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25 January 2023

Letter of the week: The decline of general practice

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By New Statesman

Phil Whitaker (Cover Story, 20 January) is right that the priority should be the re-creation of GP services. The importance of primary care was described in a 1989 BMJ article titled “The Gatekeeper and the Wizard”. Briefly, the Gatekeeper (the GP) uses inexpensive methods to refer only the few patients who need the expensive magic at the hospital. Everyone else is looked after well by the GP. This analogy fitted the NHS until the end of the century, but the main point was the Gatekeeper shouldn’t try to be a Wizard, and vice-versa.

Today, there is an over-reliance on hospitals. Sadly, a properly resourced and cost-effective network of GPs and primary care teams will not be reappearing any time soon. Many of the other tribes in the NHS (consultants, hospital managers, nurses) are much better at pleading for resources, and not many doctors want to be a GP any more. When politicians think NHS, they see hospitals, despite 90 per cent of all patient contacts occuring outside of hospitals, and money is flowing to the wrong destinations. Without huge reform and investment the reinvention of traditional British general practice is unlikely. It is perhaps already a memory.
David Rance, former GP partner, Saffron Walden, Essex

[See also: Letter of the week: The Tory Bennites]

Emergency care

As a former chair of an NHS primary care trust, I welcome the thrust of your medical editor’s analysis (“How to save the NHS”, 20 January), but he omits two key problems.

First, there has only ever been one 24/7 open-access channel in the NHS: the A&E departments. This is why people who are not an acute clinical emergency end up self-referring, or being dumped there by ambulances. Dr Whitaker also describes “out of hours” services – harking back to the “working day” hours applicable when general practice was adopted back in the 1940s. Today’s society has different working and lifestyle patterns, and expectations of when and how the patient can access primary care. The 111 service is a cheap, useless substitute.

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The answer is to replace GP practices and “out of hours” services with local patient self-referral centres. Labour took a tentative step in this direction with “walk-in centres”, but Cameron et al soon scrapped those. Crucially, such primary (or initial triage) centres must be multidisciplinary-practitioner based, with immediate access to diagnostic equipment, results and so forth. District general hospitals should be replaced with specialist centres handling, for example, the very different demands of trauma injury or preventative cardio interventions.

Unfortunately, the public understands little of these problems, thanks in part to the inanity of our political debates. And the resource implications (for estate, equipment and staffing) of such changes are significant, to say the least.
John Crawley, Beverley, East Yorkshire

Phil Whitaker’s piece was incisive, but shuffling the barley loaves and fishes is not enough. The system needs more money. He quoted Age UK’s research on cuts to social care in the past ten years. There is much more evidence: I have seen it myself in more than 50 years of working in the sector – tellingly now called the “industry”. It means more taxation. Let’s not pretend otherwise.
Phil Madden, Abergavenny

I don’t know of anyone besides Phil Whitaker who could get such comprehensive sense into a four-page piece. The strategy and messages so succinctly set out should be sent to whoever might have influence and whoever might be cheered by it, as I was. 

Enough of this current mess.
Susan Stopforth, London SW15

Shine a light

It was great to see light shone by Will Dunn on the Tory and Brexit Party donor Christopher Harborne (Newsmaker, 20 January). It’s baffling how the grand schemes hatched by such figures manage to gain such traction when their motives are so visibly self-serving.
Councillor Dave McElroy, Reading, Berkshire

The Staffs connection

Reading Jason Cowley’s column (Editor’s Note, 20 January), I was reminded that, apart from their respective senses of disillusionment after leaving the editor’s chair at the New Statesman, both the late Paul Johnson and Steve Platt grew up in Stoke-on-Trent. Johnson grew up in Burslem, as recalled in his memoir The Vanished Landscape: A 1930s Childhood in the Potteries, and Platt in Longton. Platt, indeed, paraphrased NWA’s album title Straight Outta Compton by describing himself on social media as being “Straight Outta Longton”.
Richard Briand, Leek, Staffordshire

Brian Klaas, academic and author
Certain kinds of jobs are magnets to abusive people who want power. The key is to design recruitment schemes in much more thoughtful ways that attract public servants – with a lot more oversight – to ensure abusive people get screened out.
“The Met Police has proved yet again it is a haven for sex offenders”, Rachel Cunliffe, 16 January

Martin Marshall, chair of the Nuffield Trust
“What we see in the NHS today is exactly what a persuasive body of evidence says will happen to a health service that has been gutted of its expert medical-generalist layer” Solution? Invest in general practice. Well said Phil Whitaker.
How to save the NHS”, Phil Whitaker, 18 January

Annette Dittert, journalist and broadcaster
Short and crisp. And true, sadly. The way Scholz handles the Ukraine crisis might turn out to be a historic mistake that destroys European unity at the very moment when it is most needed.
“Germany has become the roadblock at the heart of Europe”, Jeremy Cliffe, 20 January

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[See also: Letter of the week: Growth to nowhere]

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This article appears in the 25 Jan 2023 issue of the New Statesman, Why Germany doesn’t do it better