Aneez Esmail’s article on general practice in a recent News from Nowhere prompted discussion about the sustainability of primary care. This month we have another perspective in a review by Kate Gardner of Phil Whitaker’s book:  What is a doctor? A GP’s prescription for the future https://canongate.co.uk/books/4323-what-is-a-doctor-a-gp-039-s-prescription-for-the-future/ 

“This book is written for patients, of which I - all of us-are one.” writes Phil Whitaker. As a retired GP and, recently, very much a patient, I found the book fascinating and challenging. Phil uses stories, including from his own life and family, and case studies from his 30-year career in the NHS, to examine what has happened to the role of doctor during his career, tracing both positive and negative developments over this time, and some of the negative unintended consequences of the positive. The book is a page turner and makes a vital contribution to the discussion about the future of doctors and the NHS. While this book is about more than general practice, this is the lens through which Phil examines the NHS. 

Phil describes entering general practice in the 90s when “aloof paternalism was being supplanted by a new style of practice that sought to forge rapport between each individual patient and their physician” and the gradual take-over, by guidelines, targets, and what he calls “EDM” (Evidence Dictated Medicine, derived from David Sackett’s Evidence Based Medicine).  He discusses the gradual medicalisation of people into patients and the epidemic of both multimorbidity and over-diagnosis. As a GP and Primary Care Trust board member I have been part of this trend, which, although leading to better preventive care in many ways, has now gone too far. Doctors have become disconnected, almost alienated, from their patients, even before Covid came along.  

Phil stresses the centrality of the GP/patient relationship in navigating the complexities of medicine today. I liked his feeling of confidence that we can regain some of what has been lost or mislaid about primary care in recent decades. He says: “Continuity with a good general practitioner is vital if we want to experience holistic care. A system, a protocol, a guideline – they are by definition impersonal. The GP, steeped in the medical world, intimately acquainted with the ways the NHS works and sometimes lets us down, and equally conversant with the myriad interplay between biology and emotions, psychology and life circumstances in the experience of illness- the GP is our expert ally”. 

The book concludes with ideas and suggestion for the future. To fulfil Phil’s vision more resources are needed, of course, but also a reset of values.  Iona Heath (former president of the Royal College of General Practice) writes in praise of What is a doctor?: “If just one member of the government could be persuaded to read this book, there might be hope for a reinvigorated NHS”. Wes Streeting recently spent a day at Phil Whitaker’s surgery. He seemed to get the message.  You can see their encounter on the New Statesman podcast (https://www.youtube.com/watch?v=G2f_BqbtXBg)  Katy Gardner, August 2023 

Long term sickness amongst working age adults

According to the Office of National Statistics the number of working-age adults who are out of the labour market because of long-term sickness has been rising since 2019, from around 2.0 million people in spring 2019, to about 2.5 million in summer 2022.  This rise in long-term sickness started before the coronavirus (COVID-19) pandemic, but since the pandemic hit in early 2020, the number of people out of work because of long-term sickness has risen by 363,000. A range of factors could be influencing this recent increase including the impacts of NHS waiting times, long COVID, and the ageing workforce. Younger people have also seen some of the largest relative increases, and some industries such as wholesale and retail are affected to a greater extent than others. 

Source: https://www.ons.gov.uk/employmentandlabourmarket/peoplenotinwork/economicinactivity/articles/halfamillionmorepeopleareoutofthelabourforcebecauseoflongtermsickness/2022-11-10

Decline in dentistry

NHS England’s 2022/23 annual dental report shows that 18 million adults were seen in the past two years as of June 2023. It marks a decrease of 3.8 million compared to before the pandemic with 22.0 million patients treated in the previous 24 months as of June 2019. It also means that 26.7 million adults in England are going over two years without visiting a dentist to maintain their oral hygiene.

The number of children visiting a dentist in a 12-month period has also declined markedly, falling from 7 million in June 2019 to 6.4 million as of June 2023. It means more than 5 million under 18s have not had a dentist appointment in the past year. The data comes amid falling numbers of NHS dentists – 24,151 dentists performed NHS activity during 2022-23, a decrease of 121 on the previous year.

Source: www.templebaradvisory.com,

Shifting problems

The NHS is a system of shifting bottle-necks. We all know about delayed discharge in hospitals, but what is happening in community hospitals, which are used by the NHS to free up beds? There is no published data on the number of patients in community hospitals but through a freedom of information request The Nuffield Trust has been able to estimate the proportion of patients who are delayed in leaving community hospitals. On an average day in April 2023 one in five (1,703) patients in community hospitals were ‘delayed discharges’. This suggests that there is a worsening backlog across the NHS and social care system. In December 2022 nearly a quarter (24%) of patients in community hospitals were classified as delayed discharge. One in six (15%) patients were delayed in acute hospitals in the same month.

Source: Emma Dodsworth Growing numbers of delayed discharges from community hospitals Health Service Journal 10th August 2023 https://www.nuffieldtrust.org.uk/resource/growing-numbers-of-delayed-discharges-from-community-hospitals?

The H word

News from Nowhere has a confession to make. Its moles have tended to smirk at the term ‘holistic’, seeing it as evidence of soggy reasoning and a cover for poor quality medical practice. No longer!  A paper by three faculty members at University of California School of Medicine shows how sharp an edge ‘holism’ can have.

As is so often the case in the USA, the problem is race. The US Supreme Court has struck down race conscious admissions in higher education, following the example of California where the policy has been banned in public schools for nearly three decades. After Proposition 209 prohibited granting “preferential treatment” based on race, sex, colour, or ethnic or national origin in 1996, enrolment of students from Black and Hispanic/ Latino backgrounds fell dramatically throughout the University of California (UC). Similar bans in eight other States led to a 37% reduction in the proportion of qualified Black, Hispanic/Latino, and Native American medical students. 

However, over the past 15 years, University of California Davis School of Medicine (UC Davis) has tripled enrolment of these students by developing an admissions model that prioritizes state workforce needs and attention to the mission fit, lived experience, and socioeconomic background of each applicant. The UC Davis experience offers lessons for institutions seeking to uphold a commitment to health and education equity.

While the US population has become increasingly diverse and US medical schools have expanded dramatically in recent decades, they have become less racially and ethnically diverse4 and more economically segregated—1 in 4 students come from families with incomes in the top 5%. Applicants from families earning less than $50 000 are half as likely to be accepted to medical school than those earning greater than $200 000.6 In effect, low-income students were shut out by a process favouring those with greater resources.

The UC Davis admissions committee developed a multipronged holistic process emphasizing each applicant’s lived experience, community service, and potential to serve patients from all walks of life.  Asking the question, “How will this applicant add to or strengthen the future physician workforce in California?” broadened the perspective of admissions committee members, prompting them to consider attributes including maturity, work experience, military service, personal illness, disability and other adversity.

Progress was slow and iterative but has yielded greater economic representation among students entering the medical school, with 60% coming from families earning the median US income or less compared with 24% nationally, and racial and ethnic representation more closely reflecting California, a ‘majority- minority’ state. These students’ life experiences are as valuable as their academic credentials in the fight against health disparities. 

Levelling the playing field for low-income students can reduce segregation of medical schools, enhance the impact of scientific teams, grow the primary care workforce, improve access to care for underserved communities, and increase provision of culturally humble care. Do we have lessons to learn from the California experience?

Source: Mark C. Henderson, Tonya L. Fancher & Susan Murin  Holistic Admissions at UC Davis—Journey Toward Equity Journal of the American Medical Association (JAMA) Published online August 14, 2023

Read more News from Nowhere and articles on the NHS in ERA 3 at http://www.healthmatters.org.uk/