In spite of everything, in praise of GPs

 

GPs eh? Have you seen what the research says about them? They struggle to look after patients in the time they have to see them, find it hard to keep up with evidence, and lack the technical resources and training to do any better. They seem to think they are more consultative with their patients than the actual patients do, over-ride patient decisions where they think they know better, and even treat patients differentially based on how attractive they are (Bryan, Ford and O’Reilly references at the bottom of the piece).

Many health economists don’t like GPs either. They think that they have got loads of money for the QOF when their productivity may even have fallen since its introduction, and that the QOF itself isn’t really evidence-based so that paying them for achieving points won’t accomplish much in terms of patient care (Fleetcroft and Cookson). They would regard the replacement of face-to-face appointments with Skype-based consultations a good thing – bound to be more efficient.

Then, of course, we are asking GPs to do all the commissioning in the NHS when the evidence of what they achieved as fundholders in the 1990s is rather limited at best (Greener and Mannion).

This doesn’t add up to a very promising picture. It seems that GPs don’t treat everyone equally, are harried in terms of time, limited in terms of expertise, didn’t make a great job of commissioning in the 1990s, and have followed the incentives of the QOF to score as highly as possible on it.

But here’s the thing – what on earth are we expecting from our GPs exactly? The research above suggests that they tend to be nicer to people who are easier to deal with. Well – I’ll let you in to a confidence. I tend to be too. It suggests that they struggle to deal with complex problems in ten minute appointments. Perhaps we should ask ourselves why we are surprised by this – if I had to deal with every student who came to see me in ten minutes then I would probably be pretty bad after it after two or three.

It also seems that GPs are limited in terms of expertise. Again, do you know anyone who isn’t? Medicine is difficult, and because of that GPs will sometimes make mistakes. The difference, of course, is that when a GP makes a mistake, someone gets hurt. If I give a bad class, students don’t learn as much as they might have. I have yet, however, to actually harm anyone in a lecture theatre or seminar room. That doesn’t mean I’m more perfect than GPs, but that my job is of a different type – very few jobs are like those of GPs.

I also have to ask if it is legitimate to blame GPs for not being the best possible commissioners of care in the 1990s. Most teachers do a pretty good job, but if they had to buy University education for their students and monitor the result, they’d struggle as well. I’m still not clear why we think asking GPs to commission as well as provide care is a good idea – it can hardly be because they aren’t busy enough already. I thought the basis of adding value to an economy was specialisation (division of labour) – so why are we asking highly-qualified doctors to do something that they aren’t trained to do? Blaming GPs for not being good at commissioning is a bit like blaming solicitors for not being good prison officers – having a go at a profession for something related to, but outside their expertise and training.

We also seem shocked that GPs, when given a clear system of incentives to earn points through the QOF, have followed them and been really good at it. Why is that? We’ve asked a bunch of the brightest people in the country to play a care-based game, and they’ve aced it. Big surprise. If I was given points for teaching and research I think I’d vary my practice and score decently too. There are bigger questions of whether the QOF measures the right things, but you can’t blame the GPs for being good at it.

Now there are bloody awful GPs out there. There are also bloody awful professionals in every service or industry. Let’s not kid ourselves that the all-seeing market gets rid of them in the private sector – if that were the case it’s hard to argue that there would be many bankers left after the nonsense of 2007 and 2008. Again the difference is that when GPs are bad, really bad things can happen very quickly. The profession hasn’t always been on top of that, and needs to do better in dealing with its poor performers, but we shouldn’t blame GPs as a group . It does ask difficult questions of GP leaders though, and I hope they will continue to make progress to making things better.

In all, let’s try and remember to be grateful for our GPs. Most of them are pretty good. They do a tough job under difficult circumstances, and it’s about to get harder again through the introduction of commissioning groups.  GPs have flaws, but so do we all. Before you assume a GP is out to get you, or doing a bad job, I think you have to try and see the world a little from their own, very human, eyes.

References

Bryan S, Gill P, Greenfield S, Gutridge K, Marshall T. The myth of agency and patient choice in health care? The case of drug treatments to prevent coronary disease. Social Science & Medicine. 2006;63(10):2698-701.

Fleetcroft, Robert and Richard Cookson. 2006. ‘Do the incentive payments in the new NHS contract for primary care reflect likely population health gains?’ Journal of Health Services Research and Policy 11:27-31.

Ford S, Schofield T, Hope T. Observing decision-making in the general practice consultation: who makes which decisions? Health Expectations. 2006;9:130-7.

Greener, I. and R. Mannion. 2006. ‘Does practice based commissioning avoid the problems of fundholding?’ BMJ 333:Dec 2:1168-70.

O’Reilly D, Steele K, Patterson C, Milsom P, Harte P. Might how you look influence how well you are looked after? A study which demonstrates that GPs perceive socio-economic gradients in attractiveness. Journal of Health Services Research and Policy. 2006;11(4):231-4.

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2 Responses to “In spite of everything, in praise of GPs”

  1. Patricia Farrington Says:

    I would just like to agree with this article regarding why we are asking GPs to do a job they aren’t trained for and which most of them either don’t want or do want for financial gain. I am frustrated in my attempts to find answers to my worries as to where it’s all going to end. This awful government seem to be more confused with every move they make.

  2. Ian Greener Says:

    Thanks Pat. Not clear to any of us where this is going at present – and that’s part of the reform aim (to create self-generating improvement from the bottom-up). I guess we just have to either try and oppose the reforms or work with them when they eventually gain some kind of clarity to try and keep the NHS afloat.

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