New Horizons

I may be a little tardy in my response to The White Paper but I like to think that it's because I have been carefully assessing the situation before I state my position. In reality, it has just taken me an awfully long time to get round to reading it (thank goodness for summaries...).

My reaction to the government's big shake up has been mixed. It started with irritation that such huge responsibility was being handed to GP's without a hint of consultation with us first. That inevitably lead to terror - we are not managers, how on earth could we cope with what enormous PCTs have dealt with up until now (with much complaining from us about how bad a job they were doing of course)?

But the truth is we asked for this. When we grumbled about big funding decisions being made by suits and not doctors, when we've complained bitterly about new systems forced on us by managers, when we've just wasted yet another consultation ticking boxes of no discernible use. So now we've got what we wanted and the question is, can we handle it?

In a word, yes.

We'll have to work together and cooperate like never before and yes, we will need help with managing the books, but let's not forget that we are being handed an incredible opportunity here to transform our NHS. No longer will we have to put up with systems that don't work (bye bye choose and book), or have to accept second rate services. We can change them.

Of course there are threats as well: what happens if the money runs out (many PCTs found themselves in this scenario, so it's pretty likely to happen to GP consortia too)? How do we achieve the balance between being both advocates for our patients but also the purse holders? How will we ensure that we can work together without squabbling about individual practices' needs? What about practices who let the side down?

To me however, the potential for good outweighs the bad, and it's up to us to make sure this is so. We've got time to put forward our opinions and ideas to help shape the detail of these plans, so let's get involved and seize this opportunity. This change is coming whether we like it or not, don't let's be dragged kicking and screaming.

The QOF Express

As the end of the tax year approaches, the race to meet our annual targets is on. Like squirrels gathering nuts the practice must collect as many QOF points as it can in order to get paid. It's not unlike those lucky contestants at the end of The Crystal Maze, scrabbling around in the wind for £5 notes. But whilst we engross ourselves in desperately trying to squeeze in any outstanding foot checks for the diabetics, breathing tests for the asthmatics and blood pressure checks for just about everybody, I can't help wondering what our patients must make of all of this?

What has struck me most is just how much we put them through. We expect them to oblige us by continuously appearing for blood pressure measurements, diabetic examinations, COPD checks, elderly care reviews etc etc and to cheerfully knock back as many medications as it takes to achieve the 'right' results. It's one thing if you've only got one medical condition to worry about, but for many patients, and perhaps most commonly for elderly patients, there are multiple problems meaning multiple assessments, blood tests and the like. Of course it's all well intended, but until recently I had never really considered the impact that all of this must have on their lives.

Mr Mitchell, an elderly gentleman and a prominent author, was recently diagnosed with atrial fibrillation (picked up incidentally when we dragged him in for a blood pressure check). For anyone who doesn't know, this is a relatively common irregularity of the heart's rhythm. As in this case, it often doesn't cause any symptoms, but unfortunately it does put you at a greater risk of having a heart attack or a stroke. Mr Mitchell was thus advised to start warfarin treatment, to thin the blood. He was referred to the warfarin clinic and bundled out with an armful of tablets. There wasn't much discussion, this was the best treatment for him and that was that. But Mr Mitchell has not taken his tablets, and he will not attend the clinic. In the several discussions that we have had on the matter since, he has made it quite clear that he would rather take his chances than become 'a patient'. He has no intention of swapping his independent lifestyle for one which must revolve around a multitude of clinics and blood tests.

Whilst from a medical viewpoint this may seem like the wrong decision, I do completely understand his rationale. It has made me wonder how much of our screening, interventions and health checks patients actually want? How much of our time do we spend getting so carried away with our efforts to treat a disease that we forget what we are actually meant to be doing; treating the patient?

Target driven health care does not help. The truth is that the majority of GP's pride themselves in treating the person and not the illness. It's what we specialise in. We know about patient autonomy and we know that the best treatment for one person may be very different from that for another. If we are lucky (and do not work in a polyclinic) we have the time to get to know our patients, making it easier for us to help them to make the right decisions. What QOF lead health care has done is place too much emphasis on results leaving little scope for tailoring care to the individual. It's robot medicine and it's not what we're about.