Surely, nobody would be that stupid. Illustration 1

Let me illustrate the mechanics of providing standard primary care to a patient who is relatively well. This is a real patient, this really happened, and recently. This type of consultation and follow up is the bread and butter of general practice.

The patient is a professional lady in her late twenties. Let’s call her Alice. It takes her 5 minutes to walk to the surgery. She attends on a Monday morning with symptoms that may be a urine infection. She had a urine infection several months ago, and she is getting some lower abdominal discomfort; she wonders if this is another infection. I take a urine sample, dipstick it (that means putting a test strip into the urine; the results can give us a sense if there is an infection); the test is equivocal. I prescribe the recommended first line antibiotic treatment in this situation, and send the specimen off to the hospital for testing (this gives us a definitive answer). I advise the patient to ring later in the week (on Thursday or Friday) to check on the result.

Our specimens all go to the Royal London Hospital, and the results come back to us electronically and appear in our pathology inbox. We check through the results on a daily basis.

On Friday afternoon at about 3pm, I check the results and come across the urine result for Alice. It shows that she does indeed have a urine infection, but that bacterium causing the infection is resistant to the antibiotic I prescribed to her on Monday. So I ring her to let her know. She is still having symptoms, and needs a different antibiotic (the result tells me which one will be effective). Alice will not be back home from work until about 8pm so will not be able to collect a prescription from us Friday evening because we will be closed. So I arrange for her to collect the antibiotics from a local chemist that is open until 11pm. I ring the chemist whom I know well; he takes the details; I generate the prescription and put it in a tray designated for this particular chemist. One of his staff will come the following Monday to collect the prescription.

Now lets replay this real-life scenario with Alice living outside the practice area, as she has moved. Let’s say she is living in Brixton which is a one hour journey by public transport (you might think that patients would not remain registered with us at this distance: not true at all, it happens all the time). Will Alice think it is worthwhile to travel one hour to see us (actually two hours because she then has to get back home). Maybe she won’t come to the surgery, maybe she’ll ring. Let’s say she rings: over the phone I am able to decide that she might well have a urine infection; but I can’t check her urine, nor can I send the urine to the hospital lab. I’ll just have to prescribe without sending a urine. Fine, but how is she going to get the prescription? Well, I can probably send a prescription to a local chemist but that will mean ringing the chemist (getting her to choose a chemist, look up the number online), requesting the item to be dispensed, and then sending the prescription in the post.

Now come Friday I don’t ring Alice because I don’t have a urine result to tell me that the treatment will not be effective. She doesn’t ring me (in real life Alice does not ring on the Friday, I ring her). Her discomfort persists, so she rings us again the following week. We would prefer to get a urine sample from her, but she is not keen because she is really busy and does not have the time to cross London to see us. So all I can do is prescribe another antibiotic and go through the same procedure.

Or rather than ring me in the first place, Alice might go instead to a walk in centre in Brixton or to A+E. They will probably not take a urine sample, but if they do it will go to back to the requestor (it certainly will not appear in our pathology inbox, only items from the Royal London Hospital reach us in this way). Our practice will be charged for the A+E attendance, and this is problematic as we are already overspent on our secondary care budget.

Now I hope it is clear that the first scenario is much more satisfactory for the patient, for the treatment and investigation as a process, and for me as the provider. The second scenario provides poorer care, with more time spent by me, and potentially an additional cost if she attends a walk-in-centre or A+E.

Why would you design such a system? Surely, nobody would be that stupid.

 

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