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Second opinion: Dr Patel and Dr Smith

According to a consultation paper circulated by Professor Liam Donaldson, the government's chief medical officer, between three and five GPs in each health authority area have some performance problem. The aim of Supporting Doctors, Protecting Patients is to reassure the public and placate the politicians by rooting out these incompetent GPs. They will be named and shamed, and supported just as a rope supports a hanging man.

To illustrate the issues at stake here, I will contrast two of my local colleagues, Dr Patel and Dr Smith (I have chosen these names to disguise their real identities, while hoping to convey something of their distinctive characters).

Dr Patel is a single-handed practitioner, who works in a rather shabby converted terraced house. Outside there is a profusion of handwritten signs, advising about parking restrictions, surgery hours and out-of-hours arrangements. Dr Patel is in his late middle age and is not a regular attendee at local postgraduate discussions or meetings of the primary care group (which since last April runs local primary care services). He wears a rather crumpled grey suit and drives a shiny Rover.

Dr Smith works in a group practice with five partners in a modern, purpose-built health centre. A large noticeboard proclaims a comprehensive range of services provided by a team of doctors, nurses and other workers (it also indicates that the practice list is closed to new patients, who are advised to phone a helpline to find a GP). Dr Smith often gives lectures at the weekly meeting of local GPs and he is a prominent figure on the primary care group. He wears a woolly jumper, corduroy trousers and drives a rusting Golf.

The object of Supporting Doctors, Protecting Patients, which is broadly supported by Dr Smith, is to turn Dr Patel into Dr Smith - or failing that, to drive Dr Patel out of practice altogether. Yet Dr Patel has maintained a large list of patients over the years, recruiting many even before Dr Smith's list closed - and the two surgeries are only a few hundred yards apart. I once came across a patient who had transferred from Dr Smith's list to that of Dr Patel and I asked her why she had moved. 'The thing about Dr Patel', she said, 'is that he is always there'.

She, and many more, have chosen Dr Patel because he provides a degree of personal continuity and care that is not available in Dr Smith's surgery. Dr Patel has been working in the same practice for nearly 30 years, he takes only occasional short holidays and he rarely goes on courses. It seems that Dr Smith, by contrast, is scarcely ever in the surgery. He has only been in the practice for five years and he has just returned from extended paternity leave. He only works in the surgery part-time anyway as he spends half the week in research, teaching and on committees. He takes at least a month a year for holidays, another few weeks for study leave - and he is planning a 12-month sabbatical next year.

According to health minister Alan Milburn, people want fast and efficient service from their GPs. Not in Dr Patel's surgery! They seem happy enough to wait to see him (he has never got the hang of appointment systems). Perhaps this is because he has known many of his patients for most of their lives and their families for a couple of generations. At Dr Smith's they might get an appointment in two weeks' time, but they would still be kept waiting to see a doctor - probably a locum or registrar (GP in training). They can get a computerised assessment of their risk of dying from a heart attack or a stroke and up-to-the-minute advice on healthy living. But they would rather seek reassurance from Dr Patel and a letter for the hospital if he thought there were anything seriously wrong.

The prejudice that Dr Patel is not as good a doctor as Dr Smith is widely shared, not least by Dr Smith. Yet after meeting many Dr Patels, and an increasing number of Dr Smiths, I am not so sure.

Like all prejudices, it contains an element of truth. I have met a few Dr Patels who have clearly become demoralised and cynical over the years and would not pass the old test of whether you would be happy for them to be looking after a member of your own family. (I have met a greater number of hospital consultants about whom I would say the same, but that is another matter.) Like all prejudices, the one against doctors with names like Patel is grossly unfair to most people who are affected by it. I have met many such doctors who have defied not only the stereotype, but also the discrimination associated with it, to provide the highest quality of medical care.

Dr Smith is, of course, another stereotype. But this is a stereotype that is getting the full backing of the government and the medical establishment. Together they have declared war on Dr Patel. I know one Dr Smith who openly boasts about how he has 'shopped' a number of Dr Patels, whom he considers to be underperforming, to the authorities.

The government's plan is to set up special medical boot camps where 'poorly performing' Dr Patels can go to be retrained in the image of Dr Smith: perhaps even by Dr Smith, if he cuts back his surgery hours even further. In practice, Dr Patel will probably opt for early retirement. The doctor who was always there will be there no more. Neither will Dr Smith; by then he will probably have given up on the inner city to seek suitable schools for his children in suburbia. But their patients can always phone NHS Direct.

Dr Michael Fitzpatrick

Reproduced from LM issue 127, February 2000



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