While going about my normal life, fitting in appointments for dentists and  eye tests amongst shopping and hair appointments, I sometimes think about the changes in provision for these first two since I retired from clinical practice  over ten years ago.   I particularly think about how many patients I used to see for dental problems, despite the ruling from our college and health board that we should never see them.  It was usually for painful things like dental abscesses or gum disease  where patients knew that we could prescribe painkillers or antibiotics. It was a complete misuse of our time.  Dentists were trained to give preventative and  appropriate advice  in every consultation, which would lead to the patients taking better care of their teeth, and it was  a core part of their NHS contract.  At that time most dentists did some NHS work, and always saw children, but patients still appeared in our surgeries.  The problem for us was that the patient would make an appointment, and we wouldn’t know until they arrived that this was a dental problem.  We then had to  tell them that we couldn’t treat them, but these were our patients that we saw for medical conditions, and we didn’t want to  have a long argument about antibiotics in the middle of a busy surgery.  We used to put notices up telling patients to see their dentist, but as NHS dentists became scarce, (after implementation of contracts that didn’t pay them enough), the pressure didn’t go away.  Then, overnight, all that stopped in its tracks when the pandemic hit.  GP’s  closed their doors and had to implement a system whereby patients with covid could be triaged safely. 

So suddenly for the first time in the history of the NHS, GPs could do what they had always wanted to do, that is, implement a triage system, so that patients could be directed to the most appropriate professional – nurse, counsellor, physio, dentist and so on, and this immediately improved the flow through the system.  We had tried to do that in our practice years before I retired, but it had always caused controversy, with receptionists becoming a barrier and getting abuse. 

As everyone knows, once the pandemic was over, most practice continued this system, whereby the patients have to state their reason for needing an appointment, and whether they want a face to face appointment or a telephone consultation, before an appointment is given.  It must have completely revolutionised  doctors’ workload, but it doesn’t seem to have made it easier to see a doctor, mostly because of a severe shortage of doctors and other health care workers after the pandemic.

The shortages have led to some non-essential services being withdrawn from general practice.  Consider ENT and ear wax.  We GP’s used to give our nurses a day’s training, an old metal syringe, and they would remove the wax.  It was a tribute to the nurses that they mostly did an excellent job despite poor equipment.  The GP practice did not get any extra money from the NHS for providing  this service, but patients needed it done.  It is very debilitating and unpleasant to have one’s ears blocked by ear wax. But now quite rightly, it is mandatory to have better equipment, especially to visualise the ear drum, which is often obscured by the wax.  If a patient had ear pain, and the GP could only see ear wax, the GP would probably back both horses as it were, and treat with antibiotics in case it was an ear infection (otitis media), as well as ear drops to soften the wax. There was certainly potential for missing more serious infections and chronic external ear infections, caused by eczema, which would need steroid drops.  But GP practices would have to buy this extra kit, and probably do more of the work themselves, and were unwilling to make this investment when there were staff shortages, so the authorities decided that ear syringing was no longer to be done in general practice.  So now you go to SpecSavers, where they provide an excellent service with first class equipment.  But of course there is a fee; quite a reasonable one I would say. But we know that many patients really cannot afford to pay anything nowadays with the cost of living crisis. Where do they go?  I’m not sure but many will end up in overcrowded ENT emergency clinic seeing a hospital doctor, adding to waiting lists.

Nowadays in the UK most dentists have withdrawn from the NHS.  If you can’t pay the high fees  when you have a dental emergency, there are often local emergency services available, at a modest charge, but the treatment is usually quite basic.  It is definitely a two tier system as most dentists  have improved their surgeries with more and more expensive  kit, and can do more and more cutting edge  treatment and more cosmetic dentistry.  If you are well off you will get a first class service.

A similar situation now happens with eye problems. Most patients, even when I was practising, knew it was no use going to a GP for visual problems such as poor vision, floaters, and so on; the place to go is the optometrist, even though there was always a charge.  But I used to see patients in primary care with acute conjunctivitis, hay fever, and tear duct problems, and did the best I could armed with only an ophthalmoscope.  At that time optometrists could not prescribe antibiotic or steroid eye drops. But with contact lenses  becoming so popular, most optometrists went on courses to enable them to prescribe, whether privately or for NHS medications.  High street pharmacists can also prescribe antibiotics for simple conjunctivitis, if they have been specially trained to do so, but not many are.  In England, Pharmacists are about to be paid for seeing patients, but GPs are complaining that the former are going to be paid twice as much as they are.  GPs get about £164 per year per patient, with a bit more for the elderly. That shows exactly how efficient they are.

Recognising the difficulty, both Wales and Scotland  have set up NHS services in Optometrist practices, if they agree.  Under the Eye Health Examination Wales initiative, “you are entitled to have your eyes examined free of charge by a registered optometrist if you have an eye problem that occurred suddenly [acutely) which you think requires urgent attention”. ¹ This has been in existence for many years and can work quite well.  Optometrists can use their skills and equipment to examine the eyes in more detail, and so can diagnose serious illnesses such as glaucoma, diabetic eye problems and tumours.  But there are problems.  In my part of Scotland some GP practices won’t see eye problems at all and refer patients direct to Optometrists.  Optometrists triage the scheme vigorously and don’t advertise it in case they get overloaded,  and they also aren’t able to provide the full range of primary care eye care which requires liaison between hospital consultants.  Patients can be shunted from GP to Optometrist and back again and patients never know whether they are expected to pay for the services or not. Some Optometrists also want to recoup their expenditure on scans and other  tests and  will perform them, and charge, despite there being no relevant indication for their use at that time. 

Patients with painful eye conditions don’t expect to pay fo this service and Optometrists can put barriers in the way.  I suspect many patients will go to their local eye department in the hospital if there aren’t such schemes operating and they can’t pay. 

We always come back to the difficulty with private services sitting alongside “free at the point of use” services – how to manage demand.  When the workforce is depleted it becomes impossible.  Patients paying to see a consultant privately and hoping they can be pushed up the waiting list has been happening for years. 

There is no doubt in my mind that the NHS has been neglected since 2010, and pay has fallen considerably. Professional people will go where they can earn more money and have better conditions. Last year, my ophthalmic consultant moved to Saudi Arabia, to earn more money before he retired, causing havoc in his department. A Psychiatrist  I know moved to New Zealand for the same reason, citing poor conditions and low pay.Young doctors are leaving the NHS early in their careers citing overwork and poor conditions. 

Marketisation and privatisation in the NHS is happening more and more.  There are so many on-line  advice lines where patients can  get up to date information about what to do about their symptoms.  The old system of a doctor knowing their patients has gone; general practice is hard work and many GPs are leaving, and their practices then have to be taken over by the Health Authority. So attention is turning to establishing centres which will do the full range of treatment, including eyes and dental work, physios and psychologists.   If Labour win the next election plans include ‘GP hubs’ where patients can walk in at evenings and weekends, bringing together doctors, nurses, dentists pharmacists and treatment of minor injuries to take pressures off A&E. ²  Chronic disease management, the core of primary care these days, could be managed there, by nurses and GPs who are already trained to cover these responsibilities.  This sort of neighbourhood primary care might be a good way forward.  It could be cost effective and allow scarce support services to address the needs of several practices at a sustainable level, but It should  be locally led with  several practices co-operating in each neighbourhood;

They could only do this, though, if extra money was provided, in addition to what is already spent on GP services.  This is what happened in Australia which offers walk-in services seven days a week, for situations that are urgent, but not a major emergency.

There would  undoubtedly be battles with patient care organizations and health service unions for this to happen.  While such plans may work quite well in big cities, in rural areas  it is not so easy and patients would have to travel long distances.  Getting staff would be difficult too. It would be imperative to invest more in training staff. 

One of the big problems since the pandemic has been that there has been an increase in the number of people who are too ill to work, and it is likely that failure to treat illnesses or do operations early enough is exacerbating this.  That is a very good reason to invest in the health service to get them back to work.  In a similar vein, most large companies who value their workforce will set up some sort of service locally to save their workers having to spend time going to the doctor.  And going further, I would like to see occupational health services provided for people in smaller workplaces.   But should all care be free? For some people it must be, and in the UK benefits system this is true for people who qualify.  But it is unrealistic these days to say that everything should be free at the point of use.

We also must tackle the built in advantages of private medicine that is entrenched in the UK.  Private medicine in the UK is like a leech on the NHS.  All its practitioners are fully trained doctors, the costs of whose training are born entirely by the NHS, where young doctors learn by doing procedures under supervision.  This takes up time and needs the skills of senior doctors who teach them.  I have never seen this happen in private hospitals, and I would think that patients would not agree to it, as they want the consultant to perform the operations if they are paying a lot of money.  The private sector also picks and chooses what it does — usually the straightforward operations and treatments.  Complicated and expensive treatments are left to the NHS, as are almost all cancer services.  Also, If anything goes wrong in a private hospital in the UK, the patient is immediately transferred to the NHS, so the private sector does not bear any of the secondary costs of treating them.  It is well known that the private sector in the UK is hugely profitable because of this, but still the costs to the patients are higher than in lots of countries where these advantages do not apply.  No wonder the big US  companies are champing at the bit to get control over this licence to print money.  There is evidence that the quality of healthcare declines after private equity involvement.  In a recent  American study in JAMA, 1, an analysis of more than 600,000 Medicare patients found that private equity hospitals did fewer procedures among younger and less disadvantaged patients.  There was also a doubling of surgical site infections in the private equity hospitals compared  with those in the public sector, and there was a fall in the number of surgical site infections in private equity hospitals, a 27% increase in patient falls, and a 38% increase in central-line associated infections, despite fewer central lines being done.  These changes happened following  private equity buy out.  Explanations could include decreased staffing, changes in “operator technique” or poorer clinician experience, according to this study. ³

While I continue to hope that NHS service can survive and improve in the future if a government is elected that will continue to invest in the NHS, I wonder whether it will be possible.  There is a huge amount of pent up demand with long waiting times,  and  the workforce is not increasing. The experiences I and my family have had recently however have shown that the goodwill  and expertise is still there.  My brother had first class care in a Glasgow hospital recently for an admission after a fall just before Christmas, and I myself have had good emergency care recently although it has to be said that I knew to access the services through my  GP rather than go through emergency departments.  I do feel that the staff on both occasions gave care with skill, compassion and first class diagnostic services  despite being very busy indeed, and this gives me hope that things can improve.  We just need politicians who understand the need for a professional service unencumbered by the need to make a profit, with patients at its heart. 

reference. 

1. https://thepracticeofhealth.nhs.wales/clinics-services/referrals/self-referrals/welsh-eye-care-scheme/

2. https://www.pulsetoday.co.uk/news/politics/labour-planning-gp-shake-up-resembling-darzi-centre-model/

3. https://original.newsbreak.com/@healthsia-1608606/3277518604178-private-equity-takeovers-linked-to-declining-quality-of-care-in-hospitals-nationwide-analysis