Columnist Dr Copperfield ponders the state of acute care for patients following new GPCE guidance
I’m confused, amazed, or both by GPCE’s latest version of ‘Safe working in general practice’. In one key passage it says, ‘Practices are obliged by their GMS contract to provide for the reasonable needs of their patients and for the assessment of urgent problems arising in their patients in their practice area. Emergency or urgent problems can be directed to emergency departments, 999 or 111’.
So here’s the confusion. Are we obliged to deal with acute stuff as per the first sentence of the above? Or can we just divert, as per the second?
Or is the idea that we assess, as in triage, fulfilling part one? And then, if deemed ‘urgent’ (and that word is obviously open to interpretation), we bounce, as per part two? If so, then that’s where amazement kicks in.
I’m not sure if this really is GPCE’s vision of the future or they’re simply trying to make a point. I’m as ground down as every other GP and, yes, my blogs sometimes betray a sense of doctor-centricity – aka survival instinct. But even I feel a tinge of sympathy towards patients here. It can’t be much fun having, say, raging earache and being caught in an infinite loop between 111 and general practice. Or being sent to join a nine hour queue in A&E to be seen by a casualty officer who: a) Is pissed off; and b) Doesn’t know one end of an auriscope from the other.
The problem is pretty clear. Acute illness exists. A reliable service for it doesn’t. None of the various agencies where acute care randomly lands – GP, 999, 111, A&E, pharmacy etc. – actually believes it’s their problem. Hence a buck-passing and patient carouselling system that is frustrating, inefficient and dangerous.
The overarching answer is to have a specific service dealing with acute care which is funded appropriately and commissioned clearly – and which, above all, owns the problem. Specifically for general practice, this would mean splitting acute care away from our contract, in a move analogous to the transformative one removing OOH duties in 2004.
In the meantime, whether GPCE is promoting their hard line approach as a temporary ploy or a genuine way ahead, the one certainty is that it will further alienate patients from general practice. And if we really want a better future, I’d rather have patients who smile benignly at us, rather than patients who want to punch us in the face. Not least because public opinion may sway the political one.
Besides, you might think it’s tough, clever and justified to take a stand right now. But wait until your earache kicks in.
Dr Copperfield is a GP in Essex. Read more of his blogs here
I am curious to hear your solution Dr Copperfield?
Copperfield asked me to relay this message… “For those asking what’s the solution, I’d redirect you to the piece because for once I’m not just ranting, I’m actually making a constructive suggestion. It’s this bit: “The overarching answer is to have a specific service dealing with acute care which is funded appropriately and commissioned clearly – and which, above all, owns the problem. Specifically for general practice, this would mean splitting acute care away from our contract, in a move analogous to the transformative one removing OOH duties in 2004.” OK?”
Ok, yes please commission (ie fund) an acute service but please let the practices, especially rural ones, hold the contracts to provide the service. I would rather be properly funded to see our own patients for acute problems than send them 12 miles to the nearest town on a non existent bus route (with the likely risk they then end up on the urgent care merry go round you’ve so accurately described). Proper funding and resourcing of GP near to the patients it looks after seems to be the solution to me, rather than yet more fragmentation
1. What Mark Sage says
2. Hopefully earache (example given) would be Pharmacy First or urgent care hub or WIC.
3. I think we have to use our judgement on case by case basis. I can’t see anyone turning away someone in genuine need. If we get better at diverting the stuff that does not need seeing, we could hopefully increase capacity.
The trouble is the opinion as to what needs to be seen will vary depending on whether you are a patient or medical professional. Patients are confused by the list of options they now have as to where they should take their problem. Introducing another tier is just fogging the issue. OOH being taken away was straight forward – or was it? Now patients are passed to 111 etc during surgery open times when capacity is reached. Often this tips the problem into the OOH services. To a service which doesn’t know them and promises more than can be delivered. It reduces the need for self care for the minor illnesses and so encourages more use of an overwhelmed system. General Practice needs to have the funding to sort out the needs (and wants) of the patient population and not be dissected into more fragments. This way 999 and A+E will be able to get on with the 999 and A+E stuff. Patients will feel heard and, hopefully, armed with strategies to deal with the day to day annoyances of being human that may come their way, and know that their GP will have the time and opportunity to ask for help from the specialist teams who respect our training that
allows us to assess a patient in a ten minute appointment because we have had a myriad of ten minute appointments with them over the years
1) Shift significant funding resources from secondary to primary care.
2) Allow individual PCNs to develop models of same day care on a neighbourhood basis.
3) Engage with and take patients with us to achieve the above.
What’s your suggestion, because patients also aren’t safe being the hundredth person a GP has dealt with that day, and just pointing this out and asking nicely has achieved a raft of not-doctors to supervise so that the government can say access is better.
I’m with Josephine Fleming on this. Patients are confused with the “passing the buck” fragmented “choice” of (crap) options for their acute care. They still just want the beautifully simple option of their GP sorting them out. The BMA’s main, probably only, negotiating point should be increased core funding and increasing GP/nurse numbers.
Any Govt either funds the needs of the NHS (productivity’s got nothing to do with it – it’s a public good representing our social values not a market run by the invisible hand) or continues fragmenting Market-theory tactics with a view to future corporatisation.
Labour hasn’t yet shown whether it’ll commit to a properly funded Big Bang reset for the NHS or whether it’ll continue the policy of death by a thousand cuts started by Blair.
David, If you take ‘Acute care out of Gp’s contracts who is actually going to do it?
The rot started in 2004 when out of hours care was taken over .It has resulted in an unholy bureaucratic mess with the poor patient being left to navigate a ridiculous system whilst various parties try and avoid taking responsibility. .Splitting off acute care will result in more of the same but I suspect much worse.[See how acute care is managed in A and E for reference]
General practice will become a lot less interesting and patient care will suffer further.We all know there aren’t enough Drs but a solution needs to be found .Freeing up Gps to actually have more time to see patients rather than endlessly tangling them up with QOF, meetings endless petty directives, , safeguarding courses etc the list is endless would be a good start.Productivity would improve and the job would become far more satisfying closer to what people actually signed up for in there first place .
@paul.loxton – although admittedly Copperfield does sound Dickensian at times (I picture him in a frock coat and purple cravat), he prefers to be addressed as Tony 😉
Splitting it off in order to demonstrate the fiscal cost is OK but risks loss of continuity of care. The same problem occurred with the OOHs going. They valued it so low that GPs took the drop in income because we were paying more than that we lost to run OOHs co-ops and deputising services. Thus the true cost of OOHs hit the NHS. I don’t think the true volume of work in acute care done in primary care is appreciated by those in hospitals or management. They see GP as a problem as they do not have the control they like. That is precisely why GP is so relatively efficient to the rest of the NHS but is now massively under funded to the point of practices closing as it is no longer economically viable. 340million primary care consultations would hit A&E like a massive tsunami.
There is a failing of Governments DHSC NHSE and thus ICBs to commission safe services. GPCE is pointing GPs to protect themselves for the sake of general practice. All the time we act as the risk sink and mops for the NHS, more and more will be expected without the recourses coming to General Practice. So Copperfield is correct that a service other than us is commissioned. A bus route, train or plane that is full cannot carry anymore safely [and will not] and neither can tired burnt out staff but until we all take action against others failings (not ours) nothing will change. Support the GPC and BMA, a union is only as strong as its members. (DOI: GPCE rep for Berkshire and NE Hampshire)
The trouble with removing ‘acute’ GP is who decides what’s acute. 2004 was ‘here are the hours you are responsible’ and even that has been tricky to work – does that mean if a patient calls at 18:29:59 they’re still our responsibility or do they have to be able to have been seen and dealt with by 1830? I can’t see an acute GP service doing anything but worsening the churn for patients – ‘now go back and see your regular GP’ , or as we have locally with our ‘GP front door’ at the hospital – we can’t do 2ww so contact your GP urgently for them to do it’ and worsening the job so we get even more attrition of workforce.
Why not just fund the actual GP service properly? We didn’t have this concern when pt:wte numbers weren’t so high, and also, of course, when hospitals saw patients and completed episodes of care.-
As the NHS could be said to be a monopsony employer, then for those who say that an alternative acute service should be commissioned, the logical fiscal endpoint is that the NHS buyer decides to buy/contract all services elsewhere and not from GP contractors…why would they need “expensive” GP contractors? When GP employees, agency GPs, SAS or primary care drs will do, and contracts are handed over to corporations (likely USA, under a terrible free trade deal).
A bus route or train analogy is a false position as they are private companies and based on the (profit) motive. A country chooses what goods and services it wants in its public sector (healthcare in our case) and so by definition it should be funded properly based on its need. There is always money available, especially in the 8th richest country – start by appropriate taxes on capital.
I hope the BMA is not too short-sighted to see they may be the unwitting midwives of possibly privatising another part of GP. Because the BMA’s beginning to remind me of the Black Knight in the Holy Grail. Another limb chopped off but still stupidly pretending he had fight left in him…
Full support for ideas above- keep acute care in GP land, but resource us adequately.
I used to see extras, try to help wherever I could – until a spurious complaint from family of someone I was trying to help went all the way to NHSE. The outcome was “no concerns about performance” but it taught me a lesson: do not try to help people, they will hold it against you. They accept all the crap from secondary care, but if they believe that you hold all the responsibility – they will come after you. So let’s assume the responsibility remains with GP- then resource us properly so we are able to deal with it.