Anthony Daniels: A drastic remedy: get rid of all the general practitioners

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The Independent Online

Recently in my hospital I've been struck by the number of patients, newly arrived in the area, who say they have been unable to register with a general practitioner.

Recently in my hospital I've been struck by the number of patients, newly arrived in the area, who say they have been unable to register with a general practitioner. They are not the kind of patients with whom, alas, we are all too familiar: the patients who are so rude or violent that they are passed from surgery to surgery like packages of TNT, each doctor taking an unwilling three-month turn to provide them with medical care. On the contrary, they are perfectly respectable and decent patients: there are simply not enough doctors to go round.

Is this a problem or is it a crisis? Is there realistically a prospect of large numbers of people going without primary medical care? And if there is a problem or a crisis, who – or what – is to blame?

It is unlikely that carts will have to be sent round our streets, as during the Great Plague of London, picking up the dead who have died overnight through having been unable to find a general practitioner to look after them. There are always our overworked casualty departments, which large numbers of people already use as their preferred source of primary medical care. The seriousness of the problem depends upon the scale by which you measure it.

The GPs are caught in a situation in which it is impossible that they should answer all the demands made on them at once. The Government has tried to divert patients from hospitals to GPs – in the hope of reducing hospital waiting lists, thus avoiding damning headlines in the newspapers – by offering GPs incentives to do more for themselves rather than referring patients to specialists.

GPs now find themselves with responsibility for blood tests that were once taken in hospital. They now run clinics for asthmatics, diabetics and other chronically ill patients. Some even undertake minor surgery; though the pattern of incentives is such that much of this surgery – for example on warts – does not relieve pressure on hospital waiting lists, because the patients would never have been referred to hospitals for surgery in the first place. Surgery on warts increases the GPs' incomes, but it adds to the pressure on their time.

Patients are, likewise, more demanding. They are reluctant these days to be treated as sausages being squeezed through a machine. I remember 25 years ago being reassured by a GP for whom I was doing a locum that I would be able to finish his surgery in an hour. There were 60 patients, and the doctor for whom I worked never examined any of them, and clearly didn't expect me to either.

This won't do nowadays, when patients grumble even if they have five times as long with their doctor. They expect to discuss their diagnosis and treatment, rather than blindly to follow hurried advice of a generic nature. Meanwhile, there is a growing shortage of general practitioners. A large number of Asian doctors who came to Britain in the 1960s, and who often worked in the most deprived areas, are now at retirement age. No one is rushing to replace them. Increasing numbers of doctors are choosing to retire the moment it becomes financially viable for them to do so. Between the pressures placed on them by the Government, and by the patients who come armed with information taken from the internet with a clear disposition to sue if not satisfied, medical practice is not much fun any more.

For GPs to comply with modern standards, they should not have lists of more than 2,000 patients (1,500 would allow them to work at a pleasant, steady pace; they have up to 3,500 now). But the primary care trusts, like the family practitioner committees before them, are empowered to force doctors to take patients, if those patients cannot find another doctor. In other words, any individual doctor might be obliged to have a list that is simply too large for him to provide with an acceptable – and demanded – standard of care, unless he devotes all his time and energy to doing so, to the point of exhaustion.

It is one thing to devote all your time and energy to a practice because you want to, because your profession is the very centre of your life, and another because you are being browbeaten into doing so because the Government says that every citizen has a right to be registered with a general practitioner, and to receive a certain level of service from him, without at the same time ensuring that the infrastructure and personnel are in place to deliver that level of service. The main principle of health care management in this country is to squeeze blood out of a stone.

There is a deeper question about general practice in Britain: is it needed at all? Just as practice receptionists act like the dog with eyes the size of saucers, to deter as many patients as possible from entering the GP's sanctum, so the GP acts as gatekeeper to the specialist. Other countries do not have this system: a patient with something wrong with his skin goes straight to the dermatologist without first trying the prescription of someone who knows only a little dermatology. Of course, that means there have to be a lot more dermatologists.

In the meantime, the GPs are unhappy. The more they are compelled to accept central direction, the more they will passively resist, insofar as it is in their power. They feel not that they are members of a liberal profession, but that they are slaves of the state: and one day there might be a full-scale revolt.