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When I first started looking at general practice in other areas, I was surprised by the differences in the way we run things.
Originally, I was intrigued by the variation in practices in my area as I locumed my way round the county, then I was interested in the difference between London, inner city practices and those of rural Shropshire where there may not be a hospital within easy reach or indeed any closer than thirty miles away and how that impacted on the working lives of GPs. Finally, I got the chance to look further afield when I was elected as a member of the BMA Delegation to UEMO (the European Union of General Practitioners). In one of the first meetings I attended, I talked at a workshop on consultations. I told the audience that we saw everyone who was ill or who believed themselves to be ill, the standard NHS pledge. The audience started laughing and it was apparent that I had made a very good joke. Discussing this with the delegates over lunch, I came to realise that what I regarded as GP work, they didn’t.
For a start, it was obvious that with a different payment system, either insurance or means-tested or co-payment, patients tended to go to their GP or Family Doctor with strictly medical matters, the kind of stuff we were taught to deal with in medical school. Patients did not go to a Family Doctor with relationship problems, or redundancy worries, or damp housing or truanting children.
In fact, they didn’t go with children at all. In most EU countries, children went straight to the paediatrician. Children under four especially but often children up to the age of sixteen. As a result, GPs don’t do ante-natal or post-natal care. This spills over into gynaecological problems. Partly because of lack of GP skill, women are automatically referred to secondary care though this may often be in the same building. A Family Doctor Clinic will have a paediatrician and gynaecologist on site, as well as, probably a psychiatrist since mental health is also an area for early referral. Chronic Disease management is a hospital job, though I have worked long enough to remember a time when that happened in this country too; when diabetics were referred to the Diabetic Clinic and hypertensives to the Hypertension Clinic. I was interested to find out that in Lithuania, the trigger for referral of a diabetic into the hospital system is a HbA1c of 7% (53 mmol/mol). Here we would feel very comfortable achieving that. GPs don’t routinely deal with the elderly – those who are in Nursing or Residential Homes have care supplied by an appointed geriatrician, or in the Netherlands by their “Nursing Home Doctor Scheme”, which seems to be a way of keeping retiring GPs in a step-down clinical role.
So, what European GPs do is roughly like our Out-of-Hours, seeing the acutely unwell and those with undifferentiated diagnoses.
They do have easier days, I think. Their lists sizes are smaller, 1100-1250, and their consultation times longer, 20-30 minutes. They count telephone calls as consultations and seem to do fewer house calls. They certainly see less of their patients. In this country, on average, a patient will see their GP 6-8 times a year. In most of Europe it’s twice a year. Their working day is shorter – eight hours at most, starting at nine and ending at five. The Danish GPs close their doors at 4 o’clock on Monday to Thursday and at 2 o’clock on Fridays. The health of the Danish population does not seem to be adversely affected by this.
I have been conducting a series of surveys to try and clarify differences in workload, teams, consultations, and training. It was interesting that to the question “Is your general practice workload reasonable or sustainable?” 60% of European nations answered No, 16% thought it might be reasonable with minor changes and 24% answered that it was fine. Looking more closely at that 24%, they had certain things in common; their list sizes were smaller, their consultation times longer, and their working day shorter. However, the strongest correlation was the number of consultations one doctor had in a day. 25 or less and the workload was reasonable – more than 25 and more stress was reported.
General Practice in the UK is in crisis with more GPs leaving than the numbers we can recruit. We need to make the job better, and it is the best job in medicine. Looking at our European neighbours and putting a limit on the number of consultations might be one way to do it.
Mary McCarthy is a GP working in Shrewsbury, a member of GPC and part of the BMA delegation to UEMO (the European Union of General Practitioners).
Wow. Where's my (EU) passport???
Ha. Nice. In Canada although we might do anything uk gp does and more in cities you could equally refer anything u like. Also you could work any hoyrsvu likes no need tug o have certain access or even see urgent stuff that's what emergency is for. U basically saw as many or as few patients as you wanted and were paid per consult in proportion to length of consult and what was done. Pretty good
Sums up nicely why I am a locum GP. I see 15 patients per surgery, 30 per day. Any more that this and I start to feel drained and no longer able to give my best, which leaves me feeling dissatisfied and stressed.
Very good reference. Perhaps it's time to stop treating british GPs as super-doctors, and add more limits to their medical scope along with working conditions.
"count telephone calls as consultations"? Of course! Is there really any practice that is failing to do this? Any work not recorded on your appt system or timetable won't be recognized as work by your employer. We need to stop thinking of visits/repeat queries/ phone calls someting to fit in rather than something that requires its own dedicated time (and phone consultations are usually AS long as a face to face to consultation as you don't have the "short cut" of examination). We also need to stop thinking there is anything efficient about a 10 min consultation where all you do is "fire-fight" and dealing with the urgent unimportant.
European general practice sounds boring though. You dont just want to be a referral machine do you? take out the paeds, O&G, geriatrics and psych and what sort of a generalist are you now? Hardly "family" medicine.
As a European GP myself and having worked as a GP in the National System of Greece for more than 5 years and as an NHS GP over the last 4 years I believe the golden recipe is somewhere in the middle. A GP should be able to manage the whole spectrum of general practice including pediatrics, antenatal, mental health and gynecological ailments but there is definitely a need for a limit in the number of patients that we see daily. Seeing more than 30 patients a day definitely lowers quality. After all, we are not machines we are humans. And patients deserve more time than a 10min consultation with their GP and not less and less depending on GP availability. We have to consider ourselves as possible patients and only then we will realize how dysfunctional and sometimes inhuman feels the current GP system in UK.
Lola Tomás. Bradford, GP working in Sexual Health.
Very interesting reminding what a doctor should be in primary care. I still remember the Alma-Atta Declaration and the definition of health: "which is a state of complete physical, mental and social wellbeing". It does't mean, effectively that the GP has to be the one to cover all these needs. Spain is still different, the appointment list could have three patients every ten minutes slot. Who is surprised with "count telephone calls as consultations"? Solicitor charge you by minute when you call them.
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