|
|
4. Changing practice: towards the practice team |
Retired doctors are constantly surprised when they see the increasing numbers of personnel that are filling premises to bursting point. And the employees recalled by the oldest doctors in the Paisley project belong to a bygone age. At least one of the town’s practitioners boasted a chauffeur while most engaged housekeeper-receptionists. (1)
The optimism generated by the idea of the health care team is not new. In 1948 nurses expressed enthusiasm for the imminent National Health Service and the opportunities for co-operative working that it promised. (2) Whereas doctors initially were less enamoured by the prospect, today many are knowledgeable and supportive of their staff and attached personnel. Nevertheless, there are distinct areas of tension revealing an ongoing process of redefining professional roles. (3) While some of the changes inherent in the development of the team can be seen as advantageous, others seem to represent a threat to the position that doctors have traditionally held in the delivery of primary care. The testimonies of GPs reveal numerous issues that can be seen both to underpin and to undermine the primary health care team. These issues include issues of power, status and the skill mix within the practice, as well as wider issues of medical responsibility and professional autonomy. All of these contribute to a reappraisal of the doctor’s own role in an effort to maintain the unique value in being a GP.
Perhaps the most challenging realization that doctors have encountered in the development of the team is the utility of the nurse. The nurse’s expanded role goes beyond taking on medical tasks to include exercising what is regarded within nursing as one of the nurse’s more established skills, that is, social assessment, providing a more holistic knowledge of the patient and the community. While nurses seem to be particularly confident in this area, patient care in the community has been seen at different times as an area contested by practitioners and nurses.
Amongst the attached personnel, it is the changing relationship with district nursing and the subsequent growth in the numbers of practice nurses that best encapsulates the fluidity of professional boundaries in general practice. The well-documented decline in the doctor’s home visits (4) marked a watershed in the relationship between nurses and doctors. In the early years of the NHS the number of house-calls requested of doctors increased placing doctors under a great deal of pressure of time. As district nurses became attached to practices in the 1960s, improved communication and partnership between GPs and nurses saw a decrease in doctors’ house-calls as nurses were able to take on some of this work. The oral evidence suggests that prior to this decrease doctors were much more ambivalent about the role of district nurses. After the reduction in home visits doctors were much more likely to view the nurses in a more positive way, although the decline itself encouraged an expansion in the remit of district nursing.
The legacy of this unspoken historical settlement is the prevailing ambivalence in terms of the nurse/GP relationship. Some practitioners appreciate that the district nurse saves the doctor time, while others are not entirely comfortable with the extension of the district nurse’s role. That the notion of autonomy is constantly being negotiated between individual members of the professions also reflects the tension of the nurse/doctor relationship within contemporary general practice. While the doctor needs to utilize the nurse’s skill without the added work of supervision, the boundaries of autonomy are blurred with no clear consensus amongst GPs of what the nursing role does and should involve.
The changing role of all primary health care team members can be seen in the expansion of the nursing role and in the creation of new posts (including specialization of administrative posts). There are new opportunities available for the development of traditional practice jobs, for example, receptionists becoming practice managers. Not only have the number of posts in practice increased, the responsibilities attached to these posts are constantly being redefined.
For some of the Paisley doctors a growing practice team is a source of status – an indication that the practice is making progress. Others are less sure and reservations were expressed, including the difficulties of managing large numbers of employees. Concerns were also aired about whether the quality of patient care was becoming compromised with some of the doctors spending increasing amounts of time on managing the growing bureaucracy of practice. Many of the working GPs were to varying degrees unsatisfied with the way their primary care teams had evolved and hinted at their lack of control over this evolution.
While the strategic intervention of receptionists and nurses have streamlined the service and specialist tasks, hitherto the province of the GP, have been devolved to other staff, the doctor has remained essentially passive. Perhaps these developments have served to reinforce the generalist nature of the GP and indirectly raise the profile of the medical skill of diagnosis, which remains firmly in the GPs domain. The success of the health care team begs the question of the relative value of medical diagnosis, which seems to be the only secure place for the GP in the present situation.
The oral evidence
|
GPP3 recalls his practice establishing an appointment system rather earlier than other practices in the town. In '53 we started [an] appointment system … and the receptionists were completely looked after… One or two occasions you got a nasty person in and were told to leave the list. But our receptionists were first class… They are the first people to see the patient, they’ve got to welcome them to the place, treasure them. If the matter seems urgent they’ll push them through. If they look a bit sad and weary give them a cup of tea... (5) For most practices the Family Doctor Charter marked a change in the duties and status of reception staff. Robert E.: Prior to 1966 we had a kind of housekeeper-receptionist. We had a flat attached to the old surgery and we had a family who lived in it. The wife of the family kept the close clean for us and she answered the phone for us during the day. … When we formed the group practice and moved to the premises in Neilson Road we no longer needed a receptionist-housekeeper of that kind. She got a council house … and we continued to employ her as a receptionist. … She was full-time and we had two part-time ones … then one of the part-timers became full time … that was sufficient for many years … I don’t know how they get on with things nowadays, but they seem to have a staff of about a dozen in the place now. (6) Different doctors took a variety of approaches to appointments and reception staff. David R: I always had three receptionists and we were open six days a week and we always ran open surgeries. Because one of things that pissed me off most about the previous practice was the way in which they just came down on the patients every time… I thought it was a dreadful appointments system and it utterly discriminated against the poor. …You know, they [patients] didn’t have the same options, because they had to think about the bus connections all the time because they were in the peripheral schemes. And secondly, they didn’t tend to have the phone so all the receptionist had to do was keep them on the phone till their money ran out (laughs). (7) Since 1990 practice administration has not only grown, but has also included new groups of staff. Linda F: So it’s five receptionists and practice manager… It’s been a gradual thing over the years. I think the first increase was 1990.… There’s more forms to be filled in, there’s more things that need to be discussed, there’s more bits and pieces to be planning ... (8) David D: When I came here [in 1988] … the practice had absolutely no management structure … we had a bookkeeper but the principal seemed to do everything in terms of actually dealing with the genuine business side of things… We did have a manager, probably quite late in the game in relative terms compared to other practices… and then we went through a number of managers with a series of disasters, because we were totally unrealistic about our expectations of the manager. … These people came in and they would all have significant strengths in one area or another but be completely disastrous in one area or another…. Eventually we got so disillusioned with the idea of having practice managers that we decided to abandon that completely. …We now have a reception manager and a practice administrator... (9) The employment of new staff has added considerably to the pressure on space within practice premises. Gerard D: So when we want to bum we add on two extra rooms. We talk about “the office”, the practice manager’s “office” and … we talk about “the computer room”. I mean there’s no door to it or anything. I mean it’s …a corner in the corridor. (10) Establishing the primary care team has been slow and there have been difficulties, including communication between GPs and nursing services that reflect a wider tension arising from sharing responsibility for patients. Has the role of the district nurse changed in your time in practice? Donald W: You mean did district nurses seem to me in 1964 to be the enemy? Were health visitors the enemy? By that I mean that your district nurse would go out and see somebody in the morning and she’d put in a call in the afternoon, and the same with the health visitor. …So you then found yourself picking up these things, which had been probably known for a while but have now come in as a so-called 'emergency visit'. And that didn’t go down well… Well this was work that they were introducing at a time when you’d already done about fourteen calls that day, and a long surgery, and you knew there was another long surgery coming up, and you were in the process of trying to digest a meal, and they’re on the phone. So, yeah they were looked upon as the enemy (laughs) in that sense. District nurses are very much part of the team [now] and if there are problems you have a chat with them and when there are long-term problems with people they’re more in charge of the situation really than you are. I mean the health visitor and district nurses I see every day and have a chat with and if there are problems we decide how to approach them and how we should go about it. (11) John H recalls in the early 1980s discussing caring for patients with Parkinson’s Disease with his trainer. Now I had swatted up on Parkinson’s disease and seen lots of folk in hospital and I thought I knew everything about it. … And it was very obvious that I didn’t know about dealing with people at home with Parkinson’s disease. “How do you manage this?' And I said, 'You give this drug, that drug and the next drug”. And he said, 'Well no, that’s not what we really mean by managing it. You involve your district nurses, you get the OT out… and you organize care'. … And you learn more about teamwork in general practice and they had regular meetings with the whole practice team; the social worker was involved as well. There was a much better relationship between the social work input there. (12) Practices recruit and retain staff in a variety of ways. Fiona T: The two girls who are currently practice nurses are the only practice nurses we’ve ever had. And they both came from our district nursing staff. We pinch them. Ehem, our health visiting staff, has evolved over the years … but we haven’t had a great deal of turnover of nursing staff. … So I hope that reflects that they, feel as if their a valuable part of the team. (13) Some of the GPs spoke of having to acquire understanding with individual non-GP colleagues. David D: I think partly it’s initiative and partly it’s fulfilling a role that compliments what we’re doing and obviously you’ve got to compliment what they’re doing as well… There’s one of my health visitors that I know when to involve her and she knows when to involve me… it’s a negotiated order, it’s a negotiated position over time. (14) There is a sense amongst some of the younger GPs of continuing tensions in the primary health care team. Graham D: Nurses are very good at working to protocol…but nursing as a whole is under-utilized. I think there’s a danger that if we over utilize them there’ll be less of a job for ourselves being that there is a lot of things that they can do and do very well. (15) This feeling that the nurses are doing too much was reiterated by another GP with reference to the concerns of dermatologists. Brian R: The dermatology system is being redesigned and the dermatologists are very nervous about the nurses looking after leg ulcers and having access, if the nurse isn’t happy, to refer directly to the clinic. They would rather that the nurse asked the GP for an opinion and the GP referred to the clinic. …The GPs job is changing all the time. What we’ve got to do is, or I’ve got to do as a GP is, I’ve got to make sure that I’m doing something which is something I can do. For instance, only I can do. (16) |
Acknowledgements
The study was funded by The Wellcome Trust, History of Medicine programme.
References
(1) The project was funded by the Wellcome Trust’s History of Medicine programme.
(2) See The Nursing Times, Sat. 3 July, 1948, Vol xliv, No.27, p.471 – “Nurses are fortunate in being a most essential part of the service. Some nurses have been appointed to help in the control and management of it. The majority will, in many people’s minds, be the service. More nurses will be visiting the homes of the people as health visitors, domestic nurses and midwives. More people will meet the nurse at the clinics, health centres and hospital out-patient departments, and they will judge the service by the personal care and consideration they receive.” See also ‘Towards a Real Health Service’ in The Nursing Times, Sat. 3 July, 1948, Vol xliv, No.27, p.475 – “The distribution of individual duties is less important than making sure there is true teamwork. For the first time in our history, the health visitor, the district nurse and the midwife will all be employed, directly or indirectly, by the same employer, the county or county borough council, and will be under the control of the same chief officer.”
(3) See Jeffreys, M General practitioners and the other caring professions. In: Loudon I, Horder J, Webster C, editors. General Practice under the National Health Service 1948-1997. London: Clarendon Press, 1998: 128-164.
(4) Cartwright, A, Anderson, R. General Practice Revisited. London: Tavistock. 41-46.
(5) GPP 03. Compare this statement with Damian S’s (GPP 19) presented in the second article in this series, Smith, G, An oral history of everyday general practice 2: Why do GPs become GPs?, Br J Gen Pract, 52: 604-5.
(6) GPP 07.
(7) GPP 06.
(8) GPP 18.
(9) GPP 09.
(10) GPP 27.
(11) GPP 15.
(12) GPP 21.
(13) GPP 28.
(14) GPP 09.
(15) GPP 04.
(16) GPP 05.
Project Description | Participants | Recordings | BJGP Articles | Resources | Home Page|