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Stephen Black: On GP face-to-face appointments, sacred cows and bad arguments

Stephen Black: On GP face-to-face appointments, sacred cows and bad arguments
A sacred cow (well, sort of)

This guest post by Steve Black is drawn from his thread on Twitter about the current fuss over GP access. Steve is one of the brightest and most coherent thinkers on NHS operational management issues, in policy and practical terms.

Here are a few  observations on the Daily Mail campaign to force GPs to do more face-to-face (F2F) appointments. (A campaign that Health But Social Care Secretary Sajid Javid and PM Boris Johnson seem to support.)

These following points are mostly warnings as to why anecdote-driven policy is deeply misleading, and why newspapers and the NHS leadership should look to large-scale statistical evidence: not a handful of stories.

Today's Mail reports former Health Secretary Kenneth Clarke (who should know better) saying F2F GP appointments should go back to pre-pandemic levels, saying "I don't see why they can't"... The story juxtaposes this with the claim that remote GP consultations are just not safe.

Sounds reasonable, doesn't it?

But there is a problem here: this conflates some very important issues that depend on GP capacity.

Maybe in a world where GPs had infinite capacity, they could meet every request with a same-day F2F GP appointment. And maybe the handful of requests where the GP could spot an urgent problem would lead to better outcomes in this world.

But that isn't the pre-pandemic world. The average wait for an F2F GP appointment pre-pandemic was often a week or more.

So there is a major trade-off to be made here: speed versus consultation quality (assuming the quality effect is big).

So many of the anecdotes where a patient failed to get a F2F GP appointment would have played out just as badly in the pre-lapsarian world before covid: the patient would have got their F2F GP appointment, but have suffered severe harm because of the delay.

The anecdotes tell us nothing useful. Only a large statistical analysis of the trade-off of time vs. F2F GP appointment could resolve the question of whether F2F (the pre-Covid19 way, with frequent delays) was better.

The world as it is
As it is, many online and phone triage systems do a much better job of getting fast responses from GPs (not least because triage allows GPs to focus rapid responses on those that need it).

Many systems achieve 80-90% same-day responses, which is vastly better than the typical GP response speed pre-Covid19 - and is also very popular with patients.

Again, this is an issue where large-scale data and evidence would help. Anecdotes are self-selecting; unrepresentative of the behaviour of GPs in general; and may reflect poor service from a small number of GPs.

We don't even know whether the anecdotes would occur with the same frequency because, pre-Covid19, many patients had to wait a long time for their appointment.

The Mail campaign generalises about the behaviour of all GPs, and maligns the entire profession with "why won't doctors re-open their surgeries?" and "when will selfish GPs stop freely putting their own convenience before the needs of their patients?"

Again, a ridiculous generalisation from a few anecdotes, which ignores the actual evidence that most GPs are overloaded despite doing more online or phone work than they used to.

It also presumes to know what patients want (unfortunately the GP leadership apparently agrees with this). Most, they both claim, want F2F GP appointments.

But the Daily Fail hasn't asked patients - and nor have many GPs. Those who offer a variety of rapid responses to queries (phone, message or F2F) and ask what the patient wants don't find everyone wants F2F.

In fact, one system who did ask every time found that, pre-Covid19, only 1 in 3 preferred a F2F and, post-lockdown, that dropped to 1 in 10.

So those who campaign to force more F2F are probably ignoring what patients want.

Today's Daily Fail has managed to find an NHS GP to support their campaign. But she fails to be entirely consistent in her story: "I've picked up as many cancers over the telephone as I would normally", she claims, despite generally supporting the campaign.

This one GP, too, quotes anecdotes (and not evidence) that many patients think GPs are closed.

That's no basis for policy. Many patients think Ivermectin works for treating Covid19 (which it doesn't), but that is no basis for clinical decisions.

Also, bizarrely given that the Mail campaign want to force GPs to do F2F, this one supportive GP they've found concludes "maybe the answer lies in patient choice. Let's allow people to choose between [sic] a face-to-face appointment, and video or telephone consultation".

Yet that is exactly what the best online triage tools do. You know, the ones where a majority don't choose F2F GP appointments. Let's get this clear: offering that choice is a good idea, and should be more common. But it is also completely at variance with the Daily Fail's campaign to ride roughshod over evidence and patient choice and force GPs to do more F2F GP appointments.

Two things are deeply disturbing about this whole campaign:
1) too many in the government are pandering to it, and
2) Nobody is seeking evidence to test whether the problem is a general one, or affects just a few GPs.

Yet everyone is leaping to solutions, with no attempt whatsoever to look at actual evidence. We desperately need better health policy than this clusterfuck of anti-GP rhetoric built on flimsy, unrepresentative anecdotes.