The death of a profession

By DDA Chairman Dr Richard West
Twenty five years ago when my year first gathered together we were full of enthusiasm for the profession we were hoping to join. Our collective aim was to gain skills so that we could improve the lives of our patients. We were not worried about contracts, inspections, paperwork or hours of work. There was a feeling that the system was set up to help us do our job and if we did the right thing for the patient then we would receive the support of the system.

Now, our junior doctors are on strike, and the rural GP workforce is at the point of meltdown. In Scotland, we are seeing a rising number of practices come under Board control.

Solid foundations
We felt the system worked because its foundations lay in three equally strong and tall pillars: the patients; the government and the profession. The system was set up to produce a fair result for all three pillars; the epitome of this principle is the Doctors’ and Dentists’ Review Body, which was set up to make an independent recommendation about pay.

General practice was independent which meant that different localities could have different care models and practices would be able to suit the populations that they served. The contract and the Red Book both encouraged good practice, offering financial incentives for better care, and allowing the better practices to flourish.

Instead, we have developed a system that is interested in only two things: efficiency savings and budgets, and measuring and monitoring processes.

Efficiency savings
For dispensing GP practices, branded generics are a good example of where the pursuit of efficiency savings at the local level delivers a Pyrrhic victory at the national. The short term savings of branded generic prescribing when local budgets are exceptionally pressured often seem too attractive to forego – yet, in the longer term, they work against the national formula for funding (and its profit controls) and ultimately these ‘savings’ cost the NHS overall more than they save the local organisation’s budget. You can click here for a more in-depth explanation of the mechanisms involved. At the DDA we have heard of dispensaries closing because a branded generic prescribing policy has made the business untenable.

Do processes equal outcomes?
We also now suffer from a system that makes the assumption that if the process is correct the outcome will be good. However, the following belies this assertion. Take the NHS back and neck service: in order to get a consultant opinion you have to see an extended scope practitioner but you are not allowed to see an extended scope practitioner if you have not seen an NHS physiotherapist (and private physiotherapists don’t count). If your back pain is very severe you will be rejected by the back and neck service and sent to on call general orthopaedic surgeons who do not specialise in backs. Why? The process is designed to slow access to the expensive services and not to ensure the best care for patients.

My second example comes from a recent CQC report, which describes a dispensing practice as requiring improvement despite its good and responsive care for its patients. Among the criticisms levelled at the practice is that its paperwork could be better. Does this imply that we have an inspection system that is more worried about paper than patients?

So what is the answer?
We need to rebalance the power back onto the three pillars, and a short-term fix is to suspend all processes that do not improve patient care. Arbitrary targets and measures that do not directly secure or improve patient care should be stopped. We need to trust our professionals to do the right things.