Confessions of a GP (25 page)

The reason GPs earn so much is mainly political. I appreciate that many of you will be fairly uninterested in this and have brought the book to hear some amusing stories about patients coming in with unusual objects stuck up their bum, etc. If this is you, please skip to the next chapter.

In defence of our high earning:

We are highly trained – on average, it takes about 10–12 years to become a GP from starting medical school.

We have a stressful and difficult job.

We work hard. Most GPs work long days with lots of evening meetings and commitments.

We have a high tendency to be sued and pay £5,000 per year on our defence union fees.

We are generally very popular with our patients, with 9 out of 10 of you stating that you were very happy with the services provided by your local GP practice.

We provide a very efficient service. It has been quoted that it costs the British taxpayer about £20–25 for a visit to a GP. The value of this is very evident when compared to a visit to an A&E department, which costs £75 per attendance and one visit to a walk-in centre costs £37. Amazingly, one visit to an out-patient department costs around £150.

The time spent per consultation with your GP has trebled since the NHS was created.

We earn peanuts compared to premiership footballers!

In criticism of our high earnings:

Our training is long but not as long as the training for hospital doctors, yet we tend to have higher earnings than most hospital consultants.

We do work hard but most GPs no longer have to see patients during weekends and nights, unlike most of our hospital colleagues.

We perform a vital role but so do hospital doctors, nurses, teachers, social workers and most of the public sector. Our pay is disproportionately higher.

Why do we earn so much?

We are only earning lots because we are reaching the targets the government sets us. The current GP contract was made by the Labour government, who foolishly didn’t think we would achieve these targets. GP partners are generally bright, motivated people and when they realised that they could earn considerably more money by jumping through some hoops they quickly learnt to jump and became very good at it.

I’ve talked a bit about targets before. They are called Quality and Outcomes Framework (QOF) points and basically involve us fulfilling certain criteria with certain patients. For example, if I have a patient who has had a stroke, the practice earns points if his blood pressure is regularly checked and is well controlled. There are targets such as this for patients with asthma, diabetes, mental health problems, epilepsy and many more chronic conditions. Within a couple of years most surgeries worked out that they can actually reach these targets and make a lot of money. Technology has helped a lot and we now all have systems installed on our computers that flag up all our patients who need tests to reach our targets.

For example, every time a patient who has had a stroke walks in, the computer will flash up that his blood pressure is too high and will carry on nagging me until I have entered his reading on the computer. If the blood pressure is above a certain target level, it will nag me until I have given him enough blood pressure drugs for the target to have been reached. This is why sometimes you might come to see your doctor to grab some lotion for your child’s head lice and the GP will check your blood pressure, ask if you smoke and get you to fill in a questionnaire about your mood. Your GP might not particularly care about any of these things and neither may you, but if we record this information on the computer, then we earn more points and more money.

It doesn’t take long to do a blood pressure check or ask about smoking, but to reach some of the targets requires quite a lot of work. For example, if you are diabetic, there is a long, time-consuming list of data that needs to be input on the computer. This sort of information can’t be quickly gathered in a normal consultation when you pitch up for something else. GP partners have realised this and much of the tedious data collection is best done by practice nurses. Paid considerably less than us, they do a lot of the work and basically earn the GPs their big salaries.

So if GPs are reaching all these targets and are earning all this money, why on earth did the government agree to the current GP contract? The main reason was that morale among GPs was at a particular low a few years ago. This was mostly because they were working long antisocial hours in difficult conditions without much reward. Lots of GPs were ready to retire early or move abroad and in some areas it was becoming impossible to fill GP posts. If it takes over ten years to train a GP, a shortfall could have led to a real crisis. A dearth of GPs would have meant patients waiting even longer for an appointment. Healthcare can be an election breaker and I think Labour probably felt that unless they did something to encourage GPs to stay in the profession, they could have lost the general election in 2005. The increased salary, together with the removal of an expectation that GPs would work evenings and weekends, prevented the early retirement of many very good GPs. It has also encouraged a large number of excellent young doctors to move into general practice when previously they might have chosen to stay in hospital medicine or move abroad. Many female doctors have been retained within the profession because there are now better options for family-friendly working hours. This has improved the quality of GPs and also meant that the crisis of a GP shortfall was avoided. Begrudgingly, I also have to admit that despite hating the tick-box culture, the targets are also likely to have contributed to generally better health promotion and chronic disease management.

The other aspect that needs to be remembered is that, although our wages are ultimately taken out of NHS coffers, GP surgeries are actually small, privately run businesses, making their own management decisions about pay, services, appointments and the day-to-day running of the practice. They do, of course, have to follow a huge number of regulations that are provided by the PCT and Whitehall, but they are still autonomous in many respects. As with all businesses, if the GP surgery works effectively and efficiently, it will earn more money. The practice will also get money if it branches out and provides new services such as minor surgery. The partners can then decide how that money is spent. They can choose to spend the money on improving the practice, or they can pocket the cash themselves. To be fair, most GPs have done a bit of both. Carrots are being dangled to GPs and for those who have the motivation and energy to set up new services and reach targets, the high wages are there for the taking.

Many of the extra services that can now be provided by GPs are being taken from hospitals. For example, the PCT might decide that they are paying too much money to the hospital to provide vasectomies. The hospital may have been providing vasectomies for years, but running any service from a hospital is expensive. The hospital is not interested in profit, so may well be running a fairly inefficient service. A GP might see the opportunity to undercut the hospital by training himself to do vasectomies and performing them at his surgery instead. He will then be slated in the press for earning loads of money, but by undercutting the hospital he will actually have saved the NHS considerably more than he earns. The GP is being well paid but has taken on a new responsibility and skill. He is also taking the risk that the service he is providing might be undercut by somebody else in the future.

This may all leave a slightly unsavoury taste in your mouth and I certainly didn’t expect to have to get involved in the competitive cut-throat world of business when I chose to become a doctor. A few good GPs have rejected all of these modern changes and instead just do what they have been doing for years. They ignore targets and simply stick to trying to do the best they can for their patients. These are the GPs who don’t earn as much money but have an honest wholesome glow about them. Good for them, but they are slowly being forced out of general practice as the brave new world order takes over.

As a young and sometimes still idealistic GP, I am trying to work out how to play the game. I want to make a good living but not let the greed and madness of medical politics engulf me. I will probably become a salaried GP. These doctors are employed by partnerships and earn a set wage for a set number of hours. They don’t take a share of the windfalls acquired by meeting targets, but they do often do a lot of the work to reach those targets. They earn about £60–70K per year and avoid a lot of the bureaucracy and paperwork that the partners have to put up with.

Angela

One Saturday night I was working for the on-call GP service again. I was sitting in a small cold Portakabin in the main hospital car park and was covering the emergency GP calls for the entire town. I didn’t know any of the people calling up but most of the problems could be dealt with over the phone and if not I could always drive round to do a home visit.

It was actually a fairly stress-free evening and after calls reassuring a couple of first-time mums and a brief visit to see an old lady with a urine infection, I was almost ready to go home. It was nearly 11 p.m. when the phone rang and I decided to take a last call:

Patient:
May I ask who I’m speaking to?

Me:
Certainly. My name is Dr Daniels. How can I help this evening?

Patient:
Hello, Dr Daniels. My name is Angela and I’m going to kill myself right now and it’s all your fault.

At this point the phone went dead. I tried to phone her back but the line was permanently engaged. The computer flagged up her telephone number and address but nothing else.

I had never met Angela before but apparently I was about to become responsible for her death. Even at my most narcissistic, I knew that I was unlikely to be important enough to single-handedly inspire the suicide of a complete stranger. I also very much doubted that Angela had any intention to actually die. The problem was what did I do now? I knew absolutely nothing about her. My gut instinct was that she was probably just a time-waster and the best thing to do would be to completely ignore her.

The problem was that the phone calls to the on-call doctors were recorded so if she was to be discovered dead tomorrow, I couldn’t claim ignorance. The coroner’s court case would be very embarrassing as I tried to explain why I did absolutely nothing after being told explicitly about a suicide attempt. ‘I thought she was just a bit of a time-waster, your honour’ probably wouldn’t be a very successful line of defence.

Very reluctantly, I drove to the house. As I pulled up to her address there was already a pissed-off-looking ambulance crew at the scene. They had also received a phone call threatening suicide from Angela. Nobody was answering the door and after much pointless shouting through the letter box, we grudgingly decided we really needed to break in. One of the paramedics apologetically told me that they weren’t allowed to break the door down for health and safety reasons. I would have happily kicked the door down but was held back my general weediness. We made a contrite call to the police, who, after an hour or so, came round and with irritating ease bashed down the front door with one kick.

We all charged into the house and ran into each room in turn loudly shouting Angela’s name. I dashed into the bathroom and then stopped dead. There was a woman lying in the bath. Her face was under the water with open eyes staring up at the ceiling. I could feel my heart pounding and was frozen to the spot. I assumed she was dead but then spotted a couple of bubbles coming out of her mouth. Her eyes had also moved from staring at the ceiling and were now looking straight at me. I grabbed her under the arms and pulled her up out of the water.

She was barely out of breath and looked me calmly in the face: ‘Are you Dr Daniels? You owe me a new door.’ Angela had clearly been patiently waiting for us to break the door down before sticking her head under the water.

She had evidently carefully planned the whole episode and was wearing a black swimming costume to protect her dignity for our anticipated dramatic entrance. She looked distinctly pleased with herself as she sat up in her bath with two paramedics, two policemen and me, all crammed into her tiny bathroom expectantly waiting for her next move.

I called the on-call psychiatrist.

‘Oh, Angela. We all know her a bit too well. Has she pulled one of her stunts again?’

The psychiatrist was greatly amused by my account of the evening’s entertainment. Apparently, she had made well over a hundred ‘suicide’ attempts and to date had never actually come close to causing herself any real harm. The professional viewpoint would be that Angela was a vulnerable person who struggled with effective communication and expressed her frustrations by making elaborate cries for help. One of the coppers on the scene was slightly less sympathetic and suggested that she was, in fact, a time-wasting piss artist who, after over a hundred failed suicide attempts, should have got a bit better at it by now. The psychiatrist had a chat with Angela on the phone and agreed to see her in clinic the following afternoon. I went home to bed.

I don’t like some of my patients

Marcus Smythe is one of my patients and I just don’t like him. He is privately educated and well-spoken but also has a drinking problem and beats up his wife. He is regularly rude and aggressive to the reception staff and bullies them into giving him immediate appointments that aren’t necessary. He is also rude and demanding with me and if he doesn’t get what he wants, he threatens to complain to his MP and write letters to the local paper. As each minute passes in his presence, my empathy, patience and tolerance rapidly dwindle away. During my medical school training, I learnt all about many rare diseases that I am unlikely to ever encounter, but I was never really given any preparation for how to deal with the Marcus Smythes of this world.