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Shortage of GPs will never end, health experts say | Society | The Guardian
OK, maybe the subeditor is to blame, but spare me the cartel of health think tanks and their pamphlets. Enticing people into general practice and keeping them there is not rocket science. When I was a junior doctor getting onto the best GP schemes around Newcastle was harder than getting the ‘professorial house-jobs’. Many people like, and want to be, GPs. If general practice is dying , it is in large part because the NHS is killing real general practice.
A few years back I wrote a personal view in the BMJ, arguing that an alternative model for dermatology in the UK would be to use office dermatologists, as in most of the first world. It is likely cheaper and capable of providing better care as long as you consider skin disease worthy of treatment. The feedback was not good or in some instances, even polite. The more considered views were that my suggestion was simply not possible: how would we train these people? Well jump on a ferry or book Ryanair, and look how the rest of Europe does it.
There are some general discussion points:
- The various NHS’s in the UK do many things very badly. The comparison is all too often with west of Shannon, rather than that body of land closer to us.
- The proportion of ‘health staff’ who are doctors has been dropping for over a century. This trend will — and should —continue.
- I write from Scotland: Adam Smith worked out the essential role of specialisation in economic efficiency many centuries ago. Conceptually, little has changed since, except the cost of health care.
- The limit on my third point is transaction costs of movement between specialised agents. This is akin to Ronald Coase and the theory of the firm: why do we outsource and when do firms outsource? How do we create — to use a software phrase — the right APIs
- Accreditation and a professional registration are there to protect the public. We will only encourage staff to take on the new roles needed if there is a return on their personal investment, in return for formal admission to the appropriate guilds. These qualifications need to be widely recognised and transferable, and the guilds will need to be UK wide (or, in the longer term, wider still).
- The current system of accreditation for those providing clinical care is bizarre. Imagine, you know a bright and ambitious teenager. You tell her to come and sit in your dermatology clinic for 5 years and, at the end, you employ her in your practice as a dermatologist — initially under your supervision. Well, we know that is not a sensible way to train doctors, but this is indeed the way the NHS is going about training those who will provide much face to face clinical care. Got a skin rash — see the nurse! (for a couple of personal anecdotes, see below).
- The current system of accreditation for a particularly role for doctors is based around individual registration (with the General Medical Council). What the public require is however evidence of registration for defined roles and procedures (using the term procedure in a broad sense, and not just as in a ‘surgical procedure’). If somebody is a dental hygienist they are registered with the General Dental Council. This makes sense. The sleight of hand in medicine is that individual hospitals or practices have taken on the role of accreditation. I suspect if private individuals — rather than the NHS or its proxies — did this, they would be considered to be riding roughshod over the Medical Act (I am no lawyer…).
- Accreditation of medical competence at the organisation level is indeed a possible alternative to individual personal registration. It might even have advantages. But this has not been the norm in the UK (or anywhere else), and the systems to do this are not in place.
Two personal examples:
I received an orthopaedic operation under a GA at a major teaching hospital. I was in the my mid 50’s, and previously fit. At the clerking / pre-op assessment by a nurse, my pulse and BP were recorded, and my urine was tested. I was asked : “Are your heart sounds normal and do you have any heart murmurs?” (There was no physical examination). My quip — that how could you trust a dermatologist on such matters — was met with a total lack of recognition. I recounted the story to the anaesthetist as a line was inserted in my arm. I also mentioned, for effect, that they didn’t ask about my dextrocardia….( I achieved the appropriate response — to this untruth). Subsequent conversations with anaesthetists confirmed that their opinions were in keeping with mine, and this “was management” and ‘new innovative ways of
As a second year medical student, with a strong atopic background (skin, lungs, hay fever etc). I came out in what I now know to be widespread urticaria with angioedema. On going to the university health centre, the receptionist triaged me to the nurse, because it was ‘only skin’. I didn’t receive a diagnosis, just an admonition that this was likely due to not washing enough (which may have been incidentally true or false…). A more senior medical student provided me with the right diagnosis over lunch.
The latter example chimed with me, because DR Laurence in his eclectic student textbook of Clinical Pharmacology lampooned the idea that nurses had ‘innate’ understandings of GI pharmacology, a delusion that remained widespread through my early medical career. Now, sadly, similar prescientific reasoning underpins much UK dermatology. The public are not well served.