BMJ2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2151(Published 19 April 2016) Cite this as: BMJ 2016;353:i2151
In Ireland there’s a saying: “You don’t increase the weight of a pig by weighing it.” But that’s how it feels in UK general practice right now. We’re almost alone in Europe, with our government’s entrenched belief that the more boxes we tick or the more appraisals and inspections we carry out, the better general practice will become. Yet the atmosphere of distrust and endless bureaucracy surrounding general practice in the United Kingdom is bad for doctors and, ultimately, for patients too.
The gap between the English system and that in other European states became obvious at a recent meeting of the European union of General Practitioners, where, as a BMA representative, I described the Care Quality Commission’s (CQC) inspection process. Questions and comments afterwards highlighted this disparity. And, when representatives of 25 states replied to a questionnaire about appraisals and inspections, their answers showed that the UK is alone in the intensity of its inspection and monitoring processes.
Others are commenting on the negative effects of endless bureaucracy, too. Robert M Wachter, professor in the department of medicine at the University of California, San Francisco, recently wrote about how the micromanagement of medical professionals impinges on clinical care in the United States—and how insurance companies are beginning to roll back their scrutiny.1
A Scandinavian author recently opined about the “price of mistrust”: the demoralisation of the workforce, in relation to inspections in primary care.2 And delegates at the European Union of General Practitioners meeting that I attended were surprised at the amount of regulation and inspection that UK general practices go through. The “qualities” that the CQC takes into account include:
- Patient centred care,
- Whether people are treated with dignity and respect,
- Consent procedures,
- Whether care and treatment are safe,
- End of life care,
- Record keeping,
- Adult and child safeguarding,
- Premises and equipment,
- Receiving and acting on complaints,
- Good governance,
- Equality and human rights,
- Drug management,
- Waste and water systems,
- Staff support,
- Training and appraisal,
- Risk assessment,
- Infection control,
- Data protection,
- Continuous medical education for doctors,
- Mental health policies, and
- Quality monitoring.
Making sure that all points are covered, all boxes are ticked, and all policies are in place is an exhausting chore for practice managers and their staff. It takes time away from clinical care. The CQC has found only 4% of practices to be inadequate, and most of those improved within a year, says its chief inspector of general practice, Steve Field. Perhaps those practices have just worked out which boxes to tick.
Other European health systems don’t constantly patrol their GPs, looking for minor infringements of arcane rules and trying to make sure that every possible policy is set in stone. This creates a culture of fear where doctors are so preoccupied with watching their backs that they no longer watch their patients: they treat the biochemistry rather than the symptoms, and the disease rather than the patient.
Professionals who lose confidence in themselves don’t perform so well. They may practise defensive medicine, overinvestigating symptoms and being unwilling to accept reasonable risk. They live not only with the fear of litigation but also with the anxiety that they may fail an assessment.
Other countries’ health systems survive without this burden of excessive bureaucracy, and, although all European countries have the changing demographics of an ageing population—with a subsequent increase in chronic and complex disease—few of them have GPs who feel so desperate about the future of their profession. GPs in the UK have been judged to be the most stressed in Europe.3
General practice in the UK would benefit from some imposed breathing space from the CQC. The danger is that it may be too late to reverse the trend of intolerable stress, early retirement, part time work, and the attraction of general practice abroad. I hope that this isn’t the case.
3 Commonwealth Fund. 2015 Commonwealth Fund international survey of primary care physicians in 10 nations. 2015 Dec 7. www.commonwealthfund.org/interactives-and-data/surveys/2015/2015-international-survey.