Wagging the dog

Ben Hoban is a GP in Exeter.

The time-honoured reward for a job well-done is more jobs to do well, and fewer resources with which to do them. On this basis, GPs have been well rewarded over the years. Complaints about workload, especially the kind that represents poor use of our time, are not new, although it feels as if there has been more to complain about for a while. The inappropriate transfer of work from secondary care in particular is a well-recognised problem which seems difficult to address.^1,2

Medical care of any kind inevitably generates lists of jobs, some of which are straightforward and can be done by anyone, such as looking up blood results at the end of the day, and others that require a more detailed knowledge of the patient and their situation. Even simple tasks can only be delegated successfully, however, if the working relationship between the donor and recipient allows it: at the most basic level, a senior transfers work to a junior on the basis that they also take responsibility for the junior’s actions; and one colleague hands over jobs to another at the end of a shift today on the basis of quid pro quo tomorrow. The relationship between primary and secondary care involves its own kind of reciprocity,³ although it is perhaps more like that between patients and GPs.

Just as the ideas, concerns and expectations of the patient ought usually to set the agenda in a consultation, so those of the general practitioner are the natural starting point for what happens in secondary care. This doesn’t always mean that one simply makes work for the other: it is reasonable for a GP to advise patients how to look after themselves, and for a specialist to advise us what we can do to help someone we have referred. The key in both cases is that the advice meets an agreed need and falls within the recipient’s normal sphere: if a patient is concerned about cardiovascular disease, I can ask them to arrange a blood test to measure their cholesterol level, but not a coronary CT; if a hospital colleague asks me to review someone’s analgesia following an admission, I’d be happy to, but if they want to hand over their pre-discharge task list, I’ll be handing it back.

What we consider reasonable for patients or GPs to do is of course constantly changing. Technologies like pulse oximetry and interstitial glucose monitoring that originate in secondary care are passed on to general practice and soon find their way into popular use without affecting the relationships between hospital and surgery, or doctor and patient. At the same time, however, there has been a much more fundamental change in our healthcare system that affects the flow of work, and the relationships, within it.

It is no longer self-evidently true that the purpose of the system is to safeguard the health of individual patients. Instead, these individuals are increasingly expected to act in a way that safeguards the health of the population at large – by attending appointments, undergoing investigations, and taking medication – even though they are unlikely to benefit themselves. By degrees, and without discussion, the patient’s role has changed from actively setting a personal agenda for their care to passively accepting a medical agenda set by experts and politicians. In this inverted world, the transfer of work from secondary to primary care mirrors the transfer of responsibility from the system to its users. The traditional intermediary role of general practice between patients and the wider health service has changed too, although it is increasingly bypassed by screening programmes, community specialty teams, and hospital electronic record platforms: we now act less to enable patients to access the system when they need to, and more to enable the system to access patients whenever “best practice” requires it.

Perhaps the clearest illustration of this shift is the changing balance of consultant and GP numbers in the NHS. Seventy years ago there were nearly three times as many GPs as consultants. Both groups grew steadily until the mid-nineties, although the gap between them was narrowing; since then, GP growth has been flatlining while the increase in consultant numbers has accelerated and there are now more than twice as many Full-Time-Equivalent consultants as GPs.^4-6 The bigger picture when we consider “work-dumping” is therefore not that individual hospital practitioners are behaving unreasonably, but that the system as a whole now favours a secondary care way of working, which meshes poorly with our own approach. While this may feel professionally threatening to us, the larger issue is that the medical establishment, which prioritises its own agenda, is taking from patients the ability to decide for themselves what it means to be healthy: the tail is wagging the dog.

The new Secretary of State for Health and Social Care has promised to address the disparity in funding between primary and secondary care. Let us hope that we end up not just with more money, but with a more balanced system overall, for the sake of our patients as well as our workload.

References 

1. Amy Price and Azeem Majeed, Improving how secondary care and general practice in England work together: requirements in the NHS Standard Contract, Journal of the Royal Society of Medicine; 2018, Vol. 111(2) 42–46 DOI: 10.1177/0141076817738504
2. Zahir Mughal, Rajib Maharjan, Cross-sectional analysis of hospital tasks handed over to general practitioners: workload delegation or dumping?, Postgraduate Medical Journal, Volume 98, Issue 1161, July 2022, Page e14, https://doi.org/10.1136/postgradmedj-2020-139641 accessed 27/7/24
3. Nada Khan Workload transfer in the NHS: The Great British Dump – BJGP Life accessed 27/7/24
4. Data chart: Consultant numbers have doubled over the past 20 years, BMJ 2017;359:j4726  doi: https://doi.org/10.1136/bmj.j4726 (Published 03 November 2017)
5. NHS medical staffing data analysis (bma.org.uk) accessed 27/7/24
6. Pressures in general practice data analysis (bma.org.uk) accessed 27/7/24

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