Adrian Hamilton: Time to bring back the family doctor

Patients aren't items or numbers, let alone 'customers'. They're living people, each with their own fears and frailties

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The nurses, the General Medical Association, the academics and the managers, they've all by now rubbished the Government's plans to reform the NHS. The only people we haven't heard from are the patients. They're not even properly represented on the committee reviewing the changes.

Of course not. The main point of the reforms, argues the Government, is to put decisions firmly in the hands of the people who understand you and your needs best – the doctors. "You know them," explained David Cameron, as the bill effecting the greatest changes in the NHS since its foundation came before Parliament this spring, "you trust them and you work with them."

If only that were so. Maybe in the past there was such a figure as the "family doctor", the man (for they were mostly men in those days) who knew your circumstances and your history, who was wise about your symptoms and appreciated who was the best specialist to go to. Not any more, not at least in my experience as an inner city patient. The doctor's practice has become, and been encouraged to become by the successive reforms and pay settlements of the last decade, a business in which most of the partners now work part-time, appointments have to be booked weeks in advance and you're lucky to see the doctor you are registered with, never mind call him or her or any of their colleagues out after hours.

So far most criticism of the Government's plans has been aroused by the question of whether the doctors can take on the management burden of commissioning the services needed by their patients and do it by the scheduled date of 2013. Well, they may or may not, although in my experience they are adept enough at charging for travel injections or letters to insurance companies to suggest they are not averse to the world of commerce. The real problem, however, is whether doctors any longer provide the service to patients themselves which such a shift in responsibilities would warrant.

It's not wholly the fault of the profession or those in it. Over the last decade the whole thrust of change in the National Health Service – the introduction of NHS Direct, the development of walk-in health centres and the improvement in the speed and efficiency of hospital A&E departments – has been to bypass and diminish the role of the GP as primary or regular contact with the patient in favour of rapid diagnosis and treatment.

Fall ill in the night and you ring NHS Direct, who will encourage you more often than not to go to the hospital A&E to be on the safe side. Feel ill in the day and it is easier to go to a health centre, if there is one in the vicinity, rather than wait several weeks for an appointment with your doctor. Cut yourself on the bread knife and you're best going to hospital, which will have all the equipment on hand for immediate scans, X-Rays and blood tests, however minor the injuries may be.

At the same time the doctors are busy unlocking themselves from a personal and continuous relationship with the patients on their books. You will be asked the name of your particular doctor when you come into contact with the NHS at the hospital, health centre or pharmacy, but back in the surgery you will be encouraged to make an appointment with any doctor who is available.

Induced to form themselves into "group practices" as the more efficient and lucrative way of delivering GP services, and offered substantial remuneration on the basis on services provided and the number of patients on their books, GPs have given up personal responsibility for individual clients in favour of part-time working and ticking off targets.

It's perfectly understandable. The doctors' new contract of 2005, and the performance-linked settlements of the previous couple of years, gave GPs a huge lift in their remuneration in return for meeting targets that proved relatively easy to achieve. Over the five years between 2001/2 and 2005/6, their average pay shot up by nearly 70 per cent to over £95,000 a year, making their's the second best-paid job in Britain after senior company directors. At the same time they reduced their hours by around 15 per cent.

That may be fine for those young and healthy, whose visits to the doctor are infrequent. It is not all right for those with persistent problems or those of a certain age, for whom seeing a doctor with some acquaintance with your condition is more and more necessary.

This is not a moan against the NHS, a system in which I was brought up and have never wished to stray from. Like most people I know, my experience of emergency treatment has been exemplary, certainly far better than that of the US where I started work. The problem is with the non-specific and the non-urgent. In hospital with a stroke, a suspected heart attack or serious injuries from an accident, nothing is too good for you. Be sent for routine surgery or a test and, three cancelled appointments later, you're fortunate to be seen within six months.

This concentration on technology and specialist knowledge in hospitals takes the patient further and further away from the GP, who in turn becomes a funneler of cases to hospital rather than an organiser of the patient's welfare. Little wonder that more and more people are going first to A&E with quite minor problems – the complaint of hospitals throughout the country. A senior doctor at my local hospital admitted he did the same himself.

You can see what's happening. If, as is the case over the last decade, the main concern of the Department of Health has been "outcomes", then the most calculable results come from numbers seen, length of time taken and treating conditions such as injuries or strokes where there is a specific problem and a set outcome.

But that is not what medicine in the round is all about or should be. By treating the patient as an item, or a "customer" as the Health Department seems to suggest, that is exactly what you make them. But patients aren't items or numbers, let alone "customers". They're living, breathing people, each with their own fears and frailties. While the NHS as an institution goes on about the statistics of disease and treatment and cures, the health community as a whole worries more about obesity, rising rates of depression, the increasing pains of old age and the growing amount being spent on alcohol-related sickness.

Yes, let's bring back the family doctor, but if you want to make them once again the clinician primarily responsible for the patient's welfare, fix them with the task. A good start might well be to insist that doctors, in return for their higher pay, commit themselves to see the patient registered with them at least once a year for a quick check-up, if only for five minutes. You might then add that they should make it a firm practice to see their patients after each hospital visit. The GPs might hate the burden. But it's the only way to force them into individual responsibility.



a.hamilton@independent.co.uk

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