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Wednesday, 8 March 2017

The Doctor Will See You Now

As a young child, I already had a considerable knowledge of Britain’s health system, the new National Health Service introduced in 1948, a year after my birth. I spent a lot of time in the company of ageing aunts and uncles for whom ailments and visits to the doctor were routines of life. The basic picture was this. If you were ill, you went to the Doctor who gave you medicine which was either white or pink but in both cases supplied in glass bottles. Sometimes the Doctor gave you Pills, but I wasn’t so sure about those since they were less visible on bathroom shelves. And occasionally the Doctor would give you a Letter to the Hospital (you would sometimes personally carry it there), and in this case you would have cause to be Worried. Hospitals were only interested in you if there was something seriously wrong. In contrast, you could go to the doctor in a normal frame of mind.

What my world view missed was a fact fully visible. Doctors all the time deal with things which are wrong, sometimes seriously and, indeed, so seriously that it would be irresponsible not to respond on the spot. The thing might not be immediately life threatening but would become so if you left it for 48 hours or a week. Take out life-threatening, and there are a large number of acute debilitating conditions which patients walk into the surgery and from the pain or frustration of which, they quite reasonably want relief. If you have an acute ear and throat infection which mean that you basically can’t swallow or sleep, you would not be impressed if the Doctor said to you, “Hmm. This is so serious that I must refer you immediately to hospital”. You want medicine (pink or white, that’s the Doctor’s job to decide) and you want it now. You want to be pointed onto the right path of treatment and cure, now. That’s what you have come for.

In thinking about alternative to the ten minutes with the front line triage of the GPs surgery, it’s important not to lose sight of the core need which generated the system in the first place: an immediate, practical response to a problem which is subjectively distressing and may also be objectively threatening. This includes nowadays, the possibility of a response which is based on the doctor’s judgement prior to confirmation by a test of its correctness. If a man walks in the surgery and says he is pissing blood, the doctor asks for accompanying signs of infection but even in the absence of signs will in all probability prescribe antibiotics since infections should not be left to go out of control. There is a Protocol which tells GPs to behave like this.

So alternative systems need to be able to mimic such protocols. Either the person at the end of a phone line must have authority to prescribe prior to test results or else the patient must have authority to take that decision. Indeed, already GPs quite often pass authority on to the patient as when they pre-prescribe medications for patients travelling abroad just in case. At one time, I used to keep quite a medicine chest acquired in this way and used it mainly as insurance against the vagaries of Opening and Closing times.

Of course, people walk into GP surgeries with pre-planned problems rather than emergencies. Their arthritis is getting worse and they wonder what they can do about it. It’s true, such pre-planned problems should be scheduled in ways which does not mean that they take away valuable,finite slots of time from people who are ill now. One weakness of free-at-the point-of-use appointments is that there is only a weak internal self-regulation mechanism available to us to decide whether we have an acute problem which really needs to be addressed now or whether it's a nice day and convenient  to go to the doctor to talk about that arthritis which has been bothering us. The same problem applies to Accident and Emergency. What is perhaps most remarkable is that only in very recent years does the NHS seemed to have developed a Public Education model designed to nudge people towards better (and more socially-responsible) decision-making about when to go where.

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