Saturday, 20 February 2016

Suppose we do actually need GPs?

Suppose it turns out we do actually need GPs after all? And we find out 5 years too late...

Everyone seems to be trying different ways of delivering primary care with fewer trained GPs per head of population. We have the appointment of pharmacists, physiotherapists, advanced nurse practitioners, paramedics, physician assistants and community matrons. We have techno solutions aplenty; virtual appointments, email, online booking, telehealth, skype, health apps, text, pre-doctor questionnaires, algorithms, on-line consultations. All this is being driven much more forcibly now by, amongst other things, one problem; a failure to invest in the GP workforce over the last ten years to match population growth and the multimorbidity associated with successful ageing.

All this activity makes me anxious.

As I tell my patients, if there are lots of treatments for a condition viz cough remedies, it almost certainly means none of them work very well, if at all (unless they are all merely me-toos of one treatment that does). ie if there are lots of treatments you are probably best advised to have none. The fact that there are so many things being tried in GP land tells me that no one actually has yet hit upon something that is really effective, or we would all be doing it already.

The other reason for thinking this is the simple observation that GPs have always had an incentive to get someone else to do their job, pay them less and pocket the difference. So why after 60 years of the NHS has it not happened to a great extent?

The answer must either be that GPs are all wonderfully altruistic, forgoing monetary reward en masse to absorb the work themselves (no, I didn't think you would buy that) or that it is a hard problem or that GPs are what patients actually want or both. On the face of it there are lots of studies purporting to show that X% of GP work could be done by a physiotherapist, and Y% by a minor illness nurse and Z% by a pharmacist where X+Y+Z+... >100! So why am I still here?

I have no problem with exploring these options. Indeed my own practice is taking part in the pharmacy pilot and actively looking at developing practice sub-teams. It will be great if we can get it to work but it isn't going to be easy.

Evidence is mounting that some of these approaches are not going to work as well as hoped. Trials have been done looking at minor illness nurses in primary care showing reasonable outcomes and good patient satisfaction but, and here's the rub, not a lot of cost saving once you factor in the fact that they are less time efficient and need supervision. There is a cultural block too, not the false 'nurses don't make diagnoses' one but that nurses (and other HCPs) have been trained to be risk averse; that's what doctors are for. The trials also were not powered to detect possible adverse outcomes when rarer but serious problems presented to nurses. Recent reports of increasing claims and complaints against nurse practitioners suggest these concerns may have been justified.

Technology too is begining to take a hit with concerns being raised about the algorithms and medically untrained staff used by NHS 111 in assessing patients.

However the real reasons for a lack of diversion from GPs is less to do with safety concerns and more to do with practicalities. It may be true that 15% of GP workload could be handled by a physiotherapist but the problem is knowing that for sure in advance of the consultation. And even if you can discover it by triage or on-line questionaires that is going to be scuppered frequently by the real world of patients wanting advice on more than one thing at a time. It's the multiple presentation of multi-morbidities torpedo that holes these one-dimensional solutions.

Take the common example of a young mum presenting with back pain, low mood and needing contraception. To be sure a physiotherapist could deal with the back pain and a therapist with the low mood and a family planning nurse with the contraception, but they would need at least an hour and three appointments! And each would deal with their aspect of the problem and the patient might not think to mention the other issues. Now the FP nurse, like a GP, might make the diagnosis that it is the irregular periods caused by the progesterone only contraception that is contributing to the low mood and back pain and suggest an IUS say, but however good the FP nurse is under this system the patient still has to see two other HCPs to get to that point of integrated care.

No doubt too that a practice nurse could have sorted the 8yo I saw with ear wax (well, assuming their protocol allowed ear syringing in children), but would the PN have had the experience necessary to diagnose and manage the molluscum contagiosum and viral warts that also presented? Maybe, but not reliably.

I could go on to enumerate many thousands of combinations of presentations that are routinely dealt with by generalists in one consultation in under 15 minutes but could only be managed by many more thousands of consultations by non-GPs. There is a good reason why GPs exist - most people, most of the time present with multiple cross-speciality problems that are most effectively dealt with by a generalist with GP-like training. Most patients recognise this but also value being able to see someone they know and trust. So it seems that the GP solution could turn out in the end to be the most practical, safe, holistic and cost effective one as well as being the option most desired by patients. Let's hope there are enough of us left when NHS England comes to its senses and decides to properly fund the evidence on primary care.