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The Strange Case of Dr Kronik and Dr Cute

I’m asking for your help today because I’m hearing two apparently opposite views from GPs on what a GP is for.  More precisely, which patients they should be seeing and for what?

The two schools will be represented by Dr Kronik and Dr Cute (*names may have been changed).  With GPs stretched for time and recruitment under pressure, making the best use of them is pivotal for the NHS.

Dr Kronik:  “The real priority is to keep patients out of hospital.  Most of them are in for chronic conditions which could be managed in primary care, but GPs don’t have time to manage them.  We are seeing too many acute patients, simply because they have presented and we have to do something.  Most of these patients need to accept longer waits, go elsewhere or be managed by someone other than a GP, else nothing will change.”

Dr Cute:  “GPs are the best trained diagnosticians.  The nature of generalism means we are usually best placed to deal with everything first, though having assessed the patient we may hand over to another for treatment.  Even something apparently minor & acute like earache is better managed by a GP, for example without antibiotics, or without a visit.  Our best long term value is in preventing LTCs.  Treatment of them is more protocol driven, nurses do this well, and GPs should only need to be consulted by exception when decisions are needed.”

Chaand Nagpaul speaking last week at Commissioning Live said that better use needs to be made of the wider primary care team (mentioning pharmacists as the only clinical profession with an excess of supply).  But there is a tension between spreading the workload and losing control.  It’s clear from NHS 111 and similar exercises that reducing the level of clinical expertise at the point of entry ends up costing more.

I have no axe to grind, except as a patient and taxpayer to ask, “What works, how can it work better and what’s the evidence?”

What are your views and do you have any evidence?

Harry Longman
Founder, Chief Executive
GP Access Ltd

PS as evidence all I can offer is this study on demand, which looks at what GPs actually do without attempting to say what the balance should be.  Acute 57%, routine chronic 33%, exacerbations of chronic, 10%.

14 responses to “The Strange Case of Dr Kronik and Dr Cute”

  1. Sorry, I’ve not brought any evidence with me but why does it have to be one or the other? I believe it is true that long term chronic conditions should be managed in primary care rather than the acute sector. That doesn’t mean that it needs to be a GP doing the management. GPs are in the best position to diagnose but we need to have a system in place to refer people on, post diagnosis, that is wider than just an acute referral.

    I’d like to see a proper commitment to extending the range of professionals in primary care in order to help support individual as individuals rather than a singular diagnosis. Managing long term conditions does take more support than simply clinical support and it would be good to see more of this available in primary care.

  2. Harry Longman says:

    From Steve Allder:
    Clearly all demand stream are important.
    I now think of demand streams and downstream consumption streams.
    A low volume demand stream can be associated with a large volume consumption stream.
    We also need to think about Clayton Christensen’s idea of business models!
    http://www.kingsfund.org.uk/audio-video/dr-steve-allder-delivering-high-quality-care-current-resources

  3. Harry Longman says:

    From Steve Wheeler:
    I think the answer is somewhere in the middle between these two positions.
    We need GPs to coordinate good integrated holistic care for chronically sick patients with known conditions. We also need GPs to sort the cloud of vague symptoms and stories that patients often present with that sometimes presage something serious such as cancer, or a life-threatening acute illness such as meningitis. This is what GPs are best at doing: dealing with problems holistically and also holding onto uncertainty. It’s a fine balance between over- and under-investigation and who else can deal with that? This is an area of considerable complexity. One cannot underestimate the importance of experience as well as knowledge and a willingness and openness to listen to the patient. So let’s keep a balanced view of it. The workload (whether of patients with chronic known conditions or a child with a cold) can be shared, but must be carefully coordinated, not fragmented, else important diagnoses and other issues will be missed.

  4. Harry Longman says:

    From Graham Lewis:
    You missed Dr Elf, not too surprising since all the Public ‘Elf colleagues are now within the Boroughs

    Dr Elf “The whole reason the NHS is in the state it is in is because not enough emphasis has been placed on engaging with and educating the public to manage their own health. General practice has a key role to play with its list based system, unique relationship with patients and in general high levels of trust. With the internet age knowledge is everywhere, trust and wisdom are at a premium”

    Always a pleasure to read your e-mails

  5. Allen Wenner says:

    For centuries primary care doctors were able to do their jobs very well. They saw patients in hospitals, at home, and at the office caring for people from cradle to grave in both acute and chronic conditions. Dr. Kronik and Dr. Acute are really not two different views, they saying the same thing…GPs are too busy to do their jobs. What is the real question?
    Every other industry has evolved using technology to change their workflows and increase productivity. Doctors still work basically the same way they did in 1950. The workflow is: people call up, make an appointment or line up at 9AM at the doctor’s office with whatever complaint they have, wait in the waiting room, have vital signs taken by the nurse, are seen by the doctor face-to-face, and given a prescription or referral. The real question is why haven’t doctors changed how they work to be more efficient?

  6. Davoev says:

    Let’s expand the primary care team but do it effectively.
    Using pharmacists to manage minor illness within the GP practice will lead to a further 111 scenario.

    Much more important to allow pharmacists to manage our repeat prescription systems.

    Our practice has been doing this fpr five months.

    Repeat prescribing in our practice is now better managed,safer and saving each GP approximately one hour per day.

  7. Harry Longman says:

    From Shahid Ali:
    My view on the subject is that GPs should deal with and see those patient who need the skills and experience of a GP and not another team member. GPs are part of a wider team and should not be seen in isolation.

    We need to be more proactive than reactive. More than half of what GPs see at the present time in face to face consultations is not necessary. We have seen that with our telephone triage. That’s why I feel strongly about enabling patients to take control of their health and use technology to manage demand and work more proactively with timely intelligence.

  8. Harry Longman says:

    From Malcolm Ridgway:
    The big problem nowadays is patients presenting with multiple problems and complex multimorbidity. So it is an oversimplification to compare chronic to acute. For me GPs should concentrate on complexity, supporting other professions for simpler problems,

  9. Harry Longman says:

    From Fiona Kameen:
    It’s both . Our skills are as diagnosticians and sorting out wheat from chaff but also managing more complex ltc when nurses come to the end of protocols. Marrying the silos together. – as we have so many patients with so many ltc and conflicting protocols so as GPs we have to decide which trumps which!

  10. Harry Longman says:

    From Adrian McCourt:
    I believe that changing the medium of the consults makes a big difference to this. GPs can still be at the start of the pathway if patients enter their symptoms online. The beauty of this is that they can then triage very quickly when appropriate e.g. symptoms- earache, email back- go to local pharmacist who will be very able to assist. Ditto dandruff, ditto cold/ flu etc etc. This will have a huge impact on the consultation times for many appointments, freeing up GP resource to manage complexity.

    In addition, patients could self-manage far more effectively and prevent their own LTC developing through the use of apps, which GPs could prescribe if there was an easy way for them to do so and they could see the benefit. Use of gaming et al will be huge in gaining personal ownership and improving outcomes.

    Getting patients to provide some of the resource, by entering their own symptoms, and leverage digital technology are the future for better and more accurate healthcare in this country and elsewhere. We all need to stop hiding behind clinical services being exempt and open our practices and patient populations to the opportunities.

  11. Harry Longman says:

    From Simon Gilbert:
    Presumably Dr Kronik forgot to mention his magic ingredient – ‘care plans’! Thanks for vocally challenging the new orthidoxy of what GPs do, or are good for. It’s important to highlight that acute, undiagnosed, work is often more difficult than follow up of someone with a known diagnosis, and that ‘minor’ is a retrospective diagnosis.

  12. Allen Wenner says:

    So are you really saying that doctors should use the internet to practice medicine? Would the patient’s symptoms determine if they could be treated without coming to the surgery?

  13. Harry Longman says:

    From Scott Brunt:
    I think what you have highlighted here is at the root of the choices about where primary care should go from here. Many different pilots and schemes are testing one or other of these theories. In Manchester they are reviewing urgent care (“Urgent Care First Response”) with the idea that acute care can be separated out to a different response.

    My view is that well-resourced GPs do all these things well, but with resource pressure, other professionals can have a role in acute and/or chronic care, as part of a primary care team. You can focus on either and either will probably have benefit in releasing GP capacity. The key is having a team that contains all the right competences and where colleagues are appropriately supervised and supported, with clear policies and procedures for sharing the management of patients. It’s obvious that skillmix is needed, to deal with the workforce crisis. My concern is that taking some of this outside the primary care team (e.g. NHS111) is when it falls down, because you don’t have the same safeguards and efficiencies (medical record, supervision, clear team structure, holistic integrated care of patient). Even federations providing extended hours will suffer from this to an extent, although they tend to have access to the patient record.

    So in response to your question, I think lots of different things can work and it could be different in different places. My view is that the danger is fragmentation, because of the additional risk and inefficiency it brings.

  14. Harry Longman says:

    From Andy Harris:
    Experiential evidence- mine( 32 years) and others:

    GP’s are the best clinicians to manage risk reactively -‘what walks through the door’
    It’s difficult to do and requires skill,knowledge,experience and emotional energy.Continuity of care/ list based GP is a key enabler

    Managing risk proactively/predictively requires a team approach.Key members of that team are highly skilled nurses who are far better at following protocols of care(there are some hard outcome measures around AF management and stroke prevention)
    In any team there needs to be clarity about accountability , roles and responsibilities.My view shared by others but not everyone is that the GP is the Accountable clinical lead in the community

    GPs manage local populations over multiple generations and GP leaders should be reshaping the health system into Population Health management systems

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