On the flight back from his summer holiday, Dr David Salkin reflects on what has really happened to general practice as the reality of returning to work looms
Travel, they say, broadens the mind.
Yet I want this journey, a flight back home, to focus the mind and answer a question that continues to trouble me: what has really happened to general practice?
The flight attendants go through their routine safety checks, but I don’t listen.
Instead, I think about the then, and the now.
There was a time when I’d start surgery thumbing through a shoebox full of notes, looking for any heart sinks that may task my patience. Now I start surgery looking through email inboxes, and my heart sinks with the number of tasks about my patients.
There was a time when I’d wear a tie, and shake people’s hands for rapport. Now it is I who is sometimes worn, and tied to deadlines and meetings. Not to mention that if I dared shake a patient’s hand, I may well be reported to infection control. Or worse.
There was a time when I was the friendly type who would open doors for patients. Now I just type ‘S’ on the keyboard, and with James Bond efficiency I can eliminate patients’ waiting-room-to-consulting-room strolling time. That’s 26 seconds saved per consultation, Miss Moneypenny.
Then there was a time when we’d have tea and buttered toast during the mid-morning surgery break, putting the world to rights with colleagues in an informal act of group psychotherapy. Now we wouldn’t have the time to plug in the toaster, let alone burn the toast through idle gossip.
But I don’t think it’s all bad news. I still manage, on occasions, to get up and open the door for patients when they leave, because a GP does need their exercise (and sometimes I want to glance down the corridor to check whether a clumsy limp actually lasts beyond the consulting room).
As we ascend to 28,000 feet, my mood descends as I decide to compose a moaner’s list on the back of the in-flight magazine:
- Why has nine-session working become impossible albeit for the few stoics among us? What other profession would have allowed this?
- Why have GPs not been better supported by those in power to develop our careers in medicine, to learn new skills and take on roles beyond routine general practice, in the same way as our nurses?
I scribble ‘variety is the spice of life’, ’funded protected time for learners’ in the margin, before my pen becomes even more vindictive and takes on a life of its own.
- If community pharmacies have taken GMS income from various activities, why can’t we open dispensing from all of our own surgeries?
‘Level playing field’ is also entered in the margin, and then I notice that the flight attendant seems to disapprove of a man with a tan defacing the company magazine. I try to distract her by requesting a whiskey, but forget it’s not yet dinner time, and then my pen continues to dispense its bile.
- How is it that GP partners’ investment in premises – a financial reward for long-term commitment to their local community – has become rare, and more often a prize for Big Business?
As I write this, the scotch is deposited on my dinner tray by the chief steward. No communication, not a hint of a smile. He probably senses trouble as more pages of the magazine are defaced.
- How have we allowed ourselves to be swamped by a contract that allows for unlimited work and responsibilities while being ‘rewarded’ with limited, and now reducing, resourcing? What other profession or business would tolerate or indeed survive that?
The glass of whiskey shakes as the captain warns of turbulence. I’m unsettled and imagine a strategy for the new GPC leadership facing the emergency crash-landing of our profession. I picture all the adult passengers around me who must be selfish, reaching for the oxygen to save themselves before caring for their dependents, and then imagine how we as a profession could look after our interests first, so that we can survive to care for the patients who depend on us.
The thought alarms me, and I dismiss it, for above all else, we must do no harm. I still feel the turbulence, though, and wrestle with the arm rests. An unsettled sleep follows, and when I wake up, I look through broken clouds at the green, green grass of home below.
But what I cannot see is the answer to my question: what has really happened to general practice?
Dr David Salkin is a GP in Leicester
The real question, David, is *why*?
Eloquent and asking the right questions as always David. As an ex partner in Leicester for 20 years and now a GP locum who has worked alongside you in the past, I often ask the same question. Answer is we don’t value ourselves enough and have not been selfish enough to ask for what we want. We have been failed by leadership and by the NHS which initially for me was an inspiration but now feels like a bullying monster who cares not an iota for it’s staffs wellbeing and development. We can see the past and see what general practice has become. But to newcomers this is the norm and a “new” way of practicing where 9 sessions is not only impossible but harmful. But general practice will not crashland. It will just morph into something more dire and non functioning than it already is and limp on.
Excellent musings on the tragedy that is general practice. Seeing the writing on thewall, I left my partnership seven years ago to work as a Locum. I was amazed to see how practices not run by GPs were cutting corners and penny pinching to try and make a profit. I spent a year in management which involved running an APMS practice. Due to previous poor management and funding, it became clear that it was not viable and we handed the contract back.
The fundamental problem that has led to the decline of general practice is the lack of increased funding to match the increased demand. General practice as it was in the 1990s will never return.