healthmedicinet

The pressures on general practice are, says one doctor from a busy inner-city London practice, leading to a “budget airline” style service. Writing in this week’s Scrubbing Up column, Rebecca Rosen, a London GP and senior fellow at the Nuffield Trust, says the trend is a mixed blessing for doctors and patients.

For a combination of work, family and leisure reasons, I travel a fair bit and, until their recent efforts to improve customer service, I used to try hard to avoid budget airlines.

It was the sense of contempt for my custom and their inflexibility in the face of passengers’ problems that I disliked.

So it was with some horror that I realised recently that the changes we are making in my GP practice to cope with rising demand, falling income and increasing contractual and regulatory requirements risk pushing us into a budget airline-style modus operandi.

General practice is acting as a safety valve for growing deficiencies in the wider NHS. Alongside those who need an appointment for acute illness or chronic disease management, others now pile in.

Frustrated by repeated calls to hospital answer-phones, patients default to the GP for help with hospital services. Schools demand proof of professional advice for absences due to minor illnesses, so parents who can competently manage childhood illnesses are contacting the surgery.

Operations are rescheduled repeatedly so symptoms worsen and a holding treatment is required.

In each of these situations, the most direct access to professional help is through the GP’s front door.

‘Toxic comments’ risk

In response we are re-designing our services.

We have launched a morning walk-in clinic to improve access for people with acute problems. We have introduced e-mail consultations and web-based-options for requesting medical certificates and repeat prescriptions.

But we are also wary of supply-induced demand – which means the more services are available, the greater the number who will come.

If we open the doors wider and longer we need to ensure that precious, easily accessible slots with GPs and nurses are not swallowed up by patients who don’t need face-to-face care.

So we have introduced a checklist for receptionists – who should be steered towards the computer in the waiting room? Who should be asked to see an alternative member of staff? And who really needs to see the GP?

This risks toxic comments on our web site about nosey and intrusive questioning but we are giving it a go.

This is where the fear of budget airline-style general practice looms ominously.

We will not issue repeat prescriptions in the walk-in clinics because experience tells us that appointments will be used by people who can easily request their medicines in other ways (including via a phone app).

We won’t do repeat medical certificates (requests sent to the patient’s usual doctor) or pill checks (can be done online, with a visit to the self-service blood pressure machine in reception).

‘Cut out the frills’

Such changes feel inevitable but also defensible. They will enable us to direct the skills and experience of the GP to those with the most complex problems.

But I nevertheless fret about the impersonal, inflexible rules we are creating. Many highly regarded surgeries are making similar changes, which are increasingly seen as “good practice”.

For some, face to face consultations must be preceded by a phone call. In others it is getting harder to reach the surgery without first making electronic contact.

Telephone numbers are buried deep in practice websites, stoking the blood pressure of those with limited IT skills who simply want to phone to book an appointment.

We are facing the reality of austerity funding, rising demand and an ever more demanding GP contract.

This is pushing us to cut out the frills. It’s become harder to personalise care for patients who struggle to attend appointments.

We are creating rules that we aim to stick to (for experience also tells us that unless we all do the same thing, patients “shop around” until they get what they want). And so we shift closer to the cold inflexibility of budget travel.

We are trying our best to mitigate these effects;. But the reality remains that we feel we can’t avoid working in ways that jar with our expectations of ourselves.

Friends and former colleagues have found this shift too intolerable and have retired from clinical practice.

For now we are pressing ahead; monitoring patient and staff feedback and measuring access.

We have joked that if we can’t offer business-class services then we should aim for EasyCare (the medical equivalent of EasyVet, perhaps).

I still see the job of a GP as a huge privilege, and I find enough job satisfaction in every clinic to keep me going – but I never expected to practise “budget airline-style”.

It remains to be seen whether the new models of general practice that are emerging will propel our services to premium economy status.