The rumbles, when they first reached me, seemed distant. Reports of GP surgeries closing in far-flung places – Folkestone, Swindon, north Wales, Tyneside. The downward spiral was similar wherever the stories originated. One or two partners would reach retirement, their practice would get no response to recruitment adverts and the workload would pile up on the remaining doctors.
In time, the cracks would deepen: another GP out through long-term sickness; another resigning because of stress. What had once been a healthy, viable, five-partner surgery would be down to one or two doctors, propped up, if they were able to find them, by expensive locums or transient salaried GPs. In the end, the exhausted survivors would have no choice but to hand their contract back and shut the practice down.
Each individual closure causes a domino effect. Thousands of doctorless patients are suddenly added to the lists of neighbouring surgeries (often some distance away), increasing the pressure and causing the same cracks to appear elsewhere. Brighton and Hove, for example, has lost nearly a quarter of its surgeries since 2015, with 35 left. Nationally, around 450 practices have shut in the past five years, displacing more than a million patients. I work in a sought-after part of south-west England; recruitment has never been a problem. But two years ago, the training scheme in our area – which was second only to London in popularity among young doctors embarking on a general practice career – failed to fill its places for the first time.
This year, one of my neighbouring practices has been unable to replace a partner who resigned after burnout. And a friend ten miles down the road is now one of only two doctors remaining in what was once a thriving six-doctor practice. They’ve introduced a “last man standing” clause into their partnership agreement, so that neither of them can jump ship and leave the other bearing the costs of staff redundancy and potential premises losses alone.
What were, to begin with, distant rumbles are now loud and close.
****
I no longer recall her name, but I remember picking up her notes. They were contained in one of those buff Lloyd George envelopes ubiquitous in British general practice in the 1990s. The white sticker bore her name, address, phone number and date of birth. She was a similar age to me, in her early thirties. And below all that, printed in bold type, the name of her doctor: Dr PJ Whitaker.
I felt a distinct tightening in my stomach. I’d been building up to this day for months, the moment when I would become a fully fledged “GP principal”. I’d qualified ten years before, and had a good amount of experience both in hospital medicine and general practice. But although I’d always taken very seriously my duty of care, every patient I’d looked after had been someone else’s ultimate responsibility – be that the consultant whose firm I was working for, or the GP principal whose locum I was undertaking.
Now, on my first day as a partner, the medical care of this woman whose notes I was holding was down to me. Anything might befall her over the course of her life – diabetes, difficulty conceiving a child, scares over a lump found in a breast, depression resulting from an abusive relationship, a disfiguring skin condition such as psoriasis, torrid anxiety complicating the menopause. And whatever she faced, I would be the one to whom she would turn. It would be me she would rely on to diagnose and treat her to the best of my ability, and to organise timely additional help if that was what was required. And what was true of that one woman – someone at a very similar stage in life to me – was also true of another 1,800 people of varying ages and backgrounds, from tiny newborns to frail nonagenarians, drug addicts to distinguished academics. My list of patients.
Seeing my name on that set of notes brought home the weight of it. I remember how daunted I suddenly felt. Who did I think I was, believing I could be that person to all these unknown people? Their doctor. It was the huge responsibility of so many other human beings relying on me for so many important and often life-changing things. Could I really be worthy of the trust they would place in me?
I suppressed the wave of apprehension, summoning memories of Dr Forshaw, who had been our family doctor throughout my childhood, and Dr White, who had assumed that role when my parents moved house when I was 18. My father had endured serious health problems since his thirties, and I’d seen first-hand the importance of those long-standing, personal doctor-patient relationships to him. Dr White remained a source of support and understanding. Earlier, Dr Forshaw had discerned the impact that Dad’s ill-health was having on us as a family and had organised help.
I had my role models. And now I had my chance to emulate them. Back then, virtually all GPs were partners in their practice; the contract with the NHS both required and incentivised it. Practices were stable entities, a home for one’s entire career, and when the time came to retire there would be, without question, new entrants vying to take one’s place. Indeed, partnership was so desirable that it was common for new incumbents to work for up to five years on a reduced share of earnings. I had negotiated favourable terms – it was only going to take me two years to reach full parity. My future was assured.
****
Marion looked highly anxious. It was hardly surprising. The symptoms she’d been describing, in a woman in her mid-sixties – pain in her mid-back, nausea, appetite suppressed, a little bit breathless – immediately raised the spectre of cancer. It was now some 20 years since I first became a GP principal, and I’d gained a wealth of further experience. The diagnostic possibilities flicked readily through my mind – stomach, bowel, perhaps pancreatic or lung; maybe spread from an occult breast tumour, or ovarian cancer, or some kind of blood cell malignancy.
There were less sinister possibilities as well, including peptic ulcer, medication side effects and liver problems. Investigative strategies formed: bloods first, maybe a chest X-ray, with an ultrasound or gastroscopy to follow depending on the results.
But I’d also known Marion for ten years. While I examined her on my couch, I gently teased out her principal concern. She feared she had pancreatic cancer: she had been researching online, and her symptoms fitted exactly. I palpated her abdomen. No doubt she’d also read that tumours of the pancreas are impossible to detect clinically; that they have to be diagnosed by some form of investigation.
Examination over, I sat her back beside my desk, and put a reassuring hand on her arm. “Listen,” I told her. “I think this is going to be fine.”
She looked startled, and shifted in the chair. Her voice when she spoke was almost pleading. “Can’t you even arrange a scan?”
She was absolutely right, of course: what she was experiencing could very easily be a textbook case of pancreatic cancer. I had to make a conscious effort to quell my own niggling uncertainty, and keep my focus on what I thought was truly wrong. I shook my head, and gave her my most confident smile. “No, no scan. I’m sure this is going to be fine.”
Another day, another morning surgery. Ellen brought Charlie in, hoisted up on her hip. “He seems unsteady somehow. I’m not really sure what’s wrong.”
At first glance Charlie, who was two years old, looked well. He was reluctant to get down and walk, but a lot of young children are scared at the doctor’s. I tried him with various toys. In the end, Ollie the Wobbly Owl proved too tempting. He got down and toddled across the room to where the clockwork plastic bird was swaying mechanically from side to side. Sure enough, Charlie had a limp.
The likeliest cause was an irritable hip – a short-lived joint effusion, or fluid build-up, common in children of Charlie’s age. But I was aware of a faint unease. The gait disturbance didn’t seem quite right. And there was no history of a cold or flu, which precipitate a lot of irritable hips. When I wiggled his leg once he was back on Ellen’s lap, he didn’t seem to mind, and the range of movement was full. “I think we’d better send him in,” I told her.
She took the news calmly, correctly reading my better-safe-than-sorry tone. Nevertheless, as she was gathering her things, she asked if I thought there was something serious going on.
I shook my head and gave a reassuring smile. “I don’t think so, no. I’m sure it’ll turn out to be fine.”
****
Over the past 20 years, hospital medicine has undergone rapid expansion – consultant numbers have more than doubled. In part this is due to sub-specialisation: where once a general surgeon, for example, might have undertaken the full range of surgical cases, there will now be multiple consultants each concentrating solely on one particular area – bowel, vascular, breast, and so on. There has also been an evolution to a consultant-led service, requiring more and more senior doctors to staff the rotas. The side effect was that by 2004 there was a dearth of doctors entering general practice. My own surgery tried to replace a retiring senior partner; we had only two applicants, neither of whom ultimately joined.
The New Labour government responded to the GP recruitment crisis with a new contract. There were three key elements. First, the funding model that had incentivised partnership was abandoned, enabling the creation of a new type of primary care doctor, the salaried GP. Second, practices were liberated from their 24-hour responsibility; care of patients with urgent problems arising out of hours was delegated to the local health authority, which removed the punishing sleep deprivation and disruption of family life that had characterised the GP’s lot. Third, a new funding stream was introduced, linking a practice’s income to performance, through the Quality and Outcomes Framework (QoF).
QoF caused a surge in GP pay, and with no requirement to be on duty at nights and weekends alongside the normal working week, demand for partnerships revived. But alongside this, surgeries now had the ability to replace outgoing partners with salaried doctors, typically at around two thirds of the cost. A practice still needed a certain number of partners to undertake management duties, but beyond this it made financial sense to recruit colleagues as employees rather than partners.
The salaried role suited some doctors well: they might have little interest in running a surgery, and were content to undertake only clinical work; or they might not want to commit to a practice at that stage. But many doctors were desperate to become partners, and fewer and fewer opportunities were becoming available. Practices in the most popular locations could expect over 100 applications for a single post.
Looked back on with a historian’s eye, this era in British general practice will be seen as a gross mistake. The advent of the salaried GP role – now a third of the total GP population – has helped to disrupt one of the greatest strengths of primary care: its continuity. This new breed of GP is every bit as clinically competent, but many change job with great regularity.
From the patient’s perspective, it is becoming ever harder to form a long-term relationship with “their” doctor – GPs seem to come and go, and patients complain about never seeing the same doctor twice. The trust-based relationship and in-depth personal knowledge – the cornerstones of efficient and holistic general practice – are becoming rarer.
Partners who benefited financially during the early years of the 2004 contract are living to rue its consequences, too. The past ten years of austerity have led to partner incomes falling by 25 per cent, while salaries for employed GPs have been protected. There is now a much narrower difference between the two roles.
At the same time, the risks of partnership have become all too apparent. Practice closures are now running at 140 per year; in many cases the partners will be left with substantial financial liabilities. Joining a partnership now looks to be a decidedly risky option. Most young GPs are sticking – entirely rationally – with salaried or short-term locum roles.
****
Marion returned three weeks later as arranged. “It’s just as bad,” she told me. I was a little disconcerted. “The tablets haven’t helped at all?”
She looked at her lap, where her fingers were repetitively intertwining. “I didn’t take them,” she said. “I looked at the leaflet, and I saw that thing about them making you go jaundiced, and all I could think about was me turning yellow. My weight’s gone down some more.” She met my eyes. “You don’t think I should have that scan?”
I took a deep breath and explained about lists of side effects on drug packets: how, when we read them, it can feel as though every single thing detailed there is bound to happen to us. But in reality, serious unwanted effects such as the liver damage she had fixated on were vanishingly rare.
“I’ve prescribed them to hundreds of patients over the years,” I told her. “I’ve never had anyone have a reaction like that.”
She remained unconvinced. She was certain she had pancreatic cancer. It was frightening her doctor simply didn’t seem to get it.
I reminded her of the deal we’d struck some years before. How I promised to take seriously any symptom she developed, and how I would investigate anything that I felt ought to be checked out. But how in return she was to trust me.
“Take the tablets,” I said. “I promise you, you won’t turn yellow.”
She held my gaze. Ridiculous thoughts kept popping into my mind: how she’d be bound to get liver damage now I’d said that; or quite how I was going to feel when, after a couple of months of no progress, I would finally organise a CT scan, which would reveal an advanced pancreatic tumour.
But I suppressed the superstitions. “Come and see me in another three weeks,” I said. “And this time, take the medication.”
****
Ellen came to tell me that she was pregnant.
I was careful not to issue hasty congratulations. “How are you feeling about it?” I asked.
“I just feel numb,” she said. “I only did it for Steve.”
We sat in silence for a few moments. I weighed things in my mind: the awful days during which it had become apparent that Charlie’s limp was the result of an aggressive tumour on his spine; the endless trauma Ellen had been through as her precious boy suffered fear and the terrible side effects of chemotherapy. The desperate hope that it might achieve a cure. The soul destruction when, after nearly a year of battling, he had finally died, aged three.
For the next two years Ellen had seen me virtually every fortnight. Her notes contained innumerable entries charting the depths of her despair. The engulfing guilt at failing Charlie somehow. The intolerable pain of his loss. How despite high-dose anti-depressants she had been suicidal for months on end, with nothing worth living for. She’d hated seeing the psychiatric team; hated talking to strangers who had never known her little boy. They’d found it impossible to help her.
Somehow I’d contained it, hearing her true feelings and not trying to fix them. We’d gone into uncharted territory professionally; she’d been to a medium, and gradually we evolved a way of talking about Charlie being in another place, waiting for her. She visited his grave obsessively. Sometimes she couldn’t see the point of carrying on just to delay being with her son again.
Gradually, though, time had started to heal Ellen, and she had improved to a degree. And now this.
“I’ve got to go through with it,” she told me, indicating her tummy where a new life was under way. “But I don’t want it.” She shook her head. “As soon as it’s born I’m going to hand it to Steve. It’s him who wants another one.”
Throughout the ensuing months, Ellen would talk about how she felt absolutely nothing for the baby inside her, and how utterly horrible she felt about herself, betraying Charlie by having conceived again. She couldn’t express these feelings to anyone – not to Steve, or her family, or friends. Everyone was delighted about the pregnancy; they felt it marked a new, positive, healing chapter. Ellen put on an act for them. Only behind the closed door of my consulting room could she be true to herself.
With Ellen’s consent I liaised with Laura, the midwife who had seen her through her pregnancy with Charlie. We carefully considered referrals to child protection and specialist mental health. But we knew how intolerable and intrusive Ellen would find the involvement of outsiders, and we were sure it would make things far worse. Her feelings were very troubling, but referring her against her wishes to other agencies would involve breaching the trust she had placed in us. She would become caught in a well-intentioned but control-sapping whirlwind of procedures and protocols that would quite possibly break her.
Laura and I decided to monitor her weekly between us. We both felt that if Ellen could just get through, then the moment she met her new child the world may change. Laura undertook to ensure that when Ellen came to deliver, she would be the midwife to attend her throughout the labour.
It was a calculated risk, and we could face potential criticism were things to go wrong. But we both believed, knowing Ellen as we did, that it would prove to have been the right thing to do.
****
Dr Nigel Watson is a dynamo. A GP in Hampshire with more than 30 years’ experience, he is also chief executive of the Wessex Local Medical Committees and a player in national medical politics. In May this year he was appointed to lead a hastily convened review into revitalising the partnership model of general practice.
I heard the news with mixed emotions. On the one hand, the fact that the Department of Health suddenly appears interested in sustaining the partnership model is encouraging. Hitherto, it had been indifferent to its death throes. The version of general practice that has served patients so well since the inception of the NHS is disintegrating, and the lack of political action has been perceived as tacit approval, further discouraging potential new partners – why board a ship that’s being allowed to sink?
On the other hand, Watson is also the driving force behind a vanguard project where a large number of practices in his area have been linked together into a super-sized primary care network. This is the latest dogma from the Department of Health suggesting how general practice should be reorganised: large-scale, corporate-style primary care that feels far removed from the personalised medicine I believe most people want when they become unwell – and that I believe passionately in providing.
Watson delivered his interim report in October, which went a long way to settle my misgivings. He identified the unique strengths of the partnership model, as well as the factors that are currently destroying it, and stressed that there should be support for every type of practice, from the biggest to the smallest.
****
Marion returned looking distinctly better. Three weeks after starting the tablets, her appetite was back, the nausea had gone and the back pain and breathlessness had receded. She was relaxed and her weight was coming back on.
Sertraline, the medication that helped her, is a potent anti-anxiety drug. We’ve used it on several occasions since, whenever her debilitating health anxiety has flared again. With each episode, she has found it easier to accept the true diagnosis – anxiety – and to manage the obsessive fears about whatever terminal disease she is convinced her physical symptoms must represent.
If she did not have an ongoing relationship with one doctor, it is likely that her story would have been very different. Presenting as she does, she would be referred for repeated tests and opinions. The reassurance that would come each time is like a drug: patients such as Marion become addicted to medical intervention to manage their fear. But intervention carries significant risk of exposing them to harm, to say nothing of the cost implications to the NHS.
Ellen was delivered (by Laura) of a healthy baby girl, whom she and Steve named after the midwife who so generously helped her through. As soon as Ellen met baby Laura, she fell in love. Two and a half years’ worth of fortnightly consultations with me abruptly ceased. She has blossomed with happiness again.
She still talks a lot about Charlie, and he remains part of their family as they go through life together. But he is the son and brother who resides in another place – distant, unreachable, but still connected.
I’ll never know how things might otherwise have been, but having a doctor she has known for years who could allow her to express her absolute grief, and hear her utter ambivalence towards the new baby in her womb, certainly made a difference. Few others would have been able to support Ellen in the way that midwife Laura and I did, thanks to our deep knowledge.
****
Our political masters seem fixated with the idea that GPs can readily be replaced by algorithms and apps, and that busy patients should be able to dial-a-diagnosis in much the same way as they might order a pizza. NHS England is pushing for nurses, pharmacists, paramedics, and physicians’ assistants to take on more and more parts of our role.
What is being lost in this fragmentation is the very thing that serves countless patients such as Marion and Ellen so well: continuity of care. The concept of the family doctor, which struck me so powerfully when I saw my name on that set of notes on my first day as a GP principal, has barely featured in the rhetoric and redesigns that have emanated from the centre over the past two decades.
Might that be about to change? Nigel Watson is due to deliver his final report to the Health Secretary, Matt Hancock, by the end of the year. I and many like-minded colleagues are awaiting it with a mixture of hope and apprehension. All I want for Christmas is for Nigel Watson to find an affordable way to encourage GPs to make long-term commitments to practices and patients. Crucially, though, the government will have to act on his recommendations. That would be the greatest gift of all.
Dr Phil Whitaker is the New Statesman’s medical columnist. A book of his collected columns, “Chicken Unga Fever: Stories from the Medical Frontline”, is out now
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This article appears in the 08 Dec 2020 issue of the New Statesman, Christmas special