Monday, 9 February 2015

What Price, Freedom?

Several things are going on in my head right now and I have the feeling I'm at the stage of realising something profound and yet simple....perhaps!
This seems like a 3 blog conundrum so I'll probably break it down in order to keep it simple.

I left UK in May 2014, having worked there as an NHS Dr for 12 years and as a GP for more than 6.
Since I left, the UK Govt has finally woken up to the workforce crisis enveloping Primary Care.

Recently, a package of measures has been announced to increase recruitment and also retention.
One of the schemes is a Golden hello and a scheme to make it easy for people like me who have left the NHS to return to the fold. I was contacted by a magazine editor for my views on this scheme as I had been quite critical of the situation before I left. The Editor asked me a simple question: "Is this package enough to tempt you back?" (Package includes a 20K Golden Hello)
My response was to actually laugh. After the interview was over, I asked myself this: What is the actual reason for my leaving? Why was I discontent there?

Was it money- I earned enough
Was it the weather- I had lived there happily for many years

If not these oft quoted reasons by everyone who leaves, what else could it be?

This is Part 1 of what I think the answer maybe. I say maybe because this amounts psychoanalysing myself!

In the end I think it boils down to Freedom, autonomy or call it what you will.
I think the GP contracts in UK are completely at odds with the concept of Autonomy.
By Freedom here I don't mean something like being able to choose your own working hours or working part time (though these are hard enough themselves). By freedom I mean clinical freedom. Freedom to practice medicine according to your skills and levels of expertise, to grow and sustain an interest in the field. When I went to India I met a friend of my sister in law. She has lived in UK and Australia and now lives in Mumbai, India. She summed it up beautifully for me. She said life in Mumbai is hard, but life in UK is a drudgery. This is exactly how I felt like working for the NHS as a GP in my last few months if not years.

Let me give you an example: I went on a Minor Surgery and Joint Injection Course organised by the RCGP and it had an exit exam which I passed. This allowed me to get a certificate which I could pass on to the Primary Care Trust (PCT) which then theoretically allowed me to carry out these procedures. I had been carrying out these procedures for more than 6 years already but the PCT demanded the piece of paper. So, what happened after I got the certificate? Well, the very procedures we were taught to do were procedures the PCT had banned under the so called LPP (Low Priority Procedures) Policy- things like lipomas, cysts etc. So, now I had the training and the certificate but no way of doing them. In UK, if you suspect a cancer you are of course explicitly forbidden from doing any biopsies/excisions etc.
So, if you see a lesion where you are not certain, you cannot utilise your skills to carry out an excision. If it is benign, and the patient wants removal, your referral to tertiary care is rejected by the Referral Management Centre as a LPP. 
If the differential diagnosis includes a cancer you have to refer the patient to the Dermatology Department under the so called Two Week Wait (TWW) Referral System.

About 2 weeks after obtaining the Certificate, I went to a skin club meeting called the Skin Forum. This was organised by the Local Hospital and had an interactive format with real patients and quizzes etc. The keynote speech was by the Dermatology Cancer Lead. He said he considered any TWW referral by GPs which subsequently turned out to be non cancer as 'inappropriate'. He then went on to show us graphs and figures of how this number was rising and literally swamping the Department with work. His proposal was to 'educate GPs'. So, in essence- if you vaguely suspect a skin cancer, you cannot biopsy or refer to a normal skin clinic. If you refer to the cancer clinic and it turns out to be non cancer you need to be educated!

I realised at this point in time that this was a farce worthy of Monty Python! 
What kind of society are we living in where highly trained professionals are first made to undergo training only to be told they can't use their training. What kind of health system discourages a physician from ruling out a sinister pathology by carrying out a simple test but then blames him for referring too many people with said suspicious lesion- surely you want a system where only a very few lesions suspected of being cancer turn out to be cancer.

You might say for something as serious as cancer, surely its right to have strict guidelines. I'd say you're right. But, then to call referrals as inappropriate?

You might think this kind of idiocy is limited to cancer only, but its not. It pervades all fields. Contrast this with Australia. You are free to biopsy any suspicious lesion. Not only do you do bunch biopsies to diagnose, once the biopsy shows say a Basal Cell Carcinoma (BCC) you are free to do an excision. If you excise you get paid. And if you achieve clearance you get paid more. Equally, at the first stage itself if you don't have the skill to do a punch biopsy, you are free to refer the patient. Or, if you do do the punch biopsy but then don't feel confident about carrying out an excision, you could refer the patient at that stage. Consequently, almost every GP surgery in Australia has a skin clinic. A colleague in my current practice is now up skilling himself and will soon be able to do complicated skin flaps- in primary care!
This is a system that a)respects the skills of its highly qualified assets and b) pays them for their time and skills.

Here, I think I can work in an environment of clinical freedom. If I have an interest in mental health I can go on courses and upon completing level 1 training obtain higher rebates. Upon obtaining Level 2 training I can start doing counselling on my patients and obtain even higher rebates, or I can choose to refer them. Contrast that with UK- the minor surgery certificate allowed me to do what? If I did carry out more excisions, I'd pay higher Indemnity, probably get sued more often and the PCT and local hospital wouldn't support me if even 1 of my biopsies was reported as a BCC or god forbid an SCC. I'd be up the creek without a paddle! So why would I want to waste my time going on courses? Such a system can only breed mediocrity. And I didn't become a Dr to be mediocre. Time and again in meetings we were told to target the mean- in prescribing, in referral rates,investigation rates etc. Not once were we asked to emulate a practice that spent more  on prescribing for diabetics for example, but achieved better outcomes. The target was always the average. In Medicine you want to target excellence not mediocrity. This is lost on the current NHS management. 

So, that's why I left the NHS and UK- I think! I want to excel. Excel in a few things maybe, but not to be mediocre in everything.

And that concludes Part 1.

What's in Part 2? Even I am not sure. But, I think I see some dark clouds here in Oz too. More on this in my next.

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