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17 March 2017

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.

By Phil Whitaker

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.

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“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.

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This article appears in the 15 Mar 2017 issue of the New Statesman, Brexit and the break-up of Britain