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Sunday 25 September 2016
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Essential care vs self-care: are GP practices enabling a culture of dependency?

Focus on ... self-care

DALONI CARLISLE
Freelance medical writer

In the middle of January's "Big Freeze", my nine-year-old daughter had a temperature, cough and an earache. I argued for keeping her off school, dosing her with paracetamol and ibuprofen and keeping an eye on things. My husband, however, insisted she needed to see a GP.

Who won? I held out for four days and then off I trudged to see the GP. He listened to her chest, looked at her ears and pronounced that, yes, I was doing the right thing and to come back if symptoms persisted for more than another week or if her temperature could not be controlled with over-the-counter medicines.

So far, so uninteresting, you may think. But my family is not alone. Research published by the Proprietary Association of Great Britain (PAGB) this summer estimated that, collectively, the public uses 57 million GP appointments a year at a cost of £2bn a year for minor ailments.(1)

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With the NHS set to face a very tight spending regime from 2011, there is a powerful case for releasing these appointments by promoting self-care. The PAGB is campaigning to do just that and has the backing of some heavyweight supporters, including Professor Mike Pringle from Nottingham University, Professor Steve Field, Chairman of the Royal College of GPs (RCGP), Dr Laurence Buckman, Chairman of the British Medical Association's (BMA) GPs' Committee, as well as Health Minister Mike O'Brien and his shadow, Mark Simmonds.(2)

Mixed messages
Practice managers back this too, but worry about how to do it. When the idea was reported on the Management in Practice website in December 2009, readers who commented online unanimously supported more self-care for minor ailments but were universally frustrated at the mixed messages that have confounded their attempts to promote it.(3)

Their argument runs like this: the government has promoted wider access to general practice. Whether through longer opening hours, the right to an appointment within given time limits or new models of primary care such as GP-led walk-in clinics, the thrust has been to make GPs available 24 hours a day, seven days a week, 365 days a year.

As the health minister Mike O'Brien has put it: "Everyone has, and should have, the right to see a GP when they are ill. GPs say they would rather a patient come to them than risk missing something serious. We don't want to change that."

This very message, said comments posted on the MiP site, had undermined public health campaigns that promote self-reliance. The result: a culture of dependency in which people are far too ready to go to the GP and lack the confidence to rely on self-care.

Dr Buckman identified this idea eloquently at the PAGB's national self-care conference in November. He said: "If we overprotect people, we make them scared to proceed without permission. We must give patients the confidence to cope."

John Griffin, who manages walk-in centres and GP practices across East London and North Kent for the GP-led service provider DMC Healthcare, agrees. He has spent the last year working with three primary care trusts (PCTs) to develop more accessible primary care, only to see them swamped by people with minor illnesses.

Despite triage systems and schemes to refer people to pharmacists who can give them self-care advice, Mr Griffin says: "When people come in to see a GP, we have no filters in the sense of being able to tell them to go home."

His experience – and mine – is typical, as suggested by the PAGB's research. Gopa Mitra, PAGB's Director of Policy and Public Affairs, says: "Our research showed that when faced with symptoms of minor ailments, people's first response is to see what they can do for themselves. After an average of four days, they abandon self-care and go to the GP, often to seek reassurance."

But GPs say this is not long enough for minor ailments to resolve. "A cold can last two weeks," says Ms Mitra.

"Navigators of care"
PAGB's research also shows that while GPs say they routinely give self-care advice to patients with minor ailments, patients disagree. Ms Mitra argues that this may be because too many consultations still end with a prescription, crowding out the self-care advice. "Our research shows that doctors say they need permission not to give a prescription," she says.

The Department of Health (DH) argues that it has put in place a number of mechanisms to promote self-care, such as NHS Direct, NHS Choices and minor ailments schemes to make better use of pharmacies.

But Ms Mitra says the research so far shows that people are not using these options. "They are not going to the pharmacist or ringing NHS Direct," she says. "They are going to the GP." Is it any wonder I did not have the confidence to stick to my guns and keep my daughter at home rather than visit the GP?

In fact, Professor Field sees no problem with my visiting the GP for reassurance. He does not agree that there is a paradox between widening access and promoting self-reliance; he would rather see self-care promoted through a partnership between patient and doctor in which the doctor empowers the patient.

"GPs need to become navigators of care," he says. "We need to support patients to look after themselves with us acting as advisers. We need to work much more closely with GPs and nurses to empower patients."

A cautious industry
So should – could – GP practices be turning patients with minor illnesses away? After all, it has already been tried with swine flu.
Mr Griffin is wary: "We are strongly pushing the idea that people should be able to administer self-care for minor ailments, but this is a very cautious industry and there is always the threat of litigation."

Dr Brigid Simpson, Medicolegal Adviser at the Medical Defence Union, agrees. "GPs need to take a history, perform appropriate examinations and give advice," she says. However, she also points out that the General Medical Council's booklet Good Medical Practice requires doctors to support self-care.(4)

The swine-flu experience caused much worry for GPs who feared the consequences of missing serious illness, she says. "It is very difficult for doctors to dissuade patients from attending."

Out on the coalface, practice managers are grappling with this on a daily basis (see Box 2). Mr Griffin highlights a range of ideas from his current and previous post in Tower Hamlets. "We encourage lots of telephone interaction and signposting of patients to the appropriate place," he says. "But we need a much more robust system."

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Ms Mitra, meanwhile, wants to see doctors prescribing less and carrying out fewer unnecessary examinations that, in her view, serve to undermine the patient's confidence. She wants to see specific training modules around self-care, proper guidelines on the length of time to expect a patient to carry out self-care and for practices to develop consistent policies on how they will work with patients presenting with minor ailments.

As she puts it: "The NHS is supposed to be there at the point of need. I think we may have lost the definition of need somewhere along the lines."

References
1. Proprietary Association of Great Britain. Making the case for the self care of minor ailments. London: PAGB; August 2009. Available from: http://www.pagb.co.uk/information/PDFs/Minorailmentsresearch09.pdf
2. Proprietary Association of Great Britain. Movement for Self Care in Practice. Available from: http://www.pagb.co.uk/selfcare/movementforselfcareinpractice.html
3. See http://www.managementinpractice.com/article_19764
4. General Medical Council. Good Medical Practice: supporting self-care. Available from: http://www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care_...
5. Department of Health. Get well soon without antibiotics non-prescription pad. London: DH; 2009. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...

Related MiP stories:

Visits to GP for cold and cough treatment "costs NHS 2bn"

Primary care "dependency culture costs £2bn a year"

Related blog: Can we help put an end to patient dependency?