The whole NHS reform is based on an assertion – that GPs are somehow better placed to decide what NHS services need to be provided because they are in some sense ”closer to patients”.
The news story today that GPs seem to be failing to provide adequate services to elderly people in care homes raises doubts about this assumption. I tweeted about it and have had an interesting exchange with ”TheNiceLadyDoc” (a GP).
Let’s take motivation first – are GPs closer to patients in the sense they have their (patients) interests more at heart than others? Well, I know plenty of hospital doctors, nurses, physio’s and health managers who would dispute that. Of course, institutional factors may affect motivations. A doctor in a GP practice is in a different institutional setting to a doctor in a hospital. The former is a private contractor, the latter and NHS employee, for example. How might this affect their motivations?
The idea that GPs are inherently somehow more ”knightly” (to use Julian Le Grand’s terminology) than somehow ”knavish” hospital doctors or managers is plainly ridiculous. There can just as easily be Harold Shipman’s in GP practice as in hospital’s.
One incidental point is worth making here about individual wrong-doing and institutional context. It is much easier for a GP in a singleton practice to get away with what Shipman did than it would be for a doctor in a hospital.
Next, information. It is assumed that GPs somehow ”know” what their patients need better than hospital doctors or NHS managers. But how true is this? Many patients in urban group practices see different doctors every time they visit the surgery.
So GPs don’t necessarily know what individual patients need. Indeed, some patients with serious health problems will actually see much more of their hospital-based specialist medic than they will their GP, who will essentially be an on-looker in the process. GPS are ”generalists” and by definition in a poor position to out-guess ”specialists” in every field of medicine about what patients with specific conditions need.
So, maybe GPs are better placed to assess collective health needs of patients rather than of individuals? Again, this is true to some degree – GPs will get a (necessarily subjective) sense of what their particular group of patients ”need”. But that is of course is subject to bias, to missing out on rarer conditions, or potential patients who don’t or can’t present (e.g. dare I say elderly in care homes?).
So GPs do have access to some types of patient information that others in the NHS don’t, and they may have to some extent a more ”holistic” view, but in other areas they have little or no knowledge at all.
The myth of the saintly, well-informed, GP who ”knows best” is a comfortable throwback to the age of Dr Finlay and cosy fireside diagnosis.
So if the NHS reforms are based on a systematic myth, the question is why? The answer is rather simple. GPs are potentially the back-door through which private contractors can be brought in to run the NHS. They are themselves private contractors, and some will certainly see personal advantage in the new arrangements. Others will simply want to get on with being doctors, and hand over their commissioning role to a combination of other GPs who want the job and private companies offering attractive packages that make the ”problem” go away.
The new CCGs will also serve the purpose of shifting services from hospitals to community. This is a good thing. But it will also just happen to be shifting services from publicly owned hospitals to, in many cases, privately run community providers.
GPs have been unjustifiably elevated to a special, almost saintly, status in the health debate with one sole purpose – to use them as a back-door route into breaking up and privatizing NHS provision. As far as I can see the Health and Social Care Bill still does precisely that.
STATECRAFT - improving government 
Precisely !
I’m glad that in this article we are reminded that GPs are in the private sector, contracting in.
There’s been plenty of ‘private’ bashing going on in this debate, not least from GPs. Private does not equal evil rich people, it’s just another option.
As a provider Osteopath in the private sector I’m disappointed that currently I cannot help a small sector of society that would benefit from treatment due to affordability. (I charge £40 for my undivided attention, detailed anatomical and broad medical knowledge and hands on treatment under statutory regulation.)
But of the diverse population I do see, I can be flexible, generous with time, and best of all cater to their individual needs. My success is dependent upon my patients’ improvements and satisfaction with their experience here. And I am pleased to say, I’m still busy after 12 years in practice.
No Mercedes yet I’m afraid and no kids at public school either.
The idea that GPs are potential Shipman’s who know little of and care even less for their patients cannot be seriously considered in the one-liners you’ve used. The assumptions about what we do and how we do it that I read from politicians, think-tanks and journalists, cheered on by patients who have been treated badly (and often have good reason to complain) reflect a particular, politicised perspective.
I’ve written a lot about what GPs do, http://abetternhs.wordpress.com/2011/07/24/what-doctors-do-2/
The intimate knowledge we have of our patients: http://abetternhs.wordpress.com/2011/07/13/doctors-patients-and-obesity/
Our future role: http://abetternhs.wordpress.com/2011/10/28/role/
And the choices we help our patients make: http://abetternhs.wordpress.com/2011/01/11/the-choices-patients-make/
Having said that, I think GP commissioning will be a mechanism for privatisation: http://abetternhs.wordpress.com/2011/11/21/proof/
But you don’t have to try to prove that we’re venal, would-be murderers who are ignorant of our patient’s needs to show that.
to abetternhs: sorry if you misunderstood, I did not say all GPs are potential Shipman’s, what I actually said was there can just as easily be DHIPMan’s in hospitals as in GP practice. My point was that I very much doubts the motives, good or I’ll or both, of GPs are very much different than other health professionals.
There is incidentally an extensive reasearch literature on what’s is called “public service motivation” (PSM). It tends to show that to some extent people self-select – I.e. people with higher levels of PSM tend to go into public or caring services, but that also the context of public or caring services makes people more PSM in their outlook. But the differences are not huge, except for some private sector jobs that seem to attract and encourage people with the opposite of PSM.
I discuss some of this in my most recent book “Theories of Performance” and in an earlier book, “The Paradoxical Primate”.
Sorry, and in the ‘information’ point – I have to say my unfortunately extensive) experience of GPs is they are very good at the generalist role but tend to defer to the expert knowledge of particular conditions of hospital based doctors. I’ve never had a GP yet willing to challenge, or change, what a Consultant has recommended even when they clearly disagree. Maybe all the GPs I’ve dealt with are unique, but I rather guess not. Interesting to know if there’s any proper research ( as opposed to my subjective anecdotes) about it?
“I’ve never had a GP yet willing to challenge, or change, what a Consultant has recommended even when they clearly disagree. Maybe all the GPs I’ve dealt with are unique, but I rather guess not.” Presumption befitting a true novice. You speak like a frog in a well declaring himself to be the king of the world (until he ventures out of the well that is).
As a GP, a large chunk of my administrative time is time is spent writing to consultants at university teaching hospitals as well as district general hospitals advising and informing them why we feel that their choice of drug is not justifiable/not indicated/not supported by evidence or simply unlicensed and dangerous. There are several other GPs who do the same.
There are several examples I can give you, within the last few weeks of letters needing to be sent – painful and time consuming – but better than capitulating to wrong advice. Letters from hospitals that get scanned on to our system have hand-written ‘DO NOT PRESCRIBE X DRUG’ or “Y NOT INDICATED” printed by us for our records. Its not just prescriptions but other interventions as well which come into the fray as well.
Clearly, in your limited sphere of experience, lack of evidence has somehow become evidence of lack.
Please let me know if I can be of any further assistance to help dismantle your presumptions.
Regards.
P.s I dare you to print this comment in an unedited form.
In reply to W Adam,
Let’s leave aside the rather childish ‘dare you to print it’ – seriously.
You are quite right that my evidence on some points was anecdotal. I said as much quite clearly. But two points.
First, mine was based on extensive experience as a patient over 30 years with chronic and sometimes acute medical problems and partners with the same, in four different parts of the country. And the death of two close relatives (brother and father) in circumstances that make me more than a little sceptical. Still, it is all just anecdote, you are quite right.
Second, your response is not research evidence but your own set of anecdotes. Hardly a consistent response. If you only accept non-anecdotal evidence, then provide some. Otherwise your comments are somewhat self-canceling.