Written evidence submitted by Andrew Elder FRCGP D Ed. (Hon) (FGP0054)

Retired Inner City London GP (1972 – 2008)

Lisson Grove Health Centre/Paddington Green Health Centre

Consultant in GP and Primary Care Tavistock Centre

Lecturer/Senior Lecturer Imperial College and Royal Free Medical School

Ex-President Balint Society (UK)

 

Reason for choosing to give evidence: although retired as a GP I continue to work in the fields of practitioner health, primary care mental health and in the running of groups (Balint groups) which support GPs in studying their difficulties in the doctor-patient relationship. After fifty years of work, I remain passionate about the value to the UK population of a healthy, well-supported, responsive and creative General Practice workforce. The present situation is of grave concern.

My principal point is that the Committee needs to view The Role of GPs through a much wider and deeper perspective than is usually the case in policymaking. It is misleading to understand General Practice predominantly through the prism of the Medical Model.

In addition to all its obvious medical functions (early diagnosis, prevention, and the management of chronic and complex disorders), the principal function of General Practice and Primary Care is the Containment of Anxiety. In primary care, every day, many thousands of people come to their doctors with worries, anxieties, aches and illnesses, some of which require treatment, and some of which (rather few) require specialist attention. Often symptoms arise from family and relationship conflicts, as well as from tragedies that never resolve and entrenched and untreatable personality difficulties. The capacity of primary care teams to act as an effective and competent gatekeeper to secondary care depends on the containment of anxiety and distress at primary care level. It is widely accepted that this is critical to the satisfactory and cost-effective functioning of the whole Health Service. It is emotionally demanding and highly skilful work.

Example: When a patient who is experiencing a marital crisis (say) comes to their GP and complains of headache or abdominal symptoms it is easy (and professionally safe) to ‘do a few tests’, or request a scan’, more difficult to ask about the patient’s current life experience and then to deal with the emotional distress that might ensue….BUT, in that over-simplified example (replicated in more complex form a thousand times a day) lies the key moment (and complex skill) that determines the effectiveness of the gatekeeper function and the value  of high quality emotionally-sensitive accessible primary care for the patient. Such work requires mature and experienced professional functioning, supported by a well-functioning primary care team, and (sufficient) continuity of care through which trust can become established.

 

High quality primary care CANNOT be provided by a shifting demoralised workforce of relatively inexperienced part-time doctors. The most commonly voiced complaint about GPs at present isyou never see the same one twice’A recent complainant went on to say that ‘my doctor only tells me what I haven’t got…’ This basic error comes from doctors being anxiously attached (in their thinking) to the medical model. They repeatedly put the patient’s symptoms through a ‘medical sieve’ but don’t address adequately whatever the patient IS WORRIED about or enquire more widely about the patient’s life and circumstances. It is easy to be a signpost (although not satisfying in the long run) but hard to come to terms with life’s difficulties. Weak primary care quite simply leads to escalating secondary care costs. Across all OECD countries investment in primary care within health services leads to greater cost effectiveness, lower premature death rates and less health inequity. But investment needs to be made in a way that understands the dynamics of primary care in the way I am outlining. Current NHS policy documents show a paucity of such understanding.

GPs are Core Mental Health Professionals

It has been a problem for many years that GPs are not recognised as mental health professionals. They are, in fact, the most commonly consulted mental health professionals (by far) in the Health Service. At least one third of all GP consultations are primarily about emotional and mental health issues. In another third, mental and emotional aspects are highly significant alongside serious and chronic ill-health. These are conservative estimates. Practices are the places where most long-term mental illness resides, alongside complex families with multi-faceted mental-health, social and medical problems. This is a reality that needs to be accepted, and services built accordingly. No amount of restructuring specialist mental health services will make that much difference unless the realities of how mental ill-health presents (and is treated) in communities is better understood. This will be particularly important post-Covid, as waves of its after-effects roll into primary care for many years to come. Educational and social services are also important, but most mental and emotional distress presents (and remains) in primary care. Mental health practitioners are needed who develop skills and understanding that support GP practices. In 2007 88% of practices had access to practice-based counselling much of which was replaced by IAPT, a much more expensive and limited model with less integration into primary care. Well-equipped mental health practitioners in primary care can also offer an important contribution through participation in multi-disciplinary team discussions which support and enhance the containing function of practices.

Teamwork has always been an important feature of high-quality primary care. Within teams, clinical responsibility is key. It is easy, particularly for complex, socially deprived, difficult or less likeable patients, to get lost and then passed from pillar to post unless teams have clear systems of named, personal, responsibility. This is also key for patients. Along with ‘you never see the same one twice these days, goes ‘I’ve no idea who my doctor is these days…. Whether the partnership model is retained or not, it is essential for patients to know who carries responsibility for their care. If teams are being encouraged to delegate (as seems to be the trend) this principle becomes vital. In general, delegation doesn’t work in practice as well as is often hoped because patients’ anxieties are not adequately settled until they see someone that they have learned to trust through experience. Demand (driven by anxiety) only begins to lessen when patients feel secure within a professional relationship that they can trust.

 

 

Listening is the core clinical skill for GPs not only in enhancing the chances of a patient’s concerns being heard, but also enhancing early diagnosis, prevention and effective clinical management. But it takes time and a facilitating and supportive professional environment to develop and flourish. The Parallel Care Law states that doctors and nurses can listen more attentively to patients if they are listened to themselves. The capacity to listen to others depends on feeling secure yourself. A facilitating environment requires consonance between the aims and values of the professionals with the aims and priorities of the organisational structures that surround them.

Balint Groups

A brief word about Balint Groups. This is a tradition with which I have been involved for many years. It originated in the UK and is now worldwide. It has become a compulsory part of psychiatric training in the UK but is not yet a core part of the training for GPs. Groups are a key training method for doctors to develop their skills in the therapeutic use of the doctor-patient relationship, and they also have a marked effect on professional morale and effective teamwork. Within any practice or mental health organisation, space needs to be given for complex issues and relationships to be discussed. Even if not a formal Balint Group, a group that offers a space for discussion of the professionals’ feelings in relation to a particular case as well as discussion of the relationships involved is integral to healthy team functioning and a feeling of security amongst the staff in the team.  

 

Morale and Burnout

Much is talked about morale and burn-out. There are many factors but there are three pillars for prevention to bear in mind when changes in policy and practice are being considered.

Autonomy: overuse of performance indicators, incentives, guidelines, protocols and pathways can have perverse effects on performance and morale.

Competence: resides in acquiring depth of professional knowledge and experience, not in ‘box-ticking’.

Relatedness: professionals and staff feeling secure and respected within the organisational structures that surround them.

Doctors and nurses tend to have high levels of altruism and vocation. If allowed to flourish, these traits lead to high levels of intrinsic motivation. Reform is needed to align the organisational structures of primary care (and the Health Service) to this motivational source in professionals. There are significant areas of dissonance between the personal values of staff and the organisational matrix in which they work which is too often perceived as naively performance-related, productivity-driven, punitive, and unsupportive.  

Lastly, when considering the future of General Practice, it might be wise for us all to think about our own experience. We’ve all had crises and have needed the support of first-class medical care. Many things in healthcare are changing; the transforming effects of IT, as well as new techniques for screening, prevention and treatment will all continue to bring improvements; BUT, some things don’t change; human suffering, family tragedies, mental illness, social injustice, serious diseases, disability and mortality - and when we all have to face these things we need a trusted accessible competent medical general practitioner nearby who can help us, advise us, and stay with us for the course.

In conclusion, my submission is that the Committee’s recommendations should be assessed as to whether they would have an advantageous or detrimental effect on this deeper understanding of the role of GPs and primary care teams as outlined above.

Dec 2021

 

5