Is general practice losing its way?

British Medical Journal,  Dec 2, 2000  by Oliver Samuel

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I was feeling unwell and decided to go and see my doctor. I telephoned the practice to make an appointment but was told that his next available slot was in two weeks' time. The receptionist was very sympathetic and told me that I could see one of the other doctors, but the first time one of them was available was seven days ahead. I said that I wanted to see a doctor straightaway so the receptionist asked me what the matter was. I told her that I hoped that the doctor would be able to tell me that, but only after I had been seen. "No, really" she said, "I need to know to decide if you are an emergency." She then added that emergency appointments were only for problems that could not wait and that only one doctor was available that evening to see the "extras." My friends tell me that many general practices are run with similar waiting times.

The doctor, whom I had never met before, was kind and helpful and soon sorted my problem out. But now, two weeks later, although improved I still do not feel completely well. So I decided to go for a follow up appointment. Yes, you've guessed it. I cannot see that nice doctor again for yet a further fortnight so, next week, I am going to be seen by another, to me quite unknown, practitioner. I really do not want to wait a whole two weeks, but this time cannot claim to be an "emergency." So why don't I accept the fortnight's wait? I am actually rather worried by my symptoms and would welcome some reassurance. I have got enough wrong to be slightly scared, but not quite enough to panic. Continuous care by the same doctor would undoubtedly be best but I cannot wait that long.

The practice I go to is calm and efficient. Everyone--nurses, doctors, and other staff--is friendly and seems most competent. I am sure that if they were summoned for acute chest pain they would also be very good. But they, like very many other general practitioners these days, seem geared up to deal with routine attendance for checkups, screening visits, and the rest. I find it strange that acute illness that does not demand the attendance of an ambulance with a flashing light should apparently come quite so far down the list of priorities.

Surely primary health care should entail providing a readily accessible service with the doctors offering personal care to their own patients. Of course, if demand for appointments always exceeds availability a waiting list will develop and may steadily get longer and longer, like some hospital outpatients' departments. This is clearly unacceptable, so every practice has to make enough time available to serve the overall demand even though some days may be more difficult than others.

It is perfectly simple to run a practice without any waiting time at all, by being flexible about the length of consulting sessions and by smiting extra sessions at times of high demand. This requires that doctors and nurses work in an adaptable way but, with all their committee work and other Commitments, there may have to be some adjustment. There is little doubt that many patients wanting to see a doctor will survive despite a bit of delay, but the advantages of being seen quickly are obvious. They will have faster relief of their illnesses and anxieties.

We now have NHS Direct--a nurse run telephone service and a website providing health information. Many regard this to be more a piece of political window dressing than an adequate and acceptable substitute for immediate personal medicine. It seems to have been produced as a response to a widespread dissatisfaction with the immediate availability of primary health care. I do not see how an anonymous nurse run telephone service can be an adequate substitute for a face to face consultation, but, if that is unavailable, it might be of some use as a stop gap. Carefully briefed and guideline led nurses are likely to be safer at triage than an unqualified receptionist.

I believe that general practice has lost its way a little under the welter of demand for new or extra duties. Surely the primary purpose of medical practice is to treat the sick. No time is actually saved by allowing long waiting lists in primary care--everybody wanting to see a doctor or nurse will have to be fitted in sooner or later. So isn't it time that general practitioners and their staff stopped thinking that patients who are unwell and want immediate help are "extras?" It is the non-clinical stuff that is extra and should take second place to committing enough resources to provide proper immediate primary care.

Oliver Samuel retired general practitioner, London

COPYRIGHT 2000 British Medical Association
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