View from the Ground, by Dr Thomas Claxton
I am a GPST3 working at a practice in a medium-sized Scottish town. Most of my career has taken place against a backdrop of the resource crisis in the NHS, with endless discussion of the ageing population, increasing prevalence of multimorbidity, and dwindling workforce. Therapeutic advances continue to be made, but these are inevitably followed by concern about the increased workload they will generate in primary care. It is already apparent that it is no longer physically possible to follow every clinical guideline and meet every target.1 I derive optimism from the fact that we retain a core workforce committed to providing the best care that circumstances allow; however, goodwill can only stretch so far. For an empathetic clinician, prioritisation can be painful, yet it is clearly a necessity. More discussion is needed on what clinicians and the health system as a whole should be aiming to achieve.
One issue to wrangle, particularly in primary care, is a clinician’s relative responsibilities to the patient in front of them, their practice list, and the wider population. Sadly, a gatekeeper for scarce resources cannot also be a single-minded advocate for an individual patient. Such dilemmas are commonplace in practice: I recall a case in which a patient reported that swallowing difficulties made taking a particular tablet unpleasant. A liquid preparation existed, but it was extremely expensive. It was in the patient’s best interests for me to prescribe it, but was it in the interests of other patients on waiting lists owing to funding shortages?
A wider question is: on what basis should resources be apportioned to different services? Intrinsic to this is an inevitable difference of opinion between patients and service designers and providers. Both have valid perspectives: patients are more aware of their priorities, and healthcare professionals are more aware of the evidence base for how best to achieve them. I have witnessed this distinction first hand in the provision of preventative versus reactive care. Patients (and newspaper headlines) focus on delays in getting GP appointments for acute problems, yet rarely call for increased preventative capacity. In a recent (unpublished) audit I conducted at my practice, more than half of patients who had previously experienced a myocardial infarction and had ongoing suboptimal lipid profiles did not respond to invitations for review. In contrast, healthcare professionals seem to attach more equal importance to preventative and reactive care, viewing better management of pathologies such as dyslipidaemia as a cost-effective way to reduce the long-term burden of disease when appropriately targeted to high-risk patients.2 A balance must be struck between a hard-line, utilitarian drive to improve morbidity and mortality statistics, and responding to public sentiment to maintain a health system that delivers patients’ priorities.
Even quantifying morbidity remains a controversial economic and philosophical issue, despite the development of metrics such as the quality-adjusted life year. How should the value of something in the present be compared with its value in the future? If we agree that these things should be valued differently, then what level of ‘discounting’ should be applied for each passing year? Should quality of life be measured as the sum of all in-the-moment emotions a patient experiences? Or instead, as an evaluation of their life satisfaction as they reflect retrospectively on what they have experienced?
I certainly do not profess to have definitive answers to these dilemmas. However, I believe that further discussion may allow individuals and organisations to better reconcile their limited resources with the ever-increasing opportunities to use them. Finding a stance that I feel morally comfortable with for each of these issues has been a key component in developing the resilience necessary to do my job, and gives me the security of knowing that, whatever difficulties I may be facing, I am at least doing the best that I can.