Written evidence submitted by Dr Michael O’Reilly (FGP0022)

 

Dear Sir / Madam,

 

As well as answering the questions below I am also sending a separate email containing recent correspondence to the GMC and the SOS for Health amongst others on the state of medicine in the UK.

 

General practice cannot be ‘salvaged’ on its own.  It can only be done by dealing with the professions (medicine and nursing), and the NHS (structure and organisation) as a whole.

 

As a result of 30 years of changes we now have a completely broken and irreparable situation.  This consultation is an opportunity to open a wider debate which is essential.

 

The situation in the UK is so dire and it has resulted in many many thousands of deaths and I believe we have well surpassed the criminal threshold for the crime of democide. This is detailed in my accompanying letter.

 

 

 

This is multifactorial.  Demand is very high.  Most GP’s have reduced their hours in order to survive the bureaucratic nightmare.

 

More men should be encouraged into GP.  Conditions should be such that there is incentive for GP’s to join practices as opposed to doing locums.

 

Administration takes up an inordinate amount of time and using computers for almost everything literally slows everything up. 

 

The 10 minute appointment system is appalling.  Some patients need a lot more time in one sitting as opposed to several short appointments.  This is especially the case with chronic illness.

 

Having people seen by physicians assistants and nurse practitioners is hugely inefficient and generally substandard.  The supervision of these grades is more pressure on GP’s.

 

 

 

It doesn’t.  It will only make things worse.  What is needed is a complete reversal of changes made over the last 30 years.  It is also not possible to salvage a single part of the system.  The whole system needs to be addressed at the same time.

 

 

 

Patients get frustrated and may suffer medically.  This places more pressure on reception staff and on GP’s as well as self-referral to A&E therefore having a negative impact on hospitals.

 

Prolonging the time to see patients also puts patients in danger eg development of sepsis.

 

 

This is the ideal.  In the current environment this can still be done with the understanding that patients may need to see other doctors.  From a job satisfaction viewpoint this is very important and was a main tenet of general practice of old.

 

 

 

In one word: survival.

Changes over the past 30 years have destroyed a once excellent service that generally satisfied patients and led to career satisfaction with mutual trust. 

 

Further structural change (CCG’s, PCN’s etc) all add in bureaucracy causing non-clinical work with the addition of new bureaucratic processes and organisations.  Reducing complexity will be essential.

 

GP needs to be ‘standalone’ in the community and the centre of the medical system. 

 

Training needs a radical backward overhaul.

 

 

 

I am unable to give a detailed answer to this.  The fact that this question is asked implies “regional variation” and this is something that should not be an issue.  The model of GP should be the same throughout with relevant allowances for urban, deprived area and rural practices.

 

 

 

This is an important issue and one that has been used in the past to satisfy various agendas. 

 

Doctors qualify to treat sick people.  This is the No 1 priority and always should be.  Forcing or encouraging doctors especially with financial incentives to initiate no-smoking clinics etc changes the role of the doctor.

 

When patients are ‘lectured’ about their smoking, drinking and gambling addictions it causes huge harm.  So much so that patients are driven away from getting help and there exists a public health crisis as a result.  There is a disconnect between the preventive medical political world and the real world. 

 

It could be said that medicine has been forcefully evolved into a puritan profession. 

 

When it is appropriate to discuss preventative issues it is appropriate.  Otherwise it is not and causes more harm from unintended effects.  GP’s need to concentrate on treating sick patients.  Sending letters to patients to take part in screening etc is a waste of acute resources. 

 

NICE Guidelines:  these are responsible for a huge added workload especially in a preventative context.  GP’s should be primarily dealing with acute and chronic illness as opposed to treating potential future illness.  Having GP’s follow logarithms in many chronic illnesses is something that makes general practice inefficient. 

 

 

As noted elsewhere changes need to stop and most need to be reversed (oxymoron!).  We need to go back to basics.

 

Administration of all kinds needs to be radically reduced – eg form filling using different computerised forms for different specialties containing huge amounts of irrelevant information.  Anonymous individuals in hospitals refusing to accept referrals etc.

 

Hugely important too is Appraisal and Revalidation.  This boils down to being a crime in reality.  It is responsible for huge misery and time wasted (including out of work time).  It is responsible for huge numbers of doctors leaving and the deviation of huge amounts of money away from clinical care.  360 feedback etc is infantile.

 

Appraisal and Revalidation should be stopped immediately and replaced with a more reasonable and proper continuous professional development system.

 

 

 

With all of the changes it is hard to say what “the current model of general practice” is.  General practice is broken in many ways caused by various changes.

 

The only model that will ever work is the one that has existed before political interference.  This means that we will have to “go backwards” to the model during the 70’s and 80’s with the previous hierarchy.  Multidisciplinary teams as working now do not work;  a clear hierarchy is needed with the GP at its head.  Political correctness is not an excuse not to work properly.

 

 

 

Recruitment is largely affected by some of the points above.  Retention is essential and should be dealt with as a central issue.  More male GP’s are also required. 

 

Why are more GP’s not opting for partnerships?  This needs an answer.

 

The prioritisation of integrated care (IC):  IC is a disaster for and alien to general practice.  GP’s are medical practitioners who treat illness.  This is where the focus needs to be.  GP’s are not social workers or nurses.  For a proper service there needs to be clear lines drawn and each party knows who does what. 

 

For this to work there needs to be proper back-up facilities.  A particular area requiring attention is psychiatry.  GP’s need to be able to depend on other services in order to be able to their job properly.  This is the reason that focussing solely on general practice can’t and won’t ever work.  It requires a whole system approach. 

 

 

 

I am not in a position to answer about contracting and payment systems.  However, the fact that this is raised shows a complex issue with funding.  Funding should be clear and simple.

 

“proactive, personalised, coordinated and integrated care” – what does this mean?  Whatever it is it is alien to the concept to primary care.  GP’s are doctors and doctors should treat illness.  This should be their sole role and if they are not side-lined the service will benefit.

 

Making GP’s work as part of integrated teams is by definition taking GP’s away from their primary function and this is harmful to patients and bad for doctors making it more likely doctors will work part-time, as locums or as salaried doctors. 

 

I put it to you that salaried doctors are motivated to practice medicine in terms that suit their lives without the financial commitment of partnership and being part of non-medical systems like ‘IC’.

 

“Quality Outcomes Framework” (QoF):  This is another incentive that requires administration and achieving outcomes that tick a box.  It should be done away with primarily because practices are forced to concentrate on work that is not urgent – treating sick patients.  This is especially the case because of the difficulty accessing GP services (doctor and nursing) as well as the huge demand for services.  This is a waste of resources; clinical and financial.

 

 

Quite the opposite.  These are political initiatives and therefore doomed to failure.  The administrative burdens increase.  The introduction of PCN’s is a clear sign of the failure of the traditional model due to the incessant change.  It is an example of a solution that can be used for good publicity short-term and one that simply diminishes the service – the service should be focussed on treating patients in the community and this does not require PCN’s.  They also complicate the administration and financial burdens – exactly the wrong thing to do.

 

 

I am not aware that this has happened at all.  GP’s have always worked closely with pharmacists and I feel that this central relationship has deteriorated.  Pharmacists are now doing medical ‘things’ which takes away from pharmacy. 

 

Doctors get to know their patients the more they see them.  If they only see them for complex problems this relationship can’t evolve.  Further, it is bad for doctors to only see complex cases and many skills are lost by doing this eg ENT.  Seeing only complex cases also adds stress to the job.

 

Nurse practitioners and physician associates are a disastrous idea also doomed to failure.  GP’s should not be expected to take responsibility for these.  They should not be working in GP; it is a short-term fix that in fact does not fix the problem.  This puts pressure on GP’s and takes them away from getting on with their role of treating patients.

 

Many GP’s employ such grades.  These employers are doctors who are trying to stay afloat on a sinking ship and are sadly misguided because they are ingrained and indoctrinated in the NHS system.  It is a great example of a “fad” or a “quick fix” solution that won’t fix anything. 

 

As stated in my letter to the SOS these problems cannot and will not be properly addressed by using anyone who has been involved in getting us to where we are now and this includes ‘committee types’.  If you are serious and genuine about dealing with these problems you need people who are knowledgeable and who are not ‘committee types’ or members of various quangos or politicians responsible for the current state of affairs.

 

It is also impossible to put general practice right by dealing with it as a stand alone entity.  It is not a stand alone entity and as such it cannot be fixed until other systems are also fixed.  This is also going to require very serious intervention to the professions, especially nursing (nurses do not ‘nurse’) and changes to medical school training etc.

 

It is also going to require politicians with courage to put the NHS and the professions right because there will be a lot of upheaval and resistance.  Unless this is done many more people are going to die and it is likely that the whole healthcare system is going to fail.

 

Yours sincerely,

 

 

Michael O’Reilly

Barrister (unregistered).

 

Nov 2021