Where have we gone wrong?

The November BJGP Viewpoint article by Morrison and Gillies about the tragic death of Dr Pat Manson serves as a timely reminder of the pressures that UK general practice is under.1 I was sad when I heard of Pat’s death and 2 weeks later I became even more distressed when another GP working in rural Scotland took their own life. These tragedies mark the tip of an iceberg. The litany of burnout, depression, alcoholism, drug misuse, and relationship breakdown among GPs goes largely unseen and unrecognised. At the same time we have a culture where GPs who are struggling are reluctant to take time out as they know that the burden of their workload will fall on their colleagues (or, in the case of singlehanded GPs, there may be no-one to take up the burden) at a time when many GPs feel they have nothing more to give. Many GPs now feel that ‘traditional’ general practice is being sacrificed on the altar of box-ticking bureaucracy. Primary care has become dramatically more complex and demanding in under a decade. There has been a deliberate, cynical shifting of workload from secondary to primary care without an accompanying shift of resources and without relevant professional support, training, and development: we are just expected to ‘get on with it’. It feels like there has been a concerted attempt by politicians, with the help of the press, to smear and diminish the medical profession in the eyes of the public, which I think has worked to some extent. We now have a more consumerist, demand-driven society that talks about rights but says little about responsibility and, in many areas, treats the NHS as though it were a 24-hour supermarket or take-away outlet. This is coupled with the explicit encouragement (often by health managers no less) for the public to complain about services and an increasingly irresponsible legal profession which has fuelled a culture of litigation against doctors on a ‘no win, no fee’ basis. Many of our politicians remain ignorant. One Member of the Scottish Parliament effectively told me at a meeting earlier this year that all the problems of rural general practice could be solved by rural GPs taking back responsibility for out-of-hours care! It’s all very well for our attention to be focused on pensions. But the current pension dispute is not simply about the significant devaluation of our pensions. It’s about much more: longer working lives; the one-sided abandonment (without negotiation) of a mutually agreed arrangement made in 2008 which we were promised at the time would not be touched for at least half a generation; the fact that income for GPs has fallen by over 20% in the last 5 years while their personal costs for providing top-notch primary care continue to rise; 5 years and more of anti-doctor bias among politicians and in the media; the imposition of a non-evidence-based system of revalidation which has at its heart (in the form of multisource feedback) an ambiguous system of evaluation that has been shown to be a potentially destructive process; and an NHS bill in England and Wales which, at its heart, seeks to shift the blame for the deficiencies in funding, capacity, and service provision onto the shoulders of clinicians. The government is becoming increasingly ‘autocratic’ about the GMS contract, imposing changes which are not evidence based and which will be, for many GPs, simply unattainable.2 My practice was recently offered a new service level agreement for an enhanced service for diabetes by NHS Highland which basically came with the choice of ‘do more work for 30% less income or do more work for nothing at all’. Morrison and Gillies’ article also mentions my former, superb GP trainer in the Scottish Borders, who was also my role model. He decided to take early retirement and stopped being a doctor altogether to devote his time to other things. He recently told me that he had never been bored in the 6 years since retirement. Perhaps therein lies a lesson for us all.