I have just completed fifty sessions of general practice in an inner city practice in Leicester. This demonstrates that I intend to continue to work as a GP here, so I can remain on the “Performers’ List”. My work will be appraised annually and I will hopefully be successfully revalidated (every five years) by the responsible officer in Leicestershire. This means I can keep my licence to practise medicine in UK. Of course, as well as seeing patients, I still have to do at least 50 hours of continuing professional development, audits, reflection, feedback and planning my personal development, just like all full-time GPs in UK.
If I stopped working as a GP in UK, I would have to find another way of being appraised and revalidated. Although I would still be registered with General Medical Council as a doctor, I could not practise in UK. I would be prevented from working as a doctor overseas, too. What country would permit a foreign doctor (me) to work there if that doctor was not allowed to work in their own country?
The GMC insists I do not need a licence here if I want to work abroad.
Medecins Sans Frontieres insists I do need a licence to work here before I can be posted overseas.
I honestly don’t think that the GMC fully appreciates the problems created by the new regulations for a few doctors who volunteer or work for aid agencies overseas. But as Saul found out (Acts 26:14), “it is hard to kick against the pricks”, so I did the required fifty sessions. And I quite enjoyed it.
Working in GP here in UK is just like a curate’s egg. http://upload.wikimedia.org/wikipedia/commons/3/3d/True_humility.png (Bishop: “I’m afraid you’ve got a bad egg, Mr Jones”. Curate: “Oh, no, my Lord, I assure you that parts of it are excellent!” George du Maurier, originally published in Punch, 9 November 1895.) Some bits are good, others are bad.
This post will now become a “listicle” – defined by the Oxford Dictionary (and just included in the Dictionary last week) as “an Internet article presented in the form of a numbered or bullet-pointed list” – comparing and contrasting health care in Leicester and Mfuwe.
- Even working in England, not all my patients speak English. At every surgery session, I need to have an interpreter helping me to communicate with at least one patient. In Zambia, 99% of the patients at the health centre were Zambian but most of those who completed primary school could speak a little English. My patients in Leicester are much more cosmopolitan, mostly originating from the Indian subcontinent, but some from Eastern Europe and Africa (even one from Zambia). I suspect that more than a few patients here nodded their heads politely as if they understood what I was talking about, just like in Zambia.
- The work of a General Practitioner is incredibly complicated. Not only do GPs have to deal with clinical, psychological and social aspects of the patient’s problems, they have to feed the computer with data which is accurate (and complete enough to protect you from being sued) and they need to liaise with a fragmented army of specialist nurses to co-ordinate the patient’s care. The more information you have, the more difficult it can be to formulate what the problem is and how best to manage it. All this has to be done in ten minutes.
- This is impossible unless you know the patients well and there is good continuity of care. Unfortunately, few young doctors want to become partners in a general practice. There are many more doctors working temporarily in surgeries, acting as locums. This corrodes the strength of traditional general practice, where the doctors knew their patients well.
- In Zambia, consultations usually consist of simple problems, such as deciding if someone needs a malaria test or not, and acting on the result, lancing an abscess or suturing a laceration. Apart from having a different doctor every three months, the continuity at Kakumbi Health Centre in Mfuwe is provided by the nursing staff posted to the centre, usually for several years.
- Computer systems contain so much information that it can be difficult to find what is important among the dross. For some reason, the most popular clinical programme used by Leicester GPs, SystmOne, insists on recording entries by district nurses or health visitors, twice. In different colours. The computer screen is awash with checklists mostly recording the absence of some factor. Usually GP notes are brief and to the point, avoiding long lists of “negatives”. In contrast, medical records in Zambia are very simple, consisting of handwritten entries in a school exercise book. If a patient doesn’t want a record made of their sexually transmitted infection, they destroy the old book and get a brand new one which doesn’t contain the sensitive information.
- A great deal of time is spent in both settings collating clinical data and submitting reports. It may be heresy, but I wonder about the true value of this activity, which takes clinicians away from patients and does not seem to result in improved services.
- It can be difficult for patients to access care at their general practice in UK because of the limited number of appointments with doctors, nurses and health care assistants. If you want to see your doctor and telephone the practice after 10 am, you might be told to ring back tomorrow because today’s appointments have all been allocated. In Zambia, the patients might find it difficult to get to the health centre because of lack of public transport, but once they arrive, they will sit and wait until they see the doctor or nurse. It was not unusual for a nurse and doctor at Mfuwe to see over 150 patients in a day.
- Financial considerations are important in both countries. UK primary and secondary care are trying to cut £20 billion from the annual cost of the NHS Budget by next year. The entire Gross Domestic Product in Zambia was just £13.4 billion last year, but the Ministry of Health is still trying to save money, hopefully by spending it more efficiently, rather than just cutting the supply of drugs.
- Medication prescribed by GPs is costly. The clinical commissioning group in Leicester tries to cut costs by pressurising GPs to change their prescribing habits. Generic drugs are usually cheaper than branded versions (for example paracetamol vs Panadol), but not always – Ventolin inhalers are cheaper than generic salbutamol inhalers, for asthma. Standard tablets cost less than modified release capsules, but need to be taken several times a day. Just when the health authority has decided, for example, that the cheapest version of simvastatin is Simvador, and encouraged GPs to save the NHS some money by switching their prescribing, the prices change yet again. I seem to have spent a lot of time trying to chose the best drug for my patients, taking into account all these factors as well as what the patient wants, and still I get a message on the computer screen suggesting another option. If I ignore this message, the practice might have to justify it to a prescribing advisor. In Mfuwe, we often lacked the most basic drugs for common illnesses such as hypertension and diabetes. Sometimes, the only “choice” was to suggest the patient might travel 120km to Chipata to buy drugs at a pharmacy.
- I used to enjoy doing minor surgery for my patients in Leicester as well as in Mfuwe. It didn’t pay well, but the patients in Leicester appreciated it. However, it still costs the practice time and money to do minor operations, whereas referring the patient to hospital costs the practice nothing. Different budget, you see?
- Finally, I must say I have found the patients to be courteous and grateful in both Leicester and Mfuwe.
Medecins sans Frontieres still has me on their books and I have been offered a posting to a remote part of India, close to the Myanmar border. Last month, a posting to Swaziland fell through at the last minute. I am not counting my chickens before they are hatched. I will write again once I have more concrete information.