In the Surgery

My first patient on Monday morning was ten minutes late. I was just about to call in my second when I saw that the first had just arrived. I hate it when this happens. The second patient will complain that she was here before the first, whose case is invariably too complicated to deal with safely in the allotted ten minutes, and then every subsequent patient will be kept waiting. I am aware that some GPs run to time. How they comfort a bereaved parent, tell someone they have cancer, explain the hazards of breast screening or counsel an anxious parent about MMR in ten minutes is a mystery to me.

I knew my first patient, Kim, was going to take more than ten minutes when she walked in with a friend who immediately said that Kim was too upset to talk. Kim had come to see me once before, a few months ago. We discussed then the severe bladder pain she’d been having, thought to be due to a difficult to treat condition called interstitial cystitis. She’d asked me if it could have been caused by snorting ketamine. I had no idea, so she showed me what she’d found on the internet, and while she was with me I’d searched online for academic papers confirming her findings. The internet has changed the relationship between doctor and patient: far from threatening whatever authority doctors may have, it facilitates what the great GP Julian Tudor Hart described in The Political Economy of Health Care as the ‘co-production of health gain’. ‘Progress in health care,’ Tudor Hart wrote, ‘depends on developing professionals as sceptical producers of health gain rather than salesmen of process, and on developing patients as sceptical co-producers rather than either cynical or credulous consumers searching for bargains.’

I had arranged for Kim to have a follow-up appointment, but as is so often the case she didn’t show up. She probably would not have come today without her friend. He told me that Kim hadn’t slept for several days and had been taking drugs and drinking alcohol in an attempt to deal with her distress. Last night a friend took her to A&E and she was kept in overnight. This morning she discharged herself ‘against medical advice’, before she could be seen by the duty psychiatrist. Severely anxious, alcoholic and mentally ill patients account for a disproportionate number of emergency admissions – a consequence at least in part of insufficient community support. Mental health has been underfunded for years and will be hit disproportionately by the cuts: 30 per cent cuts to local services are expected.

All hospital care – GP referrals as well as people like Kim showing up in A&E – is billed to the GP thanks to an artificial divide between GPs (‘purchasers’) and hospitals (‘providers’) in the NHS internal market that has been in place since the early 1990s. At present the bill is actually paid by the primary care trust (PCT) that funds the GP practice – every practice has a designated share of the PCT referral budget. If a practice overshoots its budget there is no penalty, though that is likely to change. Conversely, if it undershoots it doesn’t get any benefit. Among other things this provides a (notional) incentive for GPs to keep their patients out of hospital, and for hospitals to maximise income from patient referrals. They can do this by admitting patients from A&E rather than discharging them, carrying out additional investigations or sending patients to different specialists within the hospital. As GPs we might pay, but we have limited influence over our patients’ (and hospital colleagues’) behaviour. Even extending our opening hours has had no impact on our patients’ A&E attendances.

Kim had left her last appointment with me more anxious and distressed than I had realised. The possible consequences of snorting ketamine are severe ulcers in the bladder, necessitating, in the worst cases, major surgery to remove the bladder. She had started drinking, smoking heroin and taking Valium, although she had stopped the ketamine. This didn’t relieve the pain in her bladder, even if she couldn’t be sure, in her inebriated state, whether or not she was imagining the pain.

I work in Hoxton, East London. Old Street is in our catchment area so it includes high-tech entrepreneurs as well as nearly 80 elderly housebound patients, a hostel for young people with learning difficulties, a nursing home for people with advanced dementia and major strokes, and nearly a hundred heroin addicts. As with most practices an 80/20 rule applies: 20 per cent of patients account for 80 per cent of our work. Patients who are seriously ill or housebound, the overwhelmingly anxious and mentally ill, young children and people with chronic diseases, alcoholics and drug addicts account for most of our appointments, referrals, phone calls, prescriptions and visits. They are not, on the whole, people who vote, fill in NHS questionnaires, write to their MP or to (or for) the media, complain or demand anything beyond relief from their symptoms and access to their own doctor. Twenty per cent of our patients rarely attend. We have to contact them to make sure they’re still alive. The remainder attend occasionally, when the need arises, or because we have to screen them by checking their weight, smoking status, cholesterol levels and so on. They are mostly younger, more articulate and less concerned to see their own doctor, more interested in convenience than continuity. Trying to balance the needs of these groups is an enormous challenge. We are moving ever closer to a system that allows all our patients to have their own doctor. While this is obviously important for someone with a complex history or a chronic disease, the young person who attends once a year may not care whether they see the same person, although we have found that they are more likely to come earlier with a serious or embarrassing problem if they have a doctor they know.

Kim had asked to see me specifically, and as so often happens, the appointment was triggered by a crisis. She had drunk a bottle of vodka and smashed up her flat before she phoned her friend to say that she’d taken an overdose of paracetamol. When her friend arrived, Kim was inconsolable and incoherent and he had no choice but to take her to hospital. They took blood, but she was too drunk to be assessed by the duty psychiatrist so they planned to review her in the morning after she’d sobered up. Her paracetamol levels were not high enough to need treatment and she was fairly sober when she discharged herself.

By the time I’d been told all this it was 9.30 and there were three patients and a Turkish advocate waiting to see me. About 20 per cent of our patients don’t speak English. If non-English speakers book an appointment in advance we give them a 15-minute appointment with an advocate, if we can. This is getting more difficult to arrange: advocacy services locally have been cut by more than 80 per cent. Since the advocates usually have other appointments to go to I was anxious not to keep the patients waiting, but I couldn’t finish this consultation abruptly. We discussed how safe Kim would be at home, her social network, her psychiatric history and history of self-harm. I was increasingly impressed with her friend, whom I began to feel sure I had met before.

Of the 1500 or so patients registered with me, I know about a hundred by name. They are the ones I see often or whose illnesses have made a particular impression. Nevertheless I quite often introduce myself to patients and they look bemused or even slightly offended and remind me that they’ve been to see me before. By the time I worked out who Kim’s friend was it was 9.40 and the receptionist had phoned to say that my 9.10 patient had made a written complaint and left (a complaint generates an exchange of letters, a practice meeting and occasionally reaches the public via the internet) and that the advocate wanted to know if I could see my 9.30 patient (her charge) ahead of the 9.20, so that they could get to the hospital in time for their next appointment. The patient booked for 9.20 is a middle-aged man with learning difficulties. I knew he wouldn’t mind waiting, and definitely wouldn’t complain.

Kim’s friend’s name was Sam. I’d seen him about a month before, when I’d asked him to come in to discuss his diabetes. The consultation had been frustrating and unproductive: we talked about blood sugars and cholesterol levels, damage to his eyes and kidneys, how to manage his insulin, his experience with specialist nurses and more, but it felt as if it was all for my benefit, not his. He has Type 1 diabetes, which started suddenly when he was in his early twenties. Working as a DJ by night and training to be a teacher by day, he collapsed after an all-nighter and was admitted to intensive care. Initially thought to have taken an accidental overdose, he was lucky that someone realised he had a complication of untreated diabetes, diabetic ketoacidosis. A few days later he was discharged from hospital with insulin to be injected four times a day, tablets for cholesterol and blood pressure, and without his driving licence. In a few days he had gone from having the freedom of a normal young man to no longer being able to eat what he wanted or when he wanted, always having to remember his tablets and carry his insulin and blood-testing kit, and show up for regular hospital and GP visits. Despite all that he would be subject to sudden sickening hypoglycaemic episodes and the tiredness, recurrent infections, mild depression and ‘generally feeling rubbish’ associated with high sugars the rest of the time. And he wouldn’t be allowed to drive until his diabetes was under control. A decade later his blood sugars still aren’t stable and he is still not allowed to drive.

The risk, of which Sam was fully aware, was that he would die ‘young and horribly’: first he would go blind, then his kidneys would fail and his feet start to burn as the nerves were destroyed, then an infected ulcer would fail to heal and a leg would be amputated and finally a secondary infection would lead to septicaemia and death. Imploring a young person to take responsibility for their health, even when the consequences are so dire, rarely works. Patients have to be allowed to take risks, exercise their freedom, experiment, fail, try again, fail better, and come to terms with having to take care of a body that demands a lot more maintenance than most. Increasingly, the political class shifts the burden of responsibility for health towards the individual: it is the individual’s duty to read the small print on a packet of convenience food rather than the government’s to legislate against junk-food producers. In part this stems from a belief that everyone is a rational, self-interested consumer rather than a complex, irrational, uncertain patient.

I told Sam that I really wanted to see him again and arranged to see Kim the following day. It would mean missing part of the commissioning meeting for our ‘pathfinder consortium’, which is replacing the PCT. The meeting was set up to work out how we might save 20 per cent on mental health services. At the last meeting I discovered that the PCT funds more than a hundred different mental health services, including the emergency phone-line of SANE, the national mental health charity. It had been a surprise to most of the 60 GPs in the room to find out how many services were covered and that ours was the only PCT to fund SANE. We needed to decide whether to cut funding to a charity that cares for the beaten wives of Sudanese refugees, or one that looks after the families of Afro-Caribbean men with schizophrenia. Could the huge budget for forensic psychiatry be safely cut, or the budget for antipsychotic medication sufficiently trimmed to take on another community psychiatric nurse?

Just before Kim and Sam left Sam asked if he could speak to me alone briefly. It turned out that Kim is his sister. ‘What she didn’t tell you,’ he said. ‘Well, there’s a lot she didn’t tell you, but she trusts you, that’s the thing. She needs a lot of help, more maybe than you realise. I don’t know what you can do really, I mean, thanks for listening.’

Listening remains the most important aspect of a GP’s trade. Not only does the patient’s history, or description of their symptoms, carefully elicited by the doctor, account for almost 90 per cent of the diagnostic process, it is overwhelmingly what patient satisfaction hinges on. Yet the way we are paid, which determines our working habits, runs almost entirely against listening. Continually popping up in the corner of my computer screen during my consultation with Kim was a box reminding me to check her weight and smoking status, review her antidepressant medication, discuss long-acting contraception and remind her about (or perform) her overdue smear test. At the end of the day I will be asked why, after nearly 40 minutes, I didn’t fill in these boxes. As a result we may not reach our screening targets and so suffer a significant financial penalty. With less money, we will not be able to afford to employ as many doctors and nurses and pressure on appointments will be even greater.

I have met Sam three times. I have done a lot of listening, but he hasn’t told me much. I have explained a fair bit and he has listened politely. His diabetes has been far too poorly controlled and he attends too infrequently for the surgery to earn anything from our consultations. To earn money in modern general practice, a GP needs patients to be motivated, come to their appointments, take their medications, submit to regular testing and get better, because we are paid according to clinical outcomes.

Patients who behave like Sam and Kim are at risk in such a system. NHS funding needs to increase by 6 to 8 per cent a year to keep pace with the rising costs of staff, drugs, technology, the increasing prevalence of non-communicable diseases like diabetes, heart disease and cancer, and the rising costs of administrating and regulating markets and competition. The government has effectively frozen funding. Practices are already being selective about which other practices they join with to form the new GP commissioning consortia (GPCC) and which patients they register. The GPCC don’t have to cover a particular geographical area, and a consortium is free to select the most efficient practices and leave the rest to join ‘sink consortia’. From next April GPs will be able to select their patients in the same way, and not many will choose patients like Sam and Kim. The commissioning consortia will be the equivalent of US Health Maintenance Organisations, and the insurance-based system that Department of Health strategists have been working on for the last 20 years will finally have come into being.* Selecting the least complicated patients in an attempt to maximise profits was described by Tudor Hart in 1971 as the ‘inverse care law’. It states that ‘the availability of good medical care tends to vary inversely with the need for the population served. This inverse care law operates more completely where medical care is most exposed to market forces.’