All the good things that nobody in the NHS did.

I got cross in a team meeting this week. A colleague suggested spending resources on training GPs in palliative care. ‘The problem with primary care’ I said ‘Is not a lack of training but a lack of resources’

“man standing near wall with analog clock” by rawpixel on Unsplash

It’s not the first time I have felt frustrated by talk of GPs lacking skills. It struck a nerve this time because palliative care is something that GPs take a pride in doing well. Why it is then, that we appear lacking? There is variation in performance of course. But how can an entire profession appear to lack ability in something that we spend a lot of time doing?

The GP culture is one of efficiency and pragmatism. We spend years honing our skills into a 10-minute consultation. We juggle; a vulnerable adult, chest pain, suspected cancer, medication reaction, dizziness, anxiety, postnatal depression, strange neck symptom that doesn’t fit a clinical picture; rash, lump, contraception, swollen earlobes. — (This morning’s surgery.) We make sure that everybody ends up with the advice, treatment, signposting and referrals they need.

“men's black hair” by Jesper Aggergaard on Unsplash

When it goes well it is satisfying. A patient with whom you have rapport trusts you enough to tell you what’s going on. You work together on a creative solution. They tell you that their life has improved because of your help and you can see that it has.

The temperature has been rising in primary care and we have absorbed the work. We pride ourselves in our ability to manage complexity. But this efficiency comes at a price.

“man holding chin” by Tim Doerfler on Unsplash

We don’t have time for a thorough clinical assessment with anyone other than those we are puzzling over. We refer patients with a tick of a box on a two-week wait form and an automated printout of medications and medical history.

We haven’t been able to explain the process in detail because we don’t know, we don’t have time to find out, and it’s a can of worms that we can’t open without delaying our attention from the next urgent problem in the waiting room. It’s not that we don’t think it’s important, it’s just not as important as something we’re going to do instead.

We don’t have time to consider whether patients would benefit from reasonable adjustments to their care. They end up being unable to get to an appointment within 2 weeks and are labelled as a ‘patient choice’ breech. The hospital team is upset with them before they’ve ever met.

Meanwhile, the temperature has been rising in hospitals. They shuttle patients straight to tests without seeing them. Struggling to meet two-week wait targets, they don’t have time for a thorough clinical assessment with anyone other than those they are puzzling over. They haven’t been able to explain the process in detail because they don’t know, they don’t have time to find out, and it’s a can of worms that they can’t open without delaying their attention from the next urgent problem in the waiting room. It’s not that they don’t think it’s important, it’s just not as important as something they’re going to do instead.

And so, patients bounce around the system. A succession of strangers tells them what’s not causing their symptoms. Nobody applies even rudimentary skills to get to the bottom of what is.

Everybody said that anybody could do

The clinical assessment that somebody should do.

Everybody knows that somebody should do

The clinical assessment that nobody did.

This system can work well for patients who fit pathways. Patients whose symptoms retreat once a sinister diagnosis is excluded. Patients who are comfortable with uncertainty and can access balanced, evidence-based information online. These patients will do well when the AI doctors are here.

The computers may do well for everyone who ticks these boxes.

I’d like to work in a system that enables us to do a better job for everyone who doesn’t.

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