The whole NHS reform is based on an assertion – that GPs are somehow better placed to decide what NHS services need to be provided because they are in some sense ”closer to patients”.
The news story today that GPs seem to be failing to provide adequate services to elderly people in care homes raises doubts about this assumption. I tweeted about it and have had an interesting exchange with ”TheNiceLadyDoc” (a GP).
Let’s take motivation first – are GPs closer to patients in the sense they have their (patients) interests more at heart than others? Well, I know plenty of hospital doctors, nurses, physio’s and health managers who would dispute that. Of course, institutional factors may affect motivations. A doctor in a GP practice is in a different institutional setting to a doctor in a hospital. The former is a private contractor, the latter and NHS employee, for example. How might this affect their motivations?
The idea that GPs are inherently somehow more ”knightly” (to use Julian Le Grand’s terminology) than somehow ”knavish” hospital doctors or managers is plainly ridiculous. There can just as easily be Harold Shipman’s in GP practice as in hospital’s.
One incidental point is worth making here about individual wrong-doing and institutional context. It is much easier for a GP in a singleton practice to get away with what Shipman did than it would be for a doctor in a hospital.
Next, information. It is assumed that GPs somehow ”know” what their patients need better than hospital doctors or NHS managers. But how true is this? Many patients in urban group practices see different doctors every time they visit the surgery.
So GPs don’t necessarily know what individual patients need. Indeed, some patients with serious health problems will actually see much more of their hospital-based specialist medic than they will their GP, who will essentially be an on-looker in the process. GPS are ”generalists” and by definition in a poor position to out-guess ”specialists” in every field of medicine about what patients with specific conditions need.
So, maybe GPs are better placed to assess collective health needs of patients rather than of individuals? Again, this is true to some degree – GPs will get a (necessarily subjective) sense of what their particular group of patients ”need”. But that is of course is subject to bias, to missing out on rarer conditions, or potential patients who don’t or can’t present (e.g. dare I say elderly in care homes?).
So GPs do have access to some types of patient information that others in the NHS don’t, and they may have to some extent a more ”holistic” view, but in other areas they have little or no knowledge at all.
The myth of the saintly, well-informed, GP who ”knows best” is a comfortable throwback to the age of Dr Finlay and cosy fireside diagnosis.
So if the NHS reforms are based on a systematic myth, the question is why? The answer is rather simple. GPs are potentially the back-door through which private contractors can be brought in to run the NHS. They are themselves private contractors, and some will certainly see personal advantage in the new arrangements. Others will simply want to get on with being doctors, and hand over their commissioning role to a combination of other GPs who want the job and private companies offering attractive packages that make the ”problem” go away.
The new CCGs will also serve the purpose of shifting services from hospitals to community. This is a good thing. But it will also just happen to be shifting services from publicly owned hospitals to, in many cases, privately run community providers.
GPs have been unjustifiably elevated to a special, almost saintly, status in the health debate with one sole purpose – to use them as a back-door route into breaking up and privatizing NHS provision. As far as I can see the Health and Social Care Bill still does precisely that.