Bad medicine: Grappling with fragmentation of care

Provision of primary care is splintering further

The classic idea of being a GP is being the first point of contact for a patient. As their GP you know the patient, you know their history, you even know their family, and you address their immediate problem or refer them on to further services as needed. However, as more pressure and demands are being placed on general practice, this idea of being the first point of care for a patient is beginning to dissipate into various consumer-driven services. Before I used to know exactly what was going on with my patients, now they are coming to me saying they went into such-and-such a walk-in service or private insurance company-ran clinic and got this treatment, but it didn’t work and I’m now back to you. I increasingly feel that this fragmentation of medicine can be bad medicine and can actually do patients a disservice. 

This of course is driven by demand – patients or consumers want choice and if their insurance company is heavily advertising their new shiny clinic with all the scans and bells and whistles you could want, why wouldn’t they go? Similarly, if a new walk-in clinic has popped up on the local main street that you can book into any time you like, why wouldn’t a patient see this as a convenient replacement for their own GP who they may be waiting several weeks to see?

Just as in general practice or any medical specialty, the quality of medical care provided by these services can range from very good to very poor. These services are often staffed by doctors on the general division of the medical register without any specialty training in general practice. They are very often trained overseas with little familiarity of local guidelines or prescribing protocols. Patients very often don’t understand or care about this difference, as long as they get the antibiotic they’re looking for they’re happy. Although these services can often address the patient’s exact need, they can very often lead to inappropriate imaging and prescribing, particularly of antibiotics or analgesia with no follow up.

Provision of primary care is splintering even further as pharmacists will soon have the ability to prescribe for certain conditions such as urinary tract infections (UTIs) or conjunctivitis. This sounds initially positive for both patients and the pharmacists who will be receiving a handsome fee. However, I have significant reservations about the wisdom of this; any GP can tell you of the hundreds of times a patient has arrived in declaring they have a UTI when after a detailed history and exam they actually have something completely different going on. It’s very easy to prescribe an antibiotic for the presumed once-off UTI, but the significance of recurrent issues could be missed – maybe this post-menopausal woman actually needs vaginal oestrogen; maybe this older man actually needs urology review for potential bladder cancer. 

It appears that training for this will be through online training modules, which apparently can be seen as a direct replacement for several years of medical training. I wouldn’t dream to say that I have the same expertise around medications that a pharmacist has, indeed they keep us out of trouble more often than not. Unfortunately, there does not seem to be any concern about mission creep in the other direction.

As always, the final line will always be ‘go back to your GP’ to pick up the pieces when all else fails. I do wonder who has ultimate medico-legal responsibility for this. I pay thousands of euro a year for my medical indemnity insurance – who will ultimately be responsible for inappropriate treatment or a delayed diagnosis?

This isn’t about GPs protecting our turf, we have enough work to do and would be only delighted to have more clinicians with whom to share the load. I argue this fragmentation of care actually leads to an increase in our workload, as we are left with following up patients after their initial treatment hasn’t worked, along with the complicated cases for which there aren’t any easy answers or prescriptions.  These services also belittle the skilled work that we do. It is extremely easy to write a prescription, it takes greater knowledge to know when that is not the right course of action. I add my voice to the clamour calling for more specialty trained GPs coming through the system and recognition that what we do is a skilled and unique service.

Patients will always want and should be entitled to choice, convenience, and timely access to healthcare services, but we need to ensure that we provide this in as safe and effective a way as possible. There is always going to be space for other clinicians providing care, but it is essential that there is proper regulation and quality control for the benefits of all clinicians and their patients.