If we did shift to a fee-based system, where doctors would earn based on activity, would this drive the wrong incentives? For one, we’d potentially receive better reviews.

8/End

Don’t get me wrong, the most wealthy in the US will get some of the best healthcare on the planet. But the rest will be left battling potential bankruptcy (>60% of US bankruptcies involve medical expenses or illness).

7/n

We just have to look over the pond at the US. They spend 18% of GDP on healthcare compared to our 11%, with lower health outcomes.

6/n

In fact, it can drive the opposite behaviour. The more tests you do, the more income you will generate. The more times that patient will need to see you, the more times you can charge your fee.

5/n

The private patient, one way or another, is directly paying for what they receive. Either paying for each item on the list or through their insurance premiums. There is not the same financial pressure on the private doctor that is on the NHS one.

4/n

In the NHS, if something holds no or very limited clinical value, me (as a doctor) “spending” on that causes ripple effects across the whole NHS and its ability to spend on other things. In private healthcare, that is not the case.

3/n

He found those who went along with what the patient wanted in spite of what was clinically appropriate got the higher ratings. What does this drive?

In every other walk of life, money buys you choice. You pay, you get what you want.

2/n

“The best doctors, clinically, are NOT the ones with the highest reviews,” said my friend who started in the world of private healthcare.

1/n

This type of patient will never be recorded in the measure they are going to use.

It will never hit an appointment slot to be recorded. Regardless what the contract says.

We will continue to send these to a 24hr service on safety grounds.

NHS England » Recording same day appointments for all clinically urgent patients NHS England » Recording same day appointments for all clinically urgent patients

It changes nothing except giving us more work to do collecting useless data, making sure we are hitting a target that has no benefit for patients.

england.nhs.uk/long-read/re...

6/End

We use acute slots the next day, for example when a request for help comes in late and we feel it needs to be assessed in the next 24 hours but not so urgent they have to go somewhere else. This will stop. Unless we fudge it and change the slot before booking them into it.

5/n

If there are no acute slots left and their case is urgent, they will be advised of alternatives outside of the practice. These are not recorded in any meaningful way that NHSE can pick up.

4/n

Why the mismatch:

The decision that a case is urgent happens well before a slot is booked. For example, a triage doctor will be reviewing the requests coming in.

3/n

The Measure:

Using a definition pre-applied to an appointment slot. “General consultation acute”.

Seeing if the booking of that slot and the patient being seen, happen on the same day.

2/n

NHSE put out how they are going to measure if urgent cases are being seen on the day. TLDR: Objective-Measure Mismatch.

The Objective:

>90% of urgent cases presenting to general practice are seen on the same day. Urgent being defined by the clinical team at the practice.

1/n

I pay the price to protect my health. But my patients are trapped with no option to. 😔

5/End

Consulting is my favourite part of the job but it’s the most challenging. As the week went on I could feel the light fading. I would not be the same GP come Friday. Now I’m part time, those I see, get the best GP I can be.

4/n

They are unable to stop even though their mind and body are getting burnt out. Me on the other hand. I have the privilege of being able to work less and still earn a decent living. Would I earn more if I worked more? Yes. But is the money worth risking my health?

3/n

I am grateful that I can work part time. I’ve not had one patient who could do the same. Even though their job is causing them health issues. They are not able to reduce their hours. Why? Their bank account hits zero every month. What comes in goes straight back out.

2/n

“Your back pain is due to your job” I say. “I know this is not easy but I would consider reducing how much you work”. A little smirk that I know too well comes across his face. The one that says: “What world are you living in.”

1/n

She told me he was surprised to see her and said, “I thought Dr Patel would come”. I felt hollow.

There is no tick box for continuity of care.

8/end

He appeared on my triage list one day. I was swamped, as we always are. I had to send the GP reg out to see him; she solved the issue he called about. I do wonder what was not uncovered in what was unsaid. The bits you can pick up with experience.

7/n

But who will hold on to the elements that cannot be put into boxes? Who will be the person who will be able to take him through the upsides and downsides of interventions?

6/n

Now it’s his turn. But there is no one to wheel him into my room like he once did. He is stuck at home. He will get visits that will care for his needs.

5/n

I never realised my impact until the day I called him into see me after her funeral. He told me how he had put my name into the service. That I gave her great relief from her visits to me. How would you capture this in numbers for those in power to see?

4/n

My job was to listen to her. Hold her concerns. Finding ways to unburden her from them while not exposing her to the system that would gladly swallow her up.

3/n

He once stood tall, well dressed, always with his hat straight out of the 60s. I would see him often, not for him but for his wife. He would push her wheelchair into my room. She would sit hunched over, each time a little more bent as she lost hope in life.

2/n

His name appears on the triage list again. A feeling of failing this man on some level comes over me. The contracts push me in a direction that goes against the family GP I want to be. There is no tick box for continuity of care.

1/n

So if you’re in hospital or at your GP practice and someone asks you again what’s going on:

It isn’t laziness.
It isn’t duplication for the sake of it.

It’s how the art of medicine truly works.

6/end

The notes are structured. Concise. Necessary.

But they’re filtered through someone else’s questions and interpretations.

Hearing it directly from you changes how patterns emerge.

Without that, my thinking is narrowed by the notes, rather than you.

5/n