Is there more to this than meets the eye?

Ed Miliband has promised to restore citizens’ rights to get appointments with general practitioners (GPs) within 48 hours. This makes sense. The 48 hour access rule was part of a set of targets introduced under Blair to reduce waiting time for investigations of cancer and time spent in hospital A&E departments. The NHS’s natural tendency is to grow waiting lists, which Labour knew and tried to counter, but the Tories abolished the 48 hour rule in their enthusiasm for small government.

The problem for Labour is that this rule is unpopular with GPs, who are seeing their discretion in working with their clientele eroded yet again. The aspect of discretion that matters here is the right to push back against demand, knowing that it is driven by many things, some of them difficult to articulate. This ‘demand management’ role is an historical one. Since 1948 the NHS contract with general practice has been a compact between the State and the medical profession to control public access to expensive hospital services, euphemistically called the “gatekeeper function”. The situation has changed over the years, in that GPs now seek to control public access to themselves.

Part of the demand the public makes of general practice comes from a mixture of recurrent distress, poor coping and fragile personalities. In psychiatric jargon this is ‘personality disorder’, a persistent inability to cope with the tasks of life and about one in five patients in GP surgeries fulfils the diagnostic criteria for it. Personality disorder is difficult to deal with, and adds to the emotional stress of doctors’ work. It is also a diagnosis that is contested as the medicalization of unhappiness, and is hard to talk about it without generating conflict. Some GPs privately call such patients ‘doctor-botherers’ or ‘klingons’, but in public they are more wary about denigrating those for whom they often provide a listening ear in an unkind world.

Doctors working in deprived areas also face extra demand from the consequences of their patients’ poverty. Some of this extra demand flows from higher disease rates in poor people, and some from their greater help-seeking for individual illnesses and for the social sickness of deprivation. But deprivation is not necessarily the main driver of demand in most parts of the country; medical consumerism may be overtaking it.

Medical consumerism shows itself as patient challenges to doctors’ authority, and is a feature of (amongst other things) super-diversity. Super-diverse populations bring experiences of other health services to their encounters with the NHS. Those from poorer countries may become appreciative (if deprived) consumers, whilst those from countries with more customer-friendly health services become critics of the NHS and challenge its professionals.

One consumerist challenge is about time. Whose time is more important, the doctor’s or the patient’s? The NHS has relied on restraint in the use of its services, encouraging the view that there always others in greater need than yourself, but this attitude of internalised rationing is probably shrinking. The counter argument is that those paying for the NHS deserve something in return, and they want it when it matters to them. Is this not the ‘squeezed middle’ talking – a group that Labour is keen to woo?

GPs like to use the idea of restraint, whilst dodging the question about ownership of time. Their task, they may say, is to balance demand and need. Those with sharp elbows may have least need for medical care, so attending too closely to them might deprive others whose claim is greater. Favouring the demands of the worried well may detract from helping the seriously ill. There are, after all, only 24 hours in the day.

So why not employ more doctors, to respond to the demand? General practices are independent, for-profit contractors to the NHS. They can employ doctors, nurses or admin staff to organise their surgeries differently, in response to demand. This is unlikely to happen, however, or even be considered. Recruiting extra staff would directly reduce GP incomes. GPs’ incomes lagged behind those of other professionals from the mid-1960s to 2004, when parity was restored by an increase in practice income of about 20%. In the middle of the last decade GPs in the UK became the highest paid family doctors in the world. Since 2004 parity has been eroded again, and many GPs see their income declining once more. Why would they take a further pay cut to satisfy the ‘worried well’, and work even harder for even less? Paradoxically, some practices have been making sessional doctors redundant to maintain profits for the core group – exactly the opposite of what is needed to meet the 48 hour rule.

This is a problem wired into the NHS. GPs are independent contractors whose franchised status as part of the NHS has insulated them from the risks of trading since 1948. No surprise, then, that they are instinctively risk averse and only weakly entrepreneurial. The ‘subsidy junkie’ description of GPs popular in the wider NHS is a label that fits. Worse still, when change is resisted it is tempting to replace reluctant entrepreneurs with energetic ones. Privatisation will become more attractive as an option if the existing service cannot meet this government’s expectations.

By picking the 48 hour rule to distinguish Labour from Tories on the NHS, Miliband has chosen a policy that will be troubling for general practice because it raises so many questions about the discipline’s relationships with the public and the State. It also reveals the mess that is the GP economy. There are opportunities for Labour here, if it is bold. A New Deal that stabilised GP incomes within a tougher contract, increased GP discretion and balanced citizens’ rights of access with responsibilities for using the NHS judiciously, might work for all concerned.

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5 Comments

  1. Methusalada says:

    Not sure what to say about this issue, I can only speak as I find and that is I have a good Irish GP . He addresses my concerns frankly & works in my best interests . I realise that I am privileged to live in Wales as an Englishman & have considerable medical conditions which If I may say I have paid for in to my NHS contributions for nigh on 57 years. The thought that my grand children & their children shall not receive or benefit from the same standard of NHS service that I have received & paid for appals me. For this reason & no other I am now totally an anti capitalist & hope to have that engraved on a medallion to give to all who follow after I am gone . Family, friends or joint believers . The devil walks abroad now !

  2. There’s just a little problem Ed seems to have forgotten:

    http://www.pulsetoday.co.uk/your-practice/practice-topics/employment/crisis-point-gp-partner-shortage-hits-practices/20006889.article#.U5YZ3XJdXHS

    And doctors are emigrating in large numbers, How does he think this policy makes sense without the doctors to sustain it?

  3. Methusalada says:

    Most Doctors & Surgeons whom I have met are human beings & take pride in their profession of looking after their patients , I try to think of their own position today as if it were myself in their position. They are medical professional staff & not interested in political hanky panky bullshit from successive governments. They are educated professionals who rightly seek reward for their 5/6 years of training . Above all they are mainly all human beings who have ascribed to a very important oath. One that is not uttered in Parliament or the London Stock Exchange.

  4. John Band says:

    While GPs do, in general, want to give good service to patients, they are not incentivised to do so. They also have a problem with people, particularly old people, who don’t need to see a doctor blocking up the appointment system. Telling a parent with a kid howling with, say, earache, that the doctor can’t see it for 48 hours is absurd. Doctors need mechanisms for fixing such things rather than the proposed 48 hour rule.

  5. If Ed can do this he will be forever one of the best leaders for a very long time. Thanks will come from every quarter of the land

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