Personal View: What it's really like at the coalface
Authors: Julian Stokes
Journal: BMJ (2003)

What's wrong with the NHS? I know this will sound a little like a school homework exercise, but perhaps if we all sat down and wrote down our wishes then the changes that doctors want might move higher up the political agenda. Here are my thoughts and wishes as I leave the NHS. If you would like to mark them out of 10 and let me know then please do so.

I qualified in 1974 and have worked in the NHS since then. I am a GP principal working in Leominster, Herefordshire—a market town set in lovely countryside. I have been here for the past 20 years. I am in a partnership with five others, all very reasonable people. We are based in premises that were converted for the purpose, and we manage a dispensing branch surgery. Leominster has a local community hospital for which we cover inpatient care. I have just offered my resignation from practice, which will be effective this summer, when I will be 53 years old. Why now?

One of the major difficulties of practising medicine is the unrelenting pressure. Patients present with problems, and many are easy to deal with. However, a substantial number of patients present with problems that are potentially serious, and these patients need a correct diagnosis. As soon as one problem has been solved others replace it. Problems do not stop coming just because there is a practice meeting.


Will the new contract just give us more boxes to tick?


General practice has become more complex over time, and, in order to manage, business meetings have become an integral part of the day. We also have meetings with various parts of the primary care trust—more and more people seem to want to come to introduce themselves to us. We need to meet with all the varied parts of the general practice team. We meet with our staff in order to coordinate staff roles. The trust even pays us so that we can manage a half day of education four times a year. This is marvellous, compared with the old days, isn't it? Well, yes, but it does further squeeze the available day into a smaller pot. Locum cover helps us deal with the immediate problems but does not solve the ongoing problems.

We are encouraged to take on more and more from secondary care. While I am in favour of this in principle, it does require resources.

The recurring local bed crisis puts ever more pressure on GPs not to admit people as acute patients. We are advised that many acute admissions are not necessary, but none of our patients ever seems to be discharged without being admitted. So where is my inappropriate admission? I am no longer able to admit people as acute patients to the community hospital because it is already full with patients dumped by the acute hospital. Because I do not know those patients and they are usually not local, discharging them takes considerably longer than if they were my own patients. Obviously this further slows the process of finding a bed.

In the old days the hospital would open an extra ward to cope with the extra pressure during winter. Now it is so obsessed with meeting targets on waiting lists that acute admissions have a lower priority. But they are my priority. I am left holding the baby, and when something goes wrong it is my problem, not the hospital's.

Casualty is overstretched. A recent communication from casualty suggested that patients waiting in ambulances were not its responsibility. Will I be called to an ambulance outside accident and emergency to see one of my patients who is still waiting to be offloaded?

It's a similar scenario for outpatient waits. The consultant cardiologist writes letters chastising me because my patient's treatment differs from what is stated in my referral letter. As some six months may have passed since my original referral this is hardly surprising.

Increasing waiting times in secondary care create great anxiety among patients, which often remains even if the final diagnosis is not serious. It is not uncommon for a wait for ultrasonography to extend almost indefinitely, even in serious cases. Then there is a further wait for computed tomography. Then a wait for a biopsy, then possibly a further biopsy. Six months have passed, and no treatment plan has been decided on for a patient who clearly has a malignancy. Why do I always have to be chasing the hospital? Yet my consultant colleagues are always helpful and courteous.

We have lost sight of patients and have been made to be obsessed with ticking boxes that can be audited. Will the new contract just give us more boxes to tick?