Dr Bob Hodges, a veteran of the frontline of primary care, had invited me to his practice in Gloucester to witness the more complex reality behind these headlines. Hodges is a large, genial man with an easy smile, one of nine partners in his Aspen practice near downtown and vice president of the local medical board representing the county’s general practitioners. He wears hospital scrubs because he doubles as a subspecialist in dermatology doing minor surgeries. He comes in early. “It’s either paperwork before patients or vice versa,” she says, “and we have a clinic as late as 8 p.m., so I’m usually too humble to do the admin after the last patient.” Hodges became a GP in 2008. He trained as an internist but remembers thinking, around the time he became a father for the first time, that he would rather deal with the quick than the dead. “Treating the whole person was better than looking at one of its parts under a microscope.” There has to come a point where doctors decide, I can’t do my job anymore Martin Marshall, outgoing president, Royal College of GPs Before we get to his patients, he sits me down in his consulting room and gives me a quick diagnosis of some of the problems facing doctors across the county and country as we head into another long NHS winter. For starters, there are the numbers. Covid didn’t help, but it’s not just Covid. “If you increase the age of the population by five years, the data suggests that you have to roughly double the health care available,” he says. “But what did we do?” (Answer: according to the latest BMA figures there are 1,808 fewer full-time GPs in England today than in September 2015, while each practice has an average of 2,131 more patients). Meanwhile, Hodges notes, demand for primary health care services continues to grow. His practice’s NHS contract calls for about three and a half contacts with each patient each year. there are currently about seven annual contacts. “Well: double.” These waiting list headlines, he says, and the tabloids’ spontaneous campaigns for more face-to-face consultation, are deliberately missing many points. “Right now, if you really need to see a doctor in a day or two, you always will. But if it can wait, it must wait.” The Aspen practice has just over 30,000 patients on its books. Every Monday, like today, 1,000 of them will be in clinical contact with the surgery. at 9 a.m. queues form, phones are backed up and emails are flooded with URGENT subject headings. Prioritization, phone appointments, non-urgent four-week bookings are a necessity, not an option. “When politicians stand up and make another promise that ‘your doctor will be legally required to see you in a week’ or whatever,” says Hodges, “or they promise my non-existent time or this non-existent money practice. They have no right to do that.” Hodges is engaged in telephone consultations at the Gloucester practice. Photo: Gareth Iwan Jones/The Observer Aspen’s partnership merged five smaller practices into a purpose-built complex, in line with trends across the country, to give it the scale to build specialist teams and spread risk. “There’s always,” Hodges says, “always the threat in small partnerships of being the last man standing. if you’re in a two-person partnership and your partner quits, then you have all the financial responsibility of an asset that you’re not allowed to sell.’ This is one of the reasons there are so few players. When Hodges got his first salaried GP job, there were 50 applicants. Today, all the local GPs I speak to insist that you could almost walk into any GP practice in the county and get hired on the spot. Not surprisingly, young doctors often prefer a few days a week as GPs without the pressure of also being responsible – as here – for the management and livelihood of 140 staff. The result is a sort of perfect storm of stress on the traditional partnership model – a recent unpublished BMA survey found that 42% of GPs in England are “likely or very likely to leave the profession in the next five years”, with almost half of those which suggest burnout or stress as the main reason. “It’s the boiling frog analogy,” says Hodges. “The water has not been comfortable for a decade, but now it is much warmer. It will soon reach a tipping point where there is a collapse.” If that all sounds hopeless, then Hodges opens his doors, as he does every weekday morning, to offer the daily hope of consultation. Aspen has moved to 15-minute appointments (from the normal NHS 10) because he accepts “that most people will come with a list and it makes sense to look at everything”. I sit quietly in the corner and, with my consent, observe this still sacred confession between doctor and patient. In retrospect, it’s hard not to see almost every case as a brief report on the state of the nation. First is a little boy who has been reported by his school as having ADHD. He sits quietly on his father’s lap, holding a Batman figure, looking at the doctor. He is four years old. The boy’s parents are clinging to a referral to a ridiculously overwhelmed child mental health system. “Maturity is a fickle thing,” Dr. Hodges reassures them, “and he just spent a lot of his formative years locked away.” Such referrals are a significant part of any GP’s workload at the time, he says, when the family is gone. Large areas of child behavior have been medicalized. Parents are waiting for answers. “Classic mental health issues like psychosis, bipolar disorder, that’s probably 3 or 4% of the people we see,” says the doctor. “Everything else is related to external stress and anxiety.” Anger has gotten much worse, fueled by parts of the Bob Hodges press It follows a man who has recently suffered a debilitating stroke, but a cursory external assessment has found him fit for work, so he will lose his right to the Catholic faith against the advice of his doctor and specialist. He’s not sure where to turn. Another letter is written and while there the doctor also treats him for dermatitis. Then there’s a guy who just got fired and fell off the wagon of a recommended diet for his type 2 diabetes. There are various associated problems – knee and back pain, insomnia, high blood pressure. The doctor gives him a gentle lecture about having spinach and not rice with his curry – he wonders about the steroid injections in his knees and encourages his job prospects. Some couples mix with intentions two to one. the husband is concerned about his memory problems, the wife wants to talk to the doctor about her back spasms. Several have a shopping list of complicated concerns. “How do you feel?” “Where do I begin, Doctor?” And eventually the 15-minute slots give way to a series of telephone consultations, one with a member of a traveling family on the road in Essex. “In the past,” the doctor says of some of his lonelier and more troubled patrons, “they might go to see their vicar. Now they come to us.” Watching Hodges with his patients, many of whom he has known for many years, is to be reminded of the original glue of the NHS – that comforting mythology of a family doctor. The week I was in Gloucester marked the 70th anniversary of the Royal College of General Practitioners, established in 1952 to “raise the quality and status of general practitioners”. The Guardian’s report on its creation noted that “it was generally felt that the hospital orientation of the health service had … obscured the fact that family practice is a subject with its own special art and knowledge”. The Lancet described it as an early Christmas present for the profession: “We regard the establishment of the college as a powerful psychological filler for a group of men and women, too many of whom have lost their hearts.” Country GP John Sassall, who featured in John Berger’s book A Fortunate Man, makes his rounds. Photo: © Jean Mohr, Courtesy of Canongate Books In the college’s three-and-10, outgoing president Martin Marshall offers a sobering assessment of how the profession is holding up. “There has to come a point,” says Marshall, “where the doctors decide, I can’t do my job anymore, and then things get out of hand. I would use the term crisis: so many NHS departments are under such enormous pressure that they are unable to provide the personal care that patients need, unable to provide effective care and increasingly unable to provide safe care.’ I had taken in my bag to Gloucester a couple of books that talked about the distance between the idealized doctor-patient relationship we might still hold in our heads and the often desperate reality of call waiting and emergency ambulances. Both books were created just off the A40 in the Forest of Dean and Wye Valley. John Berger’s A Fortunate Man, written in 1967, is a poetic tribute to a heroic rural doctor, Dr John Sassall, who embodied the selfless compassion of the early NHS. The second, A Fortunate Woman, by journalist Polly Morland, shortlisted for this year’s Baillie Gifford Prize, is a wonderful update of Berger’s book, about Sassall’s modern-day successor struggling with the pandemic. Morland’s portrait makes a strong…
