A rock and a hard place

Pressure is mounting on GP services, brought about by a combination of increasing patient needs with reduced resources in primary care (the rock), versus statutory regulatory authorities like the GMC and CQC (the hard place) who, for all the right reasons, have to take an idealist rather than a realist approach to regulation. Whilst their foundation is sound, I don’t think many would agree (including the CQC and GMC) that their message always comes across as it should.

In 1910, Jakob von Uexküll described how each creature has its own spectrum of senses through which it perceives its world, which he termed its umwelt. For the humble tick, its two senses, the chemical gradient of butyric acid (in sweat), as well as heat, enable it to jump from host to host, feeding and breeding. Us humans have our five senses, allowing us each to sense our own personal umwelt. If you could then amalgamate all these umwelts together, from humans, ticks, bats, eagles - every living creature - you would have what Jakob von Uexküll described as the umgebung. Even organisations have their umwelt: police, fire, ambulance services and car mechanics will all take a view on a car crash in very different ways, but it’s still the same car crash.

And it’s this umgebung, at least that spectrum much wider than general practice, wider than primary care, healthcare, that I’m worried about. It strikes me, working as a locum GP in up to 30 different practices a year, that it’s often the somewhat overstretched, under resourced, more demanding practices that need locums the most. So it follows that these practices are more likely to be slapped with poor ratings by the CQC or have GPs under investigation by the GMC. Which from one perspective is great; problems have been identified so solutions can be found, changes could be made, and everyone’s happy. But from another perspective, if those resources e.g. more GPs (whether partners, locums or salaried), are simply not available because that resource doesn’t exist, then what?
I’m not sure we fully realise what the longterm consequences of giving a GP practice a poor rating really are. If you were looking for a partnership or salaried post, would you apply for a permanent post there? How long do you think you’d be able to hang on safely locuming there? You may of course enjoy the challenge of supporting them and helping turn that practice around, but your energy and patience are not endless.

But then what happens? The practice may have to close, as some already have. Some nearby practices, if there are any, may be able to absorb some of the patients, but they too all have resource issues. Like dominoes, they too could start to fail. Patients instead end up at A&E, so like throwing petrol on fire, resources are stripped even faster.

All of a sudden, this town - part of the wider umgebung - is no longer such a safe bet to live in; it becomes a health black hole, not a great place to raise a family or retire to; house prices go down, local businesses can’t recruit, the town goes into economic decline. This could happen quite quickly in isolated communities, slower in urban settings. Then regional economic decline. Etcetera. And we know what economic decline does to a nation’s health and welfare. What the car mechanic perceived as a shunted rear end was actually a life-changing quadriplegia; what was a well-intentioned CQC assessment of a practice has lead to a collapse in local healthcare.

So how can locums help practices avoid a poor CQC rating. As locums, we are in a completely unique position. Moving from practice to practice, seeing things anew, with our own regularly updated experiences to benchmark our own perception of quality. Not even a top management consultancy company can access the experiences and insights we come across every day.

What we can do is to give helpful, confidential, supportive, non-judgemental and constructive feedback direct to those practices we work in that enables them to reflect on their practice from the fresh perspective of a respected colleague who shares their unique access to patients.

Perhaps the biggest barrier to this information sharing is the very real threat of not being asked back, as pointed out on the NASGP Facebook Group, but if this feedback can be anonymous, or anonymised by reporting back as a group or chambers. It could have a remarkable effect on the practice, with your feedback allowing them to correct a simple, unnoticed problem, tipping the balance from ‘Requires improvement’ to ‘Good’, even making it a much more enjoyable place to work, as well as being much safer for patients and reducing that potential risk of an ‘Inadequate’ CQC rating.

First published in The Sessional GP magazine February 2016.

Richard Fieldhouse

Freelance GP locum since 1995, living and working in West Sussex. NASGP chairman.

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