Why are GPs so unhappy?

Korhomme is a retired medical consultant.

When I was young we lived in the University area of Belfast; out General Practitioner (GP) lived round the corner, and worked from home, as was usual in those days. To see him—and GPs were almost exclusively male then—you went in the front door, and waited. It was important to count the number of people in the waiting room, so you’d know when it was your turn. In his surgery, you were often met by a thick fug of cigarette smoke. After a cursory examination, you got a script for whatever.

Things are different today; you arrange an appointment on the phone, and you get called when it’s your turn. The GP—increasingly often a female—sits behind a desk looking at a computer screen. She’s pulled up your details, but before she asks why you have come, she has to go through the tick box checklist menu of things that might improve your health. This checklist isn’t such a bad idea, screening for common conditions, though it’s a bit irksome to be asked the same thing every time. But the GP earns some sort of “brownie point” for completing it, and we all know what points mean.

The GP is probably as pissed off with this as you are, but she feels obliged to do it, as it helps the practice’s finances. Actually, she might well be pissed off with a lot more things than just this particular bit of “paperwork”. She doesn’t do night work anymore, there are “out of hours” providers who provide this service. These people may well be locums, though they certainly don’t know any of the patients at all, and they probably don’t have any information about them. So, if the problem doesn’t seem to awful, the people will be told to see their own GP. And that’s your GP, and she’s already seen several of these punters today, all with very little wrong with them. And she’s fed up because her last patient needed a simple investigation, an ultrasound say, and although she’s trained in how to do them the practice doesn’t have a machine, and she can’t order one directly from a hospital. Instead, she has to refer the patient to a specialist who then has to refer the patient for the scan. So, this GP will wait weeks for a result that she could have determined in a few minutes. Oh, there’s talk of her being appointed to a new commissioning group whose remit is to choose the most appropriate providers for particular services from a range of options. She knows she has neither the training nor the expertise for this.

Your GP isn’t really in control of her work. She’s a professional, and would like to work to those standards. And although she is technically self-employed, she’s really very much under the control of the local Trust, who are under the control of the Ministry, who might be controlled by a politician, who, hopefully, is “responsible”, the person who resigns, who falls on his sword when things go tits up. Like many things in the NHS, swords are rationed these days.

It’s a time-worn cliché, but still valid; managers and professionals don’t work well together. Managers want certain things done, and want their employees to do them; the professionals see managerial demands as unreasonable or impossible, and only very rarely do they speak the same language. There is little common understanding, and a suspicion from the professionals that the managers want ever more; while the managers see any difficulty from the professional as a closed shop mentality, a closing of ranks, and quite possibly a covert demand for more money; and, for the most part, all of this is correct.

It’s a failure of “organisational culture”. The NHS was originally based on what was then available, it wasn’t designed de novo. Although there have been lots of reorganisations, most recently in England when the incoming government promised that there would be no top-down restructuring, and then promptly started one. That was more about getting private providers in, what’s often called “creeping privatisation”. But what GPs and hospitals actually do, what things they are responsible for and what things they aren’t responsible for hasn’t really changed all that much. True, there’s lots more that can be done now, but the two areas of practice don’t overlap or properly interdigitate any better. It’s a failure of leadership too; you probably think that inspirational leaders are the best, the people who can lead a team forward towards the goal. Such leaders get the applause and the gongs. You’re wrong, though; the best leaders don’t just inspire a team, they get the team to lead itself, so that the team members can truthfully say that they achieved their goal, not that the leader drove them to it. Governments don’t work like this, theirs is a “command and control” culture, one that might well be suitable for officers and squaddies, but which is entirely inappropriate for a professional setting.
As it happens, I need to see my GP, not for any big problem, but I’m not so happy with some of the pills. I’ve been ringing up bright and early in the mornings, for I can only book an appointment for today. But every time I try, the phone is either engaged, or when I do get through, all the slots are gone. So I asked the receptionist how I could actually get an appointment; queue up at the door before we open, she said. Plus ça change…

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