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Today's GPs are being shamed into keeping patients out of hospital

Kay seemed seriously unwell. These days, however, GPs are expected to discuss potential admissions first.

Kay was not a frequent attender, and she’d only come that day because her two grown-up daughters had forced her to. “It’s just a cough,” she told me as she sat down. She gave her children a withering look. “I’m sure there’s nothing you can do.”

That’s true for the vast majority of respiratory illnesses: most are viral infections that antibiotics won’t cure. But every now and then, lurking among the legions of self-limiting coughs and wheezes, there’s a pitfall for the unwary – someone who turns out to have pneumonia, say; or a patient with something else seriously wrong.

Kay had a modest fever, her heart rate was slightly raised, and there was infection throughout her airways. But I see patients like this most days in winter. There was something else – a sallowness to her complexion, a subtle indrawing of her features – that made me think she might be more unwell than she appeared.

She looked decidedly nonplussed when I said that her daughters had been right to bring her. I prescribed antibiotics, took blood tests for urgent analysis, and instructed her to return the following day. I pulled the results off the system the next morning. Elevated counts of infection-fighting cells as anticipated, but also an unexplained anaemia – and, most worrying of all, a sudden deterioration in her kidney function.

Once upon a time, I would have sent her to hospital without a second thought. These days, however, GPs are expected to discuss potential admissions first. We’ve been supplied with mobile-phone numbers for consultants in every department. The idea is, if we have instant access to specialist advice, we might be able to keep some people out of hospital. I rang the on-call consultant physician. That day it was a guy called Mark.

“Can I tell you about this lady?” I said. As I talked him through Kay’s case, I grew increasingly embarrassed: there was really only one course of action. When I finished, Mark simply said, “She’s got to come in, hasn’t she?”

He sounded puzzled that I’d even rung, and I felt foolish for having done so. I explained how, day after day, we GPs get distress emails from the hospitals saying they’re on continuing “black alert” – which is every bit as grim as it sounds – and pleading with us to do anything we can to stem the patient flow. And how we’re supplied with constant feedback on how our admission rates compare with those of our peers, the agenda being to shame those who might be considered profligate into “better” behaviour. Mark hadn’t appreciated the barrage of inhibition we’re under in primary care, and expressed regret on behalf of the hospital that it was so. For my part, it caused me to reflect on how my clinical decision-making is being distorted by the constant stream of bad news.

Kay was reluctant to be admitted because she, too, had seen countless news reports likening our hospitals to humanitarian disaster zones. But her daughters looked relieved; family members often sense when there’s serious trouble.

In hospital, Kay was treated aggressively for her chest infection, but a swift succession of tests to investigate the other abnormalities showed her to be riddled with unsuspected disseminated cancer. Her bronchopneumonia was, very sadly, the result of her system finally being overwhelmed. There was nothing that could be done; she never made it back home.

She became yet another statistic that would be fed back for me to evaluate my practice: a patient who had died within a few days of admission, the inference being that I shouldn’t have involved the hospital in futile end-of-life heroics. The bean-counters who’ve decided on this particular black mark against a GP’s name have no understanding of what it’s like in the real world, where patients sometimes turn up very sick with undiagnosed illness, as Kay did, and need urgent hospital care to find out if they have any chance at all.

This article first appeared in the 16 March 2017 issue of the New Statesman, Brexit and the break-up of Britain

Photo: Getty
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Scotland's vast deficit remains an obstacle to independence

Though the country's financial position has improved, independence would still risk severe austerity. 

For the SNP, the annual Scottish public spending figures bring good and bad news. The good news, such as it is, is that Scotland's deficit fell by £1.3bn in 2016/17. The bad news is that it remains £13.3bn or 8.3 per cent of GDP – three times the UK figure of 2.4 per cent (£46.2bn) and vastly higher than the white paper's worst case scenario of £5.5bn. 

These figures, it's important to note, include Scotland's geographic share of North Sea oil and gas revenue. The "oil bonus" that the SNP once boasted of has withered since the collapse in commodity prices. Though revenue rose from £56m the previous year to £208m, this remains a fraction of the £8bn recorded in 2011/12. Total public sector revenue was £312 per person below the UK average, while expenditure was £1,437 higher. Though the SNP is playing down the figures as "a snapshot", the white paper unambiguously stated: "GERS [Government Expenditure and Revenue Scotland] is the authoritative publication on Scotland’s public finances". 

As before, Nicola Sturgeon has warned of the threat posed by Brexit to the Scottish economy. But the country's black hole means the risks of independence remain immense. As a new state, Scotland would be forced to pay a premium on its debt, resulting in an even greater fiscal gap. Were it to use the pound without permission, with no independent central bank and no lender of last resort, borrowing costs would rise still further. To offset a Greek-style crisis, Scotland would be forced to impose dramatic austerity. 

Sturgeon is undoubtedly right to warn of the risks of Brexit (particularly of the "hard" variety). But for a large number of Scots, this is merely cause to avoid the added turmoil of independence. Though eventual EU membership would benefit Scotland, its UK trade is worth four times as much as that with Europe. 

Of course, for a true nationalist, economics is irrelevant. Independence is a good in itself and sovereignty always trumps prosperity (a point on which Scottish nationalists align with English Brexiteers). But if Scotland is to ever depart the UK, the SNP will need to win over pragmatists, too. In that quest, Scotland's deficit remains a vast obstacle. 

George Eaton is political editor of the New Statesman.