John McCullough is a newly qualified GP in rural Cumbria and Course Tutor for the NHSE North Cumbria School of Generalism.
Tim Sanders is a GP in rural Cumbria and Senior Clinical Lecturer in Rural Medicine and Urgent Care at the University of Central Lancashire.
In response to the recent BJGP Life article ‘Re-wiggling primary care’,1 newly-qualified GP John McCullough speaks to the author Tim Sanders:
JM: It feels like a tough time to enter General Practice – has it always been this way?
TS: Whilst things are pretty tough at the moment, I think it’s easy to imagine a historical idyll or golden era of General Practice when there was plenty of time to provide continuity of care and everything else we hold dear. In reality, there have been significant pressures since the inception of the NHS but these have changed over time. For example, the change with the 2003 GP contract and removal of personal responsibility for out of hours cover undoubtedly changed the landscape in terms of provision of continuous, personalised care, but I don’t think there would be many of us arguing that 24-hour cover would be a sustainable thing for us to be doing now.
JM: How can we adapt to having fewer GPs per capita?2
It feels like a tough time to enter General Practice – has it always been this way?
TS: I have no doubt that relationships-based care is the most efficient and cost-effective way to respond to the challenges of falling numbers of GPs. It can be difficult to measure these efficiencies because many of them occur over long periods of time and the downstream benefits are not immediately apparent.1 One such example is reducing ‘failure demand’; the excess demand caused by patients having to return for subsequent consultations as a result of unsatisfactory initial management of their problem.
JM: I love the idea of continuity of care but there are so many barriers. For example, the outcome of many clinical guidelines seems to be referral to another team.
TS: There is no guideline for the patient in front of you, but there may be a guideline for one or more of their symptoms. Remember to treat the patient not the disease. It’s good to incorporate guidelines into your care where they are evidence-based, but your job as a GP isn’t to slavishly follow guidelines – it’s to care for individuals. For this reason, it’s also not always the right thing to refer patients on. Sometimes your patients will need referral and sometimes they will be better off remaining under your care. Either way you should still ‘hold on to them’ so you can help them and their families to navigate the confusing complexities of NHS care.
JM: Don’t guidelines help minimise risk for our patients?
TS: Perhaps. But remember a guideline is just a tool; its neither good nor bad, but highly user-dependent. When handled clumsily or applied to the wrong situation it can lead to harm.3 For example, through over-investigation, over-treatment, increased patient anxiety, wasting resources or overwhelming our secondary care colleagues. In this context, the inappropriate use of guidelines can greatly increase the risks to your patients.
JM: Deviating from guidance can feel scary. Don’t guidelines help minimise risk to me as a doctor?
What you have on your side is the gift of offering and facilitating continuity.
TS: It’s understandable to feel fearful of complaints and litigation. In my experience, good communication and investment in relationships over time always pay off when something goes wrong. As a general rule, people are reasonable; if they believe you to have acted diligently and in good faith, and particularly if you take prompt steps to acknowledge and apologise where this is necessary and put things right where it is possible they will eventually understand, even if they are angry at first.
What you have on your side is the gift of offering and facilitating continuity. This means following up patients where there was uncertainty (even if it is theirs rather than yours), gently identifying risk, and supporting patients to understand what is happening to them and why. If people feel well looked after, they will usually forgive rather than blame.
JM: Any other thoughts?
TS: My challenge to you is to champion the fragile principles of continuity and personalised, holistic care that I believe are the essence of General Practice, making what we do so unique and valuable for our patients. These are being easily lost and will be extremely hard to regain. To put it another way, we need to be principled, excellent, brave, challenging, and tenacious in the face of these threats of working in a resource-stretched system, litigation, guidelines that are not always based in good quality evidence and unrealistic expectations about ever increasing productivity.
Good luck in your future practice. In primary care we are privileged to work with wonderful communities. I am sure that, like mine, yours will truly value your commitment to them and reward you with their loyalty.
References
- Sanders T. Rewiggling general practice. British journal of general practice. 2023 Oct 26;73(736):508–8. Available at https://bjgp.org/content/73/736/508
- British Medical Association. Pressures in General Practice Data Analysis [Internet]. The British Medical Association. 2024. Available from: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis
- Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999 Feb 20;318(7182):527–30. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1114973/
Featured photo by Kelly Sikkema on Unsplash
Some very good sense talked here. Focus on each patient as a full individual, tather than systematic responses to conditions is one of the keys. As to 24hour cover – Couldn’t that be done, perhaps, by nominating, say, 3 GPs in the area for each patient, to give at least some continuity of faces? This may be more difficult in rurual areas, but in larger practices in the cities, it can be rare to see the same doctor as last time, or the time before that, or the…(and so ad infinitum)… The lack of continuity leads us to feel tht we are just numbers to be processed.