It’s time to consider what we want beyond access to general practitioners

Ever since Adam was a boy the thing that has driven policymakers into a frenzy is ‘access’ to a GP. That’s good because they recognise that the work done by a general practitioner is very important. However, it sometimes feels like ‘access’ is the only thing that really matters in healthcare policy. Politicians and bureaucrats can’t look beyond the quantum of people being seen because that’s how they think their performance will be judged by the voter/shareholder.

Of course, it is important that the public is able to access a doctor trained to deal appropriately, effectively and efficiently with all that can happen in life. However, an ‘open’ sign doesn’t mean people will get that beyond those portals. To get what we imagine lies beyond the door we need to consider how those doctors communicate because the formula is: thoughts -> feeling and feelings ->action. Action is what is needed when someone is overweight, smoking, abusing, bleeding or worrying. The person who needs to take action or consent to treatment is the person now striding through the door.

The ability to help means being able to put the needs of the other first. It doesn’t happen quite so well, or in any sustained way when the person trying to help is troubled, anxious, tired or working in a hovel. There are two parties in the mix- the one who is dealing with the crisis and the one who is trying to help. The needs of both will impact on the outcome.

An older couple I know walk miles and wait hours to see their doctor. This doctor has been looking after them for years. Her clinic is open for long hours and everyone gets seen ‘eventually’ and on the same day. I know these people well and I know they are not taking the statins, the NSAIDS, the antibiotics and list of other things that are prescribed and that the innumerable scans and X-rays ordered every year are futile. What they crave most is to be heard, for someone to acknowledge that things don’t work as they used to, or help prepare to visit their beloved daughter overseas. That takes time, it takes a willingness to see people in context but for longer than 10 minutes at a time. It takes planning for what people will think after their visit because thoughts determine feelings and feelings drive actions.  Good feelings are engendered only when the doctor can invest- not just in what happens when she is face to face with her patients but at every touch point with her practice. Then she can communicate that she cares and that she can be trusted when she says that that ache or pain isn’t something that needs yet more tests or another prescription. What the practice needs is not just another doctor to churn through the waiting list but for those doctors to work their magic. For now, she is open for business- the question is what business and who really benefits from her efforts?

In 1999 Mainous and colleagues published a paper in the American Journal of Public Health which reported data suggesting that access though necessary was not sufficient to make a real difference to patients in primary care:

OBJECTIVES: This study examined a private-sector, statewide program (Kentucky Physicians Care) of care for uninsured indigent persons regarding provision of preventive services. METHODS: A survey was conducted of a stratified random sample of 2509 Kentucky adults (811 with private insurance, 849 Medicaid recipients, 849 Kentucky Physicians Care recipients). RESULTS: The Kentucky Physicians Care group had significantly lower rates of receipt of preventive services. Of the individuals in this group, 52% cited cost as the primary reason for not receiving mammography, and 38% had not filled prescribed medicines in the previous year. CONCLUSIONS: Providing free access to physicians fills important needs but is not sufficient for many uninsured patients to receive necessary preventive services.

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6 thoughts on “It’s time to consider what we want beyond access to general practitioners”

  1. Agreed Frank. However we might consider that a significant proportion of the demand is generated by doctors themselves- their follow up habits, their test ordering, their referrals etc. These actions generate work which- when you are already just trying to get people out the door is not done thoughtfully. In the 1990sthere was a outcry when we suggested it might be possible to reduce the demand for same day appointments by telephone consultations. We had to prove it: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314295/
    The point of that was not to reduce our workload- but to spare our energy for people who needed face to face time.

    1. Great article Moyez. Also enjoyed reading the 2002 study. Confirms what I suspected. The term ‘access’ is a bit of a fallacy in the way policymakers have used it in the past. You can use the analogy of water: It’s all well and good to have access to water, but if it isn’t clean or drinkable, it isn’t going to help you much. Rather than worrying about ‘access to a GP’ we should be concerned with ‘access to a great healthcare service that helps people reach their potential.’

      1. I couldn’t agree more Chantelle. One issue that might need careful consideration en route to this outcome is why patients make appointments and how many could be managed without the need for face to face visits so that there is room for those who can be safely managed without a visit to a doctor. One aspect that needs consideration is why people are asked to return for another visit- could that be handled safely without making an appointment in the very near future?

  2. The current model of general practice where patients are seen for 5-15 minutes is no longer adequate for many of our patients with complex needs that span more than those dealth with by the traditional general practice team. The healthcare team can be supported by a model of care/funding model to provide care tailored to our patient’s self identified needs and that may be more than what a GP can provide- eg many of my patients need help navigating social and financial mazes or to get into an exercise programme tailored to them that they can afford. Having a social worker, a physio as well as well trained nurses, NPs and GPs would be great and all without having to cater to pressure from a fee for service model.

    1. Thanks Rosemary, you may be right. One thing that bothers me about that is that we may be waiting a long time before government/ funder policy moves in that direction. Therefore we may need to focus on waht we can do right now to make it a more effective visit for each patient. From what I saw HealthMint have done just that.

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