Monday, 21 March 2016

A discussion we need to have in Scotland - 2

The response to the previous piece, in Facebook groups it was posted in, has encouraged me to expand my argument on why I believe the present Scottish GP contract is not fit for purpose and maybe answer some of the concerns posters raised.

The current NHS Scotland Act places the legal provision of GP services in the hands of your local health board and my proposal is this is how it will remain in a salaried GP service. As in the teaching profession there will be pay increments for seniority, responsibility and additional specialisation within GP care, such as care for the elderly. The head of the GP practice will be in the hands of a GP, as at present, supported by a small group of GPs, nurses and administrators to ensure the practice is properly run and effectively meeting its local needs and expectations, as it is required to under the current NHS Scotland Act. The annual basic salary for GP doctors would be agreed by NHS Scotland and the BMA, as happens at present, and the contributory superannuated pension scheme for GPs will stay unchanged, as its is an attractive incentive to become a GP. In effect the GPs loose out on their current 'Principal Partner / self employed' tax and other financial benefits but keep a generous pension settlement, including ill health cover and the option of early retirement at 55 which other professional, salaried workers would die for.

This seems a simple idea but it will all fall down if the current politicisation of NHS Scotland as a vote gathering football continues to be kicked hither, thither and thon. This is especially true in the current climate where the UK national media outlets and the British parties in Scotland continue with their routine cry of 'SNP baad' at the slightest problem or failure of NHS care which will inevitably arise in as complex and multi-layered an organisation as NHS Scotland, so reliant on fallible humans to get things right first time.

For example if you can not get a 'routine' GP appointment for three weeks, as one poster averred, this is down to the reality there are not enough GPs available to meet your local need. The people responsible for ensuring there are sufficient GPs in the Health Board Area to meet the need are all sitting around a table as your local health board. A board who are apt to shrug off their legal responsibility for GP provision up the chain of command for partisan reasons, rather than looking at why they are having recruitment problems in their local area. The common reason for recruitment problems I outlined in the previous article. The most common being young doctors are not interested in training as GPs given the current overload of NHS paperwork and patients which appears is the norm; especially across the central belt of Scotland.

Well, you tell me, why not just train more doctors?

This is, in part, the solution. Currently across the UK, the GP doctor to patient ratio is around 1: 3,000. The World Health Organisation suggests, to be effective and meet patients needs and expectations while keeping GPs sane and healthy, the GP to patient ratio should be no more than 1:1,200 as is the case in Scandinavian countries. The 'but' is that to maintain the current ratio at 1: 3000, the UK is a net importer of doctors (and dentists, and nurses ...). The number of undergraduate training places can (and has) be increased by the Scottish Government but even then only a average of 50% of students on a medical or dental undergraduate course at a Scottish Universities are resident in Scotland due, in part, to the current UK wide University placement program (UCCA), EU freedom of access and countries like Qatar or Bahrain offering big financial incentives to University Deans to train their doctors and dentists. In the modern academic world, for a number of differing financial and experiential reasons, it is not practical or sensible to have undergraduate courses only open to 'Scottish' students. The good news is that most of the Scottish graduates from medical and dental undergraduate courses stay in Scotland.

Part of being 'Better Together' is we suffer from the UK's lack of capacity to train future Doctors and Dentists because there would always be always 'chaps' from the British Colonies just dying to come and work in our NHS. This is no longer true and has not been true for a number of decades. Now-a-days the 'chaps and chapesses' come from the old Soviet block countries in Europe or the Philippines but even they are starting to dry up as the economic situation in their own countries improves.

The only answer to the current GP conundrum, until training capacity can be built to meet Scotland's actual need for doctors, dentists, nurses (unlikely while tied down by Westminster's apron strings) ... without the current heavy reliance on 'imports' is to create a GP system in Scotland that meets the young doctors needs and aspirations which, by and large, are to help people get better or, at least, not get any worse in the first instance and not be buried in a paperwork mountain. 

In the current NHS Scotland GP world the young doctor's perception is  formed by reading BMA Journals, Lancet, GP 'News' and the UK media which tells them to be a GP in Scotland, is to be buried up to your neck in paperwork with MPs and MSPs endlessly telling you you are not working hard enough or seeing enough patients quickly enough. Not a very inspiring advert for a job as a GP and all the examinations, study, cost and related lack of free time you have to endure to become one.

So we, the patients, have to accept we are part of the problem, as well, because we often confuse our 'needs' with 'wants' and claim 'rights' but take no 'responsibility'. 

We have been taught by the UK media and politicians of all stripes we have a 'right' to see a GP at anytime of the day or night but not our own responsibility to consider if 'right now' is actually medically appropriate.

We are told by politicians that GP practices should be open until late at night, no matter the impact on a GP, the practice nurses and staff's personal life or patient safety. This is far easier, it appears, than ensuring the right of the worker to take time off to see a doctor with regards a legitimate medical complaint; in effect putting wealth generation before health.

The cost to UK Industry to days lost to ill health is among the highest in the world and all because of our long hours culture and work until you drop attitude. Encouraged by neo-liberal politicians and policies with their zero hours contracts, austerity and an ever disappearing welfare safety net. It seems once more the UK worker is being reduced to a Lowery stick man, to be cast aside when burnt out. Yet who has to pick up the pieces of mental illness, alcoholism, broken homes, beaten children and spouses, divorce, cardio-vascular damage caused by a bad diet, rushed poor quality meals and long hours sitting still watching a screen, then try to put them back together as some form functioning human, that will be your GP; in the first instance, but only if they can get their head out of all the paperwork the politicians want them to fill in to 'prove' they are meeting politically motivated and often meaningless 'targets' and patients demanding their 'rights' to be seen with out thought for the seriousness of their medical condition. Never in the history of modern medicine has so much been measured, in such finite detail for so little real impact on patient care.

So we, the patients, have a direct responsibility for the GP services we receive by the way we use of our vote and our own inherent selfishness - me, me, me. As a result we also have a part in bearing the responsibility for the recruitment problem with GPs in Scotland.

There is no 'simple' solution to the problems GP services in Scotland are facing, as I hope this skim over the surface of this many layered and complex issue has demonstrated. The answer involves all of us, not just the special interest groups, mumbo-speak consultancies, the health boards or the politicians - we need to start listening to GPs and debating the issues before - as is already happening in England - tens of thousands of us no longer have any GP service at all.

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