Tuesday, 1 October 2013

Shuffling the Deck Chairs

From the BBC

David Cameron says he wants to offer more patients the chance to visit a GP in the evening or at weekends.

Under a scheme to be piloted in nine areas of England, surgeries will be able to bid for funding to open from 8am to 8pm seven days a week. The prime minister said the £50m project would mean doctors "fit in with work and family life"...

He told the BBC: "Many hard working people find it difficult to take time off to get that GP appointment, so having these pilot schemes... is, I think, a very positive step forward.

"It also links to the problems we have seen in our accident and emergency departments because the number of people going to A&E departments is up by four million since the changes to the GP contract that Labour put in in 2004.

"What we need to do is enable the right people with the right ailments, as it were, to either go to a GP or to accident and emergency."

So, here's the multi-million dollar question: what's the problem with people going to A&E outside of hours instead of a GP?

OK, I know the answer to that is that A&E gets crowded and waiting times go up. But then, you can deal with that by simply putting more resources into A&E. After all, this plan is going to mean more GP resources, and fundamentally, you're dealing with the same skillset.

It's not like if you have 12 hours of A&E that you're going to get to see your GP. They can't work 12 hours - it's going to mean some sort of split-shift, so there's a reasonable chance you're going to see another GP, so any personal connection value of a GP isn't being added.

The other downside of 12 hour GP surgeries is that you're going to end up with a lot of GP time spent sitting around doing nothing, because even now, many GP surgeries are quiet at certain times of day. And you can't go moving GPs from a busy surgery to a non-busy surgery just for odd lulls. That means losing GP resources.

Look at it this way: if lots of small offices worked so well, why did we ditch town centre insurance brokers for vast call centres that you could fit an Star Destroyer in? Answer: because it's more efficient. Because you can make it that no-one is sat around waiting for customers. Because you can improve the use of specialists. You get some scale, like 1000 people working in a call centre and it's worthwhile employing a team of a dozen geeks just to work out how to improve the efficiency.

So, you build models to work out how many people to put on there at certain times, you computerise all the crap (like sending letters) to free up people, you stick a load of stuff on the net so people can do it themselves. All of this reduces the cost of the call centre, and as a result, the cost to customers. But you can only do all of that with scale, and having 2 GPs isn't going to do it.

That's not to say that there isn't a place for GPs - sometimes people need that personal connection. A woman suffering from post-natal depression probably needs that connection. But she's not going to want to see an anonymous GP any more than seeing someone at A&E. And I'm pretty sure that she'd find time in the day for something like that.


JimS said...

I can walk to my multi-GP surgery, A&E is the other side of town with no parking.
Out of hours might be better served by the doctor coming to you. That fits in with your call-centre, big practice model. A mobile GP could be directed on a call-by-call basis to minimize travel time/distance - we can do it for Taxis, why not for doctors?

Mark Wadsworth said...

Yes, but as JimS says, there is a trade-off.

In terms of efficiency, we'd do best with a single super-massive hospital in the Midlands with all manner of specialists adn steady and stable flow of patients, but that's rubbish for access.

In terms of access, you could have one GP or senior nurse for every hundred houses in the UK or so - great for access but totally inefficient (sitting around most of the time, rushed off their feet some of the time, no particular specalisation).

Lola said...

Did I ever tell you that I met a bloke from the BMA who was the chief negotiator for the GPs contract re-negotiations under the Blair gummint?
Well, once he had had a chance to read through what Blair and Co were offering he told GPs don't even argue. Just bite their arm off...

Graeme said...

and I think The Stigler is confusing the role of a doctor with a counsellor/personal advisor. Of course, there is no clear distinction but someone with post-natal depression or who needs a chat with someone warm and sympathetic does not necessarily need to visit someone with a medical degree. Those expensively acquired skills should really be used on people who are physically sick or injured

The Stigler said...


Note what the problem is that the government is trying to solve: people who are working who can't get to see their GP.

How many people work closer to their GP surgery than a hospital? OK, I'm sure that some do, but for those people, they can probably already pop into a GP surgery in the daytime.

The problem is really for people like commuters, who get out of work at 5:30 and don't get home until 6ish. You get told that the doctor can see you at 11am or 3pm, that's your morning or afternoon taken up.

So, the solution now is that GPs stay open longer. So, what's going to happen to those 6pm to 8pm appointments that are designed to help the people who work away? Well, people who work locally won't nip out in the day, they'll now go after work, and take up those appointments, so GPs will find that a lot of that capacity will by taken, and it will free up a load of capacity in the day, and it still won't solve the problem. And GPs will be under-utilised.

The benefit of the extra hospital capacity is that it allows working people to go to see someone near where they work. It means that someone working in Reading and living in London can go to the hospital unit at lunchtime and get seen about a problem.

The Stigler said...


But for something like PND, one of the first things that someone needs is drugs, generally SSRIs, and referral to cognitive behavioural therapy. You don't want them having to jump around people, you want them to have a single point.

I'm personally a bit sceptical of the whole idea behind GPs. If you have a problem with your tooth, you go and see a dentist. If you have a problem with your eyes, you see an optician. Why don't we just go and see an ENT if our ear is hurting, or a procotologist if our arse is hurting?

Kj said...

Enter marginal cost-pricing. If the NHS wants to keep FAPOU, have free appointments during regular hours. If the doctor want to keep open longer, let them charge whatever extra they want. If people need to go to the A&E, it´s obviously serious, and there´s no reason why you can´t have A&E charge of some 100 € like they have in Ireland.

The Stigler said...


That's the other way and it would certainly work - the poor can go off-peak (elderly and unemployed have plenty of spare time).

But it would be utterly mauled by the left and the Tories would be too chicken shit to implement it as s "two-tier health service".

Mark Wadsworth said...

TS: "I'm personally a bit sceptical of the whole idea behind GPs. If you have a problem with your tooth, you go and see a dentist. If you have a problem with your eyes, you see an optician. Why don't we just go and see an ENT if our ear is hurting, or a procotologist if our arse is hurting?"

Yes. In Germany (and probably most other European countries) they don't have GPs. The have skin doctors, nose doctors, eye doctors etc and you turn up at the most appropriate one.

Kj said...

TS: That´s the thing I don´t understand, far more left wing countries than the UK has pricing in the public system. And there´s already two-tier, and always will be, unless you ban private provision entirely, which would be insane.

Kj said...

MW: GPs are gatekeepers, and if the same in the UK as here, very expensive caseworkers.

Mark Wadsworth said...

Kj, yes very expensive gatekeepers, as L explains above, the fuckers managed to double their salaries about ten years ago in exchange for doing less work (or maybe the Labour government was colossally stupid or corrupt, who knows?).

Graeme said...

agrees with Mark...in France, I had an ear infection so I went to the local ear specialist - who knew far more about ear infecions than my local Uk GP. Ditto in the Netherlands. The Dutch doctor even asked me which medication was more likely to help.

Medical care is specialised. Talky-feely care, which is also very important can be handled in many more ways...often cheaper...such as visiting the local charity shops. My local high street now contains about 30 charity shops, all staffed by very friendly old dears who could no doubt help someone in need of cuddly treatment more effectively than an expensively trained GP

Graeme said...

Putting it another way...if I am unlucky enough to contract another ear infection, to which I am prone, I will probably travel to another European country and piggyback on their health service than try to get it treated here in the UK.

Graeme said...

and...if it comes down to the facts....if I go to my GP for some reason, he/she will take my blood pressure and ask me questions about my lifestyle. These questions just add cost. I could answer 300 units per week or 10 units per week, but the blood tests still get ordered. For what purpose? A 19 year old medic will make me change my lifestyle. Really?

Kj said...

Graeme: Your GP is 19? Doctor Doogie eh?