TWENTY-FIVE years ago, I moved to a small village in the Trossachs. It was remote but had everything I needed within walking distance. Though a bit faded, it was beautiful, with a primary school, a small supermarket, a butcher, a couple of pubs and a purpose-built clinic staffed with three doctors and a district nurse.
This team served all the villages around and house calls were commonplace: the doctors had a fine reputation. Today, the surgery is dark and the full-time doctors are gone – moved on or retired. Even before Covid, consultations were hard to get as the surgery was available only on a part-time basis.
As a result of Covid, consultations are either by telephone or email, followed by a long drive to another village if you get through the first line of triage. The district hospital was closed for emergencies years ago, and the nearest A&E is over an hour away on country roads.
Now that lockdown is apparently coming to an end, one would hope for a return to something like normality. But no, Our NHS is instructing GPs to ‘discourage’ people from ‘heading to surgeries for face-to-face appointments’.
Instead, doctors are urged to ‘encourage patients to accept the offer of a virtual consultation’. NHS guidance advises doctors, or more likely their secretaries, receptionists or assistants, however titled, to continue to screen patients over the telephone.
Figures last month showed that the number of people in England waiting to begin hospital treatment had risen to a record high of 4.95million. No one is counting how many are ‘putting off’ going to their doctor. We are yet to see the full physical and psychological damage of the Covid measures and await definitive figures on excess deaths.
In Scotland, where the pre-Covid baseline for public health was already dismal, 380,000 people are now waiting longer than the legal 18-week limit to begin medical treatment. Cancer treatment targets have not been met since 2018, and alcohol and drug dependency are the real pandemic. Recorded drug deaths remain the highest in Europe. An NHS dentist is a rare creature.
Statements from the geniuses who communicate the unending deterioration in the NHS reveal their priorities. They want to embed ‘total triage’ into the health service as an ‘enduring legacy of the pandemic’.
The Royal College of GPs (RCGP) has braved disagreeing publicly, saying, ‘Most GP care should be face-to-face post-Covid.’
They accept that general practice might continue to use some remote consultations as restrictions ease but reject any notion that ‘digital-first’ should be the default approach.
The college is urging the government to carry out a comprehensive review of ‘triage and remote consultations’ to ensure that they can be used safely, ‘while avoiding exacerbating health inequalities and driving unsustainable workload in general practice.’ Cart before horse comes to mind.
It was just a couple of years ago that the NHS was crowing about its adoption of ‘patient-centred medicine’ and declaring how responsive its new systems were to patient needs. The truth is that almost all NHS systems are poor and that they are designed and run for the benefit of the organisation, not for patients.
General practice, for example, is not uniformly linked to other systems in hospitals leading to inefficiencies and delays. Developments are slow: the NHS continues to use fax machines.
Choosing whether a medical consultation should be face to face or done remotely should not be a bureaucratic decision: logically it must be made on clinical need, and in the best of all worlds, would be a shared decision between clinician and patient.
General Practitioners, as they rarely reveal, are independent contractors – ‘in business for themselves’. Many are moving to a more corporate model, with takeovers by private, explicitly for-profit businesses, becoming increasingly common, especially in London. One US group, Centene, through its UK company Operose Health Ltd, has already acquired dozens of GP surgeries, including eight contracts in Camden, Islington, and Haringey.
The decision to allow the takeover of the GP surgeries with more than 375,000 NHS patients on their lists was taken by the local Clinical Commissioning Groups and it would also have required the full consent of practice partners. Patients’ views were not sought.
It is obvious that the current GP model of ‘free access’ to services at the point of need is under threat. Practitioners who intend to remain with the NHS should make clear to the Minister and Commissioning Groups that they do not accept radical unilateral changes to their clinical methods and restate their obligation to ‘see’ patients, in person, in real time.
Most people need their ten-minute slot to describe their ailments, to show their difficulties, and for the diagnostic professional, who is trained and well paid at public expense, to listen, hear, smell and touch, if required. Hippocrates said that ‘it is more important to know what sort of person has a disease than to know what sort of disease a person has’.
If GPs choose to be ‘remote’, people may not use them at all, turning increasingly perhaps to artificial intelligence if that is the kind of service they can tolerate, or seeking out alternative sources of human interaction, whether that is paying at private surgeries or turning up at A&E.
As night follows day, there will also be an increasing risk of substitution, through expansion of the use of independent prescribing nurses, medical assistants, or pharmacists. There will be changed stresses elsewhere in the system and inevitable public resistance.
Ultimately, GP practices need to come clean about their intentions. They should know their patients better than anyone else, certainly better than Mr Hancock. It is up to them to decide how they deliver services.