way forward, if there is one, is going to have to involve a new sharing of responsibility and time between the GPs and their patients.  Is that possible?  Is there any forum where it can be hammered out?

What would I do in the meantime?  Well, I wonder how useful it is to pay for two services at night - the out-of-hours and the A&E - often through doors that are actually next to each other.  

I would use the out-of-hours money to beef up A&E and have done with it.  If that's the way people want to access healthcare at night, there must come a point when we stop wasting resources to fight it.

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