u/Prokopton1

This has already been posted in the doctors subreddit but I felt it would be useful to specifically hear from GPs on this new tragic case:

https://www.judiciary.uk/prevention-of-future-death-reports/ethan-hanson-prevention-of-future-deaths-report/

The learning point I can identify from this is that you should just print a brief consultation summary to go with the patient. I always do this when sending acute presentations to AE with the belief, and I'm not even sure the belief is justified, that AE will take the patient more seriously if they read my consultation notes re query acute presentation.

However, as far as I'm aware this is standard practice, most of my colleagues print a consultation summary that patients take to AE.

The idea that GPs need to be calling secondary care for all cases of ?acute issue is just ridiculous though and totally unrealistic.

Sometimes it takes 30+ minutes to get through to some surgical specialties. If a patient is unwell, it is neither a good use of GPs' time nor the patients to make them wait in a waiting room without any medical monitoring so that the relevant specialty can know ahead of time that a ?query acute issue is coming through to them. Often surgeons will literally redirect these referrals to AE anyway because AE is a better environment for monitoring and IV fluids/abx compared to an understaffed surgical ward.

So I am personally of the opinion that the GP did nothing wrong here. A printed consultation letter may have improved outcomes but if the parent presented to AE without going through the GP, who would be liable then?

Frankly, if an 'AE clinician' needs to be spoon fed a diagnosis by a GP after a 10 minute consultation without the resources of AE, perhaps they shouldn't be managing undifferentiated presentations in AE?

I've been doing some pleasure reading on economic history, and it's always fun to come across the Soviet Union because that's where all utopianism leads to despite the usual suspects that defend it screaming the usual 'my real central planning system has never been tried before.'

It seems that when you abolish the price signal for a bureaucratic central planning committee you tend to end up with similar structural problems whether you're a country or a healthcare system.

The citizens of the USSR queued for bread and clothing.

In the NHS people queue for hips and GP appointments. Rationing moves from price to years long waiting lists and postcode lotteries.

To meet quotas set by the central government, Soviet companies would mass produce 'easy to produce' garbage that there was no demand for whilst essential necessities like toilet paper famously became scarce.

Likewise in NHS clown world we can create easy to produce garbage in the form of PAs and ACPs to help meet government quotas around waiting lists whilst doctors and nurses can't find jobs (despite apparent understaffing on wards).

And you can go on and on.

The fundamental reason why soviet like systems don't work is that the information needed to allocate scarce resources well is dispersed and local, and no central body can effectively respond to such information.

Every NHS reorganisation is another attempt from a central government to 'solve' a coordination problem that central governments structurally cannot see.

And like failing soviet factories that never went bust but would always get more inputs, the answer to the failures of the NHS is always more money to be pumped into it.

Failure is rewarded with resources because there is no competition to punish it.

https://x.com/MedRegoncall1/status/2012481339916722450

So physio ACPs are bragging on social media about how ACPs are actually both safer and better than a ‘transient workforce’ or middle grade doctors.

Amazing so this implies that we need to fix the issue of our transient workforce.

End rotational training so doctors too can become as good as these lordly ACPs.

I’m sure the government and old fart ladder pulling boomer consultants won’t have any issue with this.

And hey, if no doctor wants to work in shitholes that the NHS currently forces us to work in my mechanism of rotational training, perhaps they can be staffed by these superior ACPs anyway.

Everybody wins!

So I like to read about social dynamics. Not political slop which I find boring and stupid but musings and takes from creative and intelligent people.

One of the most interesting authors I've read over the years is Peter Turchin who has tried to understand historical social dynamics from an evolutionary dynamical point of view (Turchin's background is in mathematical biology so unlike your typical political type whose main skill is sophistry he has something interesting to say).

Anyone who has done any reading on historical political movements may be familiar with the idea that organised minorities tend to beat disorganised masses. This is how insane events like Nazi Germany or the Soviet Union become possible in the first place.

Turchin offers an analytical framework for understanding the dynamics behind some of this. One of his core extended arguments is that:

1. Societies have a limited number of high status and high power positions i.e. elite positions
2. If a social system for whatever reason produces too many people expecting elite positions then you get intensifying competition for these positions
3. This creates a uniquely destabilising form of social conflict called intra elite conflict
4. The reason why this is uniquely destabilising is that elites are usually highly educated and driven and, unlike proles, can much more effectively network and organise in groups to try and affect social change

In his books Ages of Discord and Secular Cycles he offers various quantitative case studies of how the above can explain some periods of social instability in e.g. the US.

I think that a Turchin type of analysis can be applied to the medical profession in the UK as it currently stands.

Medicine offers an elite bargain: exceptionally long training and sacrifice for status, income and security.

For structural reasons the upside part of that bargain has weakened, particularly for UK medical graduates. Doctors face high workload, falling real pay, expensive exams, rotational instability, bottlenecked training, and declining autonomy.

Now it is true that consultant medical doctors still enjoy a very elite position in the UK.

But the government has done everything it can in its power to increase aspirants for these elite positions. This includes medical school expansion, massive IMG recruitment and PA/ACP role substitution. Meanwhile, the number of consultant positions has not significantly increased.

We can thus reframe the core problem that afflicts UK medicine in this way: the UK is very much on a path to producing too many highly educated, well credentialed doctors chasing a very scarce number of well-paying and secure positions.

The UK government is betting that this will work in its favour because it gets to massively increase the supply of medical labour to meet rising demand whilst minimising costs.

But from an elite overproduction theory point of view this is a recipe for conflict.

And we've already seen a lot of this already: UK graduates versus IMGs, doctors versus PAs, trainees versus consultants, salaried GPs versus partners, service provision versus training.

The BMA’s militancy, doctor emigration, anti IMG and anti-PA/ACP mobilisation can all be read partly as 'aspirant-elite backlash' to use a Turchin phrase in this framework.

Now I will end by adding the caveat that this is all descriptive, I'm just describing trends and trying to apply an analytical framework to understand it.

I'm going to end this wall of text by offering a few predictions based on my understanding of all of this:

The profession of medicine will become less civilised and collegial, and more factional.

Resident doctors will remain politically militant.

Doctors will increasingly behave more like self-interested economic actors and less like self-sacrificing citizens who supposedly chose a lifelong caring vocation.

Despite the BMA raising the ACP issue, I’m not optimistic about anything being done about it in the NHS.

Currently it seems that every nurse and paramedic and their grandmothers want to skip medical school and become GPs via primary care ‘advanced practice.’

And why wouldn’t they? It’s a gravy train where they get to take all the simple cases leaving the salaried GPs to deal with all the complex and risky cases in 10 minute slots (without a compensating increase in consultation time for these cases).

In other words ACPs not only take jobs away from GPs but make working conditions for GPs worse too by increasing said complexity-risk load on GPs.

Even though we were told they were supposed to help relieve the increasing pressure on GPs by helping with work load (lol).

If GP were to go the way of dentistry then the market will naturally introduce compensatory mechanisms to correct this absurd situation we’re in.

Sure patients might prefer to pay £40 instead of £80 to see an ACP instead of a doctor for their foot corn but most will go to a GP for any real medical issue. Similar to how people will pay to see a dental hygienist for routine cleaning but will go to the dentist for any actual dental problem.

Like in dentistry, there will be a time price linkage mechanism where complex patients would have to be seen in longer consultations and be charged higher prices for that consultation.

Second, there will be demand filtering because most rational patients won’t pay to go see anyone about their toe corn to begin with which will reduce the overall volume of consultations demanded from GP.

This would generally lead to better working conditions for salaried GPs. Private GPs in London already enjoy much better working conditions compared to NHS salaried GPs.

Now I anticipate I’ll get moralistic outrage mongering from the usual suspects about how this will lead to poor people being unable to afford to see a doctor or how big, bad private equity corporations will eat up general practice, but the dentists made it work and from what I can see they enjoy better working conditions than the government serfdom called NHS model GP.

And sorry but I’m CCTing and fleeing to Australia if working conditions do not improve.