I am encouraged of late to remind myself of the longstanding literature on the doctor-patient relationship. For many decades I travelled with bands of students and doctors from Parsons, Freidson and active versus passive relations to more recent ideals of reciprocity, concordance and so on. But things have changed, at least in England, as at a pace. A personal example has precipitated this blog.
Having suffered briefly from a flu-like version of COVID, I found that in its wake I was experiencing quite severe pains in my joints and muscles. As invited, or exhorted, I contacted my GP practice online, wondering about a possible instance of long COVID or the possibility of polymyalgia rheumatica, and requesting a face-to-face consultation to discuss it. This was declined in favour of a phone call, during which a GP I’d never met (or indeed heard of) decided I likely had long COVID and prescribed strong painkillers for 4-6 weeks. Ok. In the event the painkillers had no effect whatsoever, so I stopped taking them after three weeks.
A month after the initial phone call, and somewhat at a loss, and frankly unwilling to settle for a second GP phone call, a protracted and insistent call to the GP practice resulted in a consultation that day. It was a good consultation, during which a preliminary diagnosis of polymyalgia was made and an arrangement for a series of blood set in pace for the following day. Two days after this consultation, and after the GP had consulted a specialist in rheumatology, I was telephoned with the results – it was almost certainly polymyalgia – and that same day I was able to pick up medication from the local pharmacy. The medication has been as effective as it was ever likely to be, and I have a follow-up phone call with the same GP I saw face-to-face already booked.
So what’s the point of this blog? I want to insist that face-to-face consultations with GPs still matter, and not just as a final resort. In fact, I will go further and suggest that there has been an accelerating and concerning deterioration in GP services and accessibility.
Note that I am not blaming GPs for this. It is due to the systemic underfunding of the NHS, all this being part of a politically calculated running down of the NHS to induce patient dissatisfaction, thus allowing for the introduction of more and more private providers (the for-profit cavalry to the rescue). To this agenda must be appended the independent impacts of COVID and loss of medical and other healthcare personnel in the messy hinterlands of Brexit. Many GPs, like others in the NHS, are coping on overly scarce resources and on the edge of exhaustion and burnout.
But I still want to make a number of points.
First, I accept entirely that health services evolve and that some/many GPs and patients alike might prefer phone calls to the inconvenience of face-to-face consultations. Telemedicine too will have a growing – if limited – part to play I imagine.
Second, it seems obvious to me that the current widespread difficulty many patients are experiencing in accessing their GPs is a function of a service under extreme pressure and not a rational re-examination of optimal ways of delivering care. It is being foisted on patients, as it were ‘out of necessity’. Some patients I am aware of are being asked to wait weeks or even denied phone calls altogether, let alone face-to-face consultations; nobody asked me about these changes.
Third, it seems to me entirely relevant, notwithstanding the undoubted changes in medicine and healthcare in the interim, to recall that when I was a boy I could see my GP any day of the week (just turn up and queue), or indeed have a home visit that same day. Moreover, my GP was then able to refer me to any hospital specialist in the country. What has happened between then and now actually IS a net loss for patients. Since Thatcher’s day, and even allowing for New Labour’s real terms annual increases in expenditure on healthcare, England’s health system has regressed. Nor can this regression be put down to unremitting increases in service costs or patient demand since Britain spends markedly less its healthcare than any other comparable country.
Finally, what’s happened to the doctor-patient relationship? Well its certainly changed, as have the criteria now used to assess its quality. I recall a piece of research I was involved in on people’s preferences for queuing versus appointments to see their GPs. People preferred what they were used to. Extrapolating, it seems likely that patients will over time adjust their expectations and evaluations of GP services. If what I have contended is correct, they will settle for a deterioration in services.
When I’ve tweeted along these lines I’ve often met with an insistence that doctors and patients alike often prefer phone calls to face-to-face consultations. Many of these responses are from doctors. Well maybe, and sometimes undoubtedly and with good cause. But who chose this transition. I think it’s a way GPs and other doctors have found to cope with what seem like impossible demands.
Of course I’m knocking on a bit and may no longer be representative of patients as a whole. But I found personally that it was important recently to see a GP face-to-face, to be listened to and taken seriously by someone who cared and might even be able to help.
Doctors, it seems to me, have a duty to educate patients about the Conservative well-advanced plans to deconstruct the NHS, which is the fundamental underlying cause of the deteriorating services on offer.
But doctors too might need educating, or challenging. One recent systematic study by the London School for Hygiene and Tropical Medicine found that 29.3% of doctors voted Labour and 26.2% Conservative in the 2015 general election, and 46.3% Labour and 19.7% Conservative in 2017. This might appear encouraging, yet a quarter (2015) and a fifth (2017) of doctors voted for the Conservative agenda. Even allowing for the pertinence of ‘other factors’ I find this disturbing.
Enough for now.