Jonathon Tomlinson

My first patient on Monday morning was ten minutes late. I was just about to call in my second when I saw that the first had just arrived. I hate it when this happens. The second patient will complain that she was here before the first, whose case is invariably too complicated to deal with safely in the allotted ten minutes, and then every subsequent patient will be kept waiting. I am aware that some GPs run to time. How they comfort a bereaved parent, tell someone they have cancer, explain the hazards of breast screening or counsel an anxious parent about MMR in ten minutes is a mystery to me.

I knew my first patient, Kim, was going to take more than ten minutes when she walked in with a friend who immediately said that Kim was too upset to talk. Kim had come to see me once before, a few months ago. We discussed then the severe bladder pain she’d been having, thought to be due to a difficult to treat condition called interstitial cystitis. She’d asked me if it could have been caused by snorting ketamine. I had no idea, so she showed me what she’d found on the internet, and while she was with me I’d searched online for academic papers confirming her findings. The internet has changed the relationship between doctor and patient: far from threatening whatever authority doctors may have, it facilitates what the great GP Julian Tudor Hart described in The Political Economy of Health Care as the ‘co-production of health gain’. ‘Progress in health care,’ Tudor Hart wrote, ‘depends on developing professionals as sceptical producers of health gain rather than salesmen of process, and on developing patients as sceptical co-producers rather than either cynical or credulous consumers searching for bargains.’

I had arranged for Kim to have a follow-up appointment, but as is so often the case she didn’t show up. She probably would not have come today without her friend. He told me that Kim hadn’t slept for several days and had been taking drugs and drinking alcohol in an attempt to deal with her distress. Last night a friend took her to A&E and she was kept in overnight. This morning she discharged herself ‘against medical advice’, before she could be seen by the duty psychiatrist. Severely anxious, alcoholic and mentally ill patients account for a disproportionate number of emergency admissions – a consequence at least in part of insufficient community support. Mental health has been underfunded for years and will be hit disproportionately by the cuts: 30 per cent cuts to local services are expected.

All hospital care – GP referrals as well as people like Kim showing up in A&E – is billed to the GP thanks to an artificial divide between GPs (‘purchasers’) and hospitals (‘providers’) in the NHS internal market that has been in place since the early 1990s. At present the bill is actually paid by the primary care trust (PCT) that funds the GP practice – every practice has a designated share of the PCT referral budget. If a practice overshoots its budget there is no penalty, though that is likely to change. Conversely, if it undershoots it doesn’t get any benefit. Among other things this provides a (notional) incentive for GPs to keep their patients out of hospital, and for hospitals to maximise income from patient referrals. They can do this by admitting patients from A&E rather than discharging them, carrying out additional investigations or sending patients to different specialists within the hospital. As GPs we might pay, but we have limited influence over our patients’ (and hospital colleagues’) behaviour. Even extending our opening hours has had no impact on our patients’ A&E attendances.

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