By Civil Service World

16 Jun 2010

This week’s interviewee is a GP with more than 20 years’ experience as a partner in an urban practice

“I followed a traditional career path as a local GP; nowadays I’ve scaled back my hours to work 3.5 days a week. In a usual working day lasting 10 hours, I will see about 35 patients and attend various meetings, with some evening work; in between, I attempt to complete all the paperwork.

The biggest change I’ve faced in recent years was the introduction of the new GP contract, which arrived in 2004. GPs are self-employed, but governments have traditionally hated that model and wanted us to be more closely controlled by the NHS. So the new contract attempts to control what we do and the clinical decisions we make – in part, through the new Quality and Outcomes Framework (QOF). This is billed as a reward for quality, but in fact it means that if we don’t fulfil various criteria, we are penalised.

There are some good points about the QOF; in particular, that it gives us clearly defined targets. The trouble is that there are so many guidelines, it can be difficult to know exactly how we should operate. And sometimes it leads us to make decisions that are of no clinical value or could even be dangerous to patients’ health. For example, we have a target for managing ‘glycated haemoglobin’ levels in patients with diabetes. But there is evidence that keeping it at the required level may kill them. We have the dilemma that we can either control levels to a point where it puts people at risk, or we run the risk of not getting paid.

I have to be clear with patients as to whether I’m telling them something because it’s government policy, or because it’s good for them. If a patient is aged 94 with high blood pressure and high cholesterol, the rules say that we should prescribe statins for life; but the patient may decide that there’s little point. If we have the conversation and the patient opts out, they are discounted from our QOF targets and we won’t be penalised. But if you have too many exceptions, the Primary Care Trust (PCT) becomes suspicious that you’re fiddling the numbers.

In one case, we were hammered because our figures for people with depression were too low compared with the national average and other practices locally. But we were seeing people with lousy home or work situations and recording them as ‘low mood’ rather than diagnosing clinical depression. After all, a diagnosis of depression would go on their medical records, which is not fair or accurate. If people who’ve been diagnosed with depression apply for a mortgage or a credit card, they can find that their credit rating has been damaged.

Anyway, we didn’t want to over-diagnose and end up medicalising a social problem. But if there’s a low prevalence at your practice, the PCT thinks you’re fiddling the numbers; in the end we had to start recording people as ‘depressed’, or it would have cost us £10-15,000 a year.

Now the election is out of the way, we’re bracing ourselves for yet another set of changes to the organisation of the NHS. Unfortunately, every time PCT managers get their heads round a new system, it changes again; this wastes time and resources. Labour seemed to have a philosophy of changing the NHS every few years; they appeared to believe that change brings out the best in people by forcing them to innovate. However, the kind of pace of change that we’ve experienced is not stimulating; it’s wearing. I’m just hoping that all this talk of localism and government taking a hands-off role will free us to get on with the job.

On the plus side, Labour did prioritise general practice as the backbone of the NHS. They regarded primary care and general practice as very important, and put their money where their mouths were in terms of building up primary care. They did invest in it, and it is going to remain viable for the foreseeable future.

The current working arrangements for GP partners are advantageous because we have the flexibility to increase or decrease our involvement. We get paid more if we work longer hours, but we also have the option of developing outside interests. This stops people burning out; there’s not much career progression for GPs, so that variety is important.

Despite the lack of a career ladder, being a GP is still a popular career. The British Medical Association said it needed more doctors, and the government increased the number of places available for medical students. It’s a satisfying job and relatively well paid, though we’re not paid as much as some media outlets would have you believe. We’re not all earning £250,000 a year, you know.

If someone asked me how the system could be improved, I would say the most important thing would probably be to stop changing it. We need stability. If you want to find incompetence, by all means root it out, but have some trust that the majority of the profession are conscientious and interested in."

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