It may seem slightly undemocratic to have our NHS not directly managed by the elected government, but the elected politicians are clueless morons and keep fucking things up! Would it work? I don’t know. Would it just add another tier of ineffectual managers? I hope not. Would it be worth a try? I think so.
Passing judgement
I know I can appear judgemental in my description of some of my patients. I don’t mean to be. I try to treat all my patients equally and fairly. If I’m judgemental at times I think that it is not because I’m a doctor but simply because I’m human.
As a doctor, it can be difficult not to allow my own personal morals to reflect on how I view and treat a patient. For example, one morning I spent a long, tearful consultation with a lovely couple in their late thirties who had just failed in their fifth attempt at IVF. They had run out of money and hope and were emotionally distraught at the recognition that they would never conceive their own children. Later that morning, a woman came in requesting her fifth abortion. I don’t have any ethical problem with abortions, but I did find myself judging her. Did she realise how hard it was for some people to conceive? Did she consider how much it cost the NHS each year to perform so many abortions? Contraception is free and readily available in this country. How could she have been so careless so many times?
I also found myself feeling very judgemental during a child protection case conference. I was in a meeting with social workers, health visitors and other professionals discussing what should be done with an unborn baby belonging to one of my patients. I knew the mum-to-be well and, quite frankly, I thought she would make an absolutely terrible mother. She was rude, aggressive and always in trouble with the police. The dad wasn’t on the scene and her own family had disowned her. I just didn’t believe that she was the right person to give that baby the best start in life. Everyone in the meeting was very professional and positive. They were looking to implement extra support for the mum to help her with her new baby. I tried to be positive, too, and I do think kids are best off with their real parents, but a big part of me wanted to take that baby away at birth. I wanted to give him to the nice couple who kept failing with the IVF. I just felt that the child would have a better future with them than with its real mother.
Deep down I knew that I had no right to pass judgement on who would make better parents. I see my patients for ten minutes at a time and don’t have the right to decide if someone should have their child taken away. What do I really know about parenting anyway? Would I like someone passing judgement on what sort of dad I am? Back at the case conference we all agreed that once born, the baby would be put on to the child protection register but stay with the mum and be closely monitored. I hoped I’d be proved wrong and that the new mum would do a great job. I know it is not my place to judge my patients but it can be very difficult sometimes.
The examination game
There is a lot of drama in medicine. As a doctor much of what I do is a performance rather than an attempt to actually gain important medical information. The examination is perhaps the most evident example of this. Examining patients is obviously important and sometimes I even find something abnormal…But a lot of the time the examination is a bit of a fraud. It is all part of my attempt to add mystique and importance to my job.
An example of this is when I visit one of my patients called Mr Briggs. Mr Briggs is well into his nineties and very frail. He has lots of things wrong with him, but unfortunately, they are mostly because of his excessive years and there isn’t a great deal I can do about them. I’m fairly certain that Mr Briggs is going to die within the next year and my main objective is to make sure he remains as comfortable as possible and that I provide reassurance and support for him and his wife. Whenever I visit Mr Briggs, I check his blood pressure. I check it every visit and it doesn’t change much. Even if it was raised, Mr Briggs has already said he doesn’t want to start any new medication and certainly doesn’t want to have any tests or investigations if he becomes more unwell.
Ultimately, I am not examining Mr Briggs for his physical health but for his emotional health. He is expecting me to examine him and by going through the motions, I am offering reassurance. Human-to-human contact is comforting. I am English so I don’t give Mr Briggs a hug. Instead, I use a blood pressure cuff and a stethoscope to reach out and make some soothing physical contact with this dying man. ‘Strong as an ox,’ I often say after listening to his heart. It sounds patronising written here but I know that Mr and Mrs Briggs are reassured by my words. ‘I wish the rest of my body was as strong as an ox,’ Mr Briggs will reply as I shake his hand on leaving. Sometimes I wonder whether my examinations of Mr Briggs are actually as much for my benefit as for his. If I didn’t have the extra gimmick of my stethoscope and blood pressure machine, how could I justify my visits? They are the instruments that define me as a doctor and without them I could simply be a visiting neighbour or the local vicar.
I am clearly not the only doctor who sometimes uses the examination as a bit of a show. One of my colleagues was visiting an elderly patient to give him a check-over and to reassure his wife. He had already mentioned that he would have a listen to his chest but then found that he had left his stethoscope at the surgery. Not wanting to admit this, he instead took out a 2p coin from his pocket and carefully placed it at various points on the patient’s back. He was using the coin to mimic the bell of his stethoscope and as the patient was facing the other way, he imagined he would be none the wiser. Apparently, the patient seemed happy enough but just as my colleague was on his way out he stopped him: ‘Just one thing, Doctor. I’ve seen some things in my time but I’ve never seen a doctor listen to my chest with a 2p coin.’ The doctor hadn’t noticed the mirror on the dresser that enabled the patient to watch him examining him. My colleague came clean and apparently they had a bit of a laugh about it. Just a lesson for us all not to ever try to pull the wool over our patients’ eyes!
Sex
An astounding part of being a doctor is that a complete stranger can walk into my consulting room and within two minutes I can be asking them about their deepest, darkest sexual habits. A full sexual history is vital for accurately diagnosing and treating many illnesses. It is also a great way to find out exactly what people get up to behind closed doors! I am still amazed by my patients’ sexual escapades and also about how honest, open and unembarrassed they are when telling me all about them. My patients make me feel very boring as they recall tales of dogging, rimming, fisting and various other sexual behaviours that I have to Google in order to know what they are talking about.
The youth in my area seem to be amazingly promiscuous and I was astonished when I met a patient who had kept her virginity until she got married at 23 years old. Her husband had apparently done the same and they had been using condoms for a couple of years until the previous month when they had decided to start trying for a baby. Jane, the woman in question, came to see me complaining of a creamy white vaginal discharge that she was now getting after sex. I feared the worst. I was sure her husband must have been having an affair and that she had caught some kind of sexually transmitted infection. I ordered a full set of vaginal swabs but everything came back as normal. It was only when she returned to see me and I asked her to explain her discharge symptoms in a little more detail that I realised that the post-coital discharge she was describing was actually just her husband’s semen.
Money
Do GPs earn too much? That has certainly been the general consensus of the media over the last few years. I personally don’t know any GPs who earn £250K as reported by the press; however, most GP partners who work full time earn over £100K, which seems a lot of money to me. I am not a partner myself but do fairly well out of being a locum GP and just a few years ago I was working considerably more hours as a hospital doctor for less than half the money.
The reason GPs earn so much is mainly political. I appreciate that many of you will be fairly uninterested in this and have brought the book to
hear some amusing stories about patients coming in with unusual objects stuck up their bum, etc. If this is you, please skip to the next chapter.
In defence of our high earning:
We are highly trained – on average, it takes about 10–12 years to become a GP from starting medical school.
We have a stressful and difficult job.
We work hard. Most GPs work long days with lots of evening meetings and commitments.
We have a high tendency to be sued and pay £5,000 per year on our defence union fees.
We are generally very popular with our patients, with 9 out of 10 of you stating that you were very happy with the services provided by your local GP practice.
We provide a very efficient service. It has been quoted that it costs the British taxpayer about £20–25 for a visit to a GP. The value of this is very evident when compared to a visit to an A&E department, which costs £75 per attendance and one visit to a walk-in centre costs £37. Amazingly, one visit to an out-patient department costs around £150.
The time spent per consultation with your GP has trebled since the NHS was created.
We earn peanuts compared to premiership footballers!
In criticism of our high earnings:
Our training is long but not as long as the training for hospital doctors, yet we tend to have higher earnings than most hospital consultants.
We do work hard but most GPs no longer have to see patients during weekends and nights, unlike most of our hospital colleagues.
We perform a vital role but so do hospital doctors, nurses, teachers, social workers and most of the public sector. Our pay is disproportionately higher.
Why do we earn so much?
We are only earning lots because we are reaching the targets the government sets us. The current GP contract was made by the Labour government, who foolishly didn’t think we would achieve these targets. GP partners are generally bright, motivated people and when they realised that they could earn considerably more money by jumping through some hoops they quickly learnt to jump and became very good at it.
I’ve talked a bit about targets before. They are called Quality and Outcomes Framework (QOF) points and basically involve us fulfilling certain criteria with certain patients. For example, if I have a patient who has had a stroke, the practice earns points if his blood pressure is regularly checked and is well controlled. There are targets such as this for patients with asthma, diabetes, mental health problems, epilepsy and many more chronic conditions. Within a couple of years most surgeries worked out that they can actually reach these targets and make a lot of money. Technology has helped a lot and we now all have systems installed on our computers that flag up all our patients who need tests to reach our targets.
For example, every time a patient who has had a stroke walks in, the computer will flash up that his blood pressure is too high and will carry on nagging me until I have entered his reading on the computer. If the blood pressure is above a certain target level, it will nag me until I have given him enough blood pressure drugs for the target to have been reached. This is why sometimes you might come to see your doctor to grab some lotion for your child’s head lice and the GP will check your blood pressure, ask if you smoke and get you to fill in a questionnaire about your mood. Your GP might not particularly care about any of these things and neither may you, but if we record this information on the computer, then we earn more points and more money.
It doesn’t take long to do a blood pressure check or ask about smoking, but to reach some of the targets requires quite a lot of work. For example, if you are diabetic, there is a long, time-consuming list of data that needs to be input on the computer. This sort of information can’t be quickly gathered in a normal consultation when you pitch up for something else. GP partners have realised this and much of the tedious data collection is best done by practice nurses. Paid considerably less than us, they do a lot of the work and basically earn the GPs their big salaries.
So if GPs are reaching all these targets and are earning all this money, why on earth did the government agree to the current GP contract? The main reason was that morale among GPs was at a particular low a few years ago. This was mostly because they were working long antisocial hours in difficult conditions without much reward. Lots of GPs were ready to retire early or move abroad and in some areas it was becoming impossible to fill GP posts. If it takes over ten years to train a GP, a shortfall could have led to a real crisis. A dearth of GPs would have meant patients waiting even longer for an appointment. Healthcare can be an election breaker and I think Labour probably felt that unless they did something to encourage GPs to stay in the profession, they could have lost the general election in 2005. The increased salary, together with the removal of an expectation that GPs would work evenings and weekends, prevented the early retirement of many very good GPs. It has also encouraged a large number of excellent young doctors to move into general practice when previously they might have chosen to stay in hospital medicine or move abroad. Many female doctors have been retained within the profession because there are now better options for family-friendly working hours. This has improved the quality of GPs and also meant that the crisis of a GP shortfall was avoided. Begrudgingly, I also have to admit that despite hating the tick-box culture, the targets are also likely to have contributed to generally better health promotion and chronic disease management.
The other aspect that needs to be remembered is that, although our wages are ultimately taken out of NHS coffers, GP surgeries are actually small, privately run businesses, making their own management decisions about pay, services, appointments and the day-to-day running of the practice. They do, of course, have to follow a huge number of regulations that are provided by the PCT and Whitehall, but they are still autonomous in many respects. As with all businesses, if the GP surgery works effectively and efficiently, it will earn more money. The practice will also get money if it branches out and provides new services such as minor surgery. The partners can then decide how that money is spent. They can choose to spend the money on improving the practice, or they can pocket the cash themselves. To be fair, most GPs have done a bit of both. Carrots are being dangled to GPs and for those who have the motivation and energy to set up new services and reach targets, the high wages are there for the taking.
Many of the extra services that can now be provided by GPs are being taken from hospitals. For example, the PCT might decide that they are paying too much money to the hospital to provide vasectomies. The hospital may have been providing vasectomies for years, but running any service from a hospital is expensive. The hospital is not interested in profit, so may well be running a fairly inefficient service. A GP might see the opportunity to undercut the hospital by training himself to do vasectomies and performing them at his surgery instead. He will then be slated in the press for earning loads of money, but by undercutting the hospital he will actually have saved the NHS considerably more than he earns. The GP is being well paid but has taken on a new responsibility and skill. He is also taking the risk that the service he is providing might be undercut by somebody else in the future.
This may all leave a slightly unsavoury taste in your mouth and I certainly didn’t expect to have to get involved in the competitive cut-throat world of business when I chose to become a doctor. A few good GPs have rejected all of these modern changes and instead just do what they have been doing for years. They ignore targets and simply stick to trying to do the best they can for their patients. These are the GPs who don’t earn as much money but have an honest wholesome glow about them. Good for them, but they are slowly being forced out of general practice as the brave new world order takes over.
As a young and sometimes still idealistic GP, I am trying to work out how to play the game. I want to make a good living but not let the greed and madness of medical politics engulf me. I will probably become a salaried GP. These doctors are employed by partnerships and earn a set wage for a set number of hours. They don’t take a sha
re of the windfalls acquired by meeting targets, but they do often do a lot of the work to reach those targets. They earn about £60–70K per year and avoid a lot of the bureaucracy and paperwork that the partners have to put up with.
Angela
One Saturday night I was working for the on-call GP service again. I was sitting in a small cold Portakabin in the main hospital car park and was covering the emergency GP calls for the entire town. I didn’t know any of the people calling up but most of the problems could be dealt with over the phone and if not I could always drive round to do a home visit.
It was actually a fairly stress-free evening and after calls reassuring a couple of first-time mums and a brief visit to see an old lady with a urine infection, I was almost ready to go home. It was nearly 11 p.m. when the phone rang and I decided to take a last call:
Patient: May I ask who I’m speaking to?
Me: Certainly. My name is Dr Daniels. How can I help this evening?
Patient: Hello, Dr Daniels. My name is Angela and I’m going to kill myself right now and it’s all your fault.
Confessions of a GP Page 19