DR BRIAN KEIGHLEY

As I approach a milestone birthday later this year, I have been reflecting on the career changes I have experienced as a rural general practitioner. The context of that reflection is a mixture of clinical, social and organisational features.

When I started as the trainee doctor to my single-handed predecessor, who had only just moved out of a surgery attached to his home, we had no secretary, we had one triple-duty nurse/health visitor/midwife and used a rudimentary records system in an age when computers filled whole rooms, not small desk-top boxes.

We were on-call 24/7 and our wives were unpaid receptionists.

Over 30 years my practice has changed out of all recognition clinically. We are now the generalists, having to live with undifferentiated illness and uncertainty, constantly co-ordinating the care of those patients whom the "clever" hospital doctors cannot diagnose or treat within the confines of their increasing specialisms. It is now GPs who organise the care of chronic illness such as heart disease, diabetes and the degenerative conditions that increasingly afflict an ageing population, often having to act as surrogate geriatricians to nursing and care homes.

All these changes have been supported by a system of postgraduate medical education for family doctors that has embraced this enhanced clinical responsibility and, since 2004, we have a GP contract that recognises quality and has at last moved away from what was known as the "perverse incentive" contract where doctors were paid on list size, not on the outcomes of care.

Emergency care at night and at weekends has also changed. Instead of there being six doctors on-call in my rural valley every night and weekend for the occasional urgent call, we developed co-operatives where experienced local nurses monitored calls and dispatched a doctor when necessary. All that experience and expertise was lost at a stroke on the introduction of NHS 24 which, only now, is beginning to replace adequately what was so carelessly thrown away by ministers.

Social changes over these past 30 years have also challenged general practice. No longer is the doctor's advice accepted without question and every opinion offered is subject to later checking with universal instant access to websites. This 24-hour, consumerist environment has raised demands for the "Tesco" approach to healthcare - instant gratification for any least discomfort - but without the profit-based business model that motivates supermarkets.

General practitioners, among all doctors, are those most adaptable to change. We have always been small businesses, and have learned how to survive the whims of our political masters. What is more important, however, is what has not changed.

Patients are still seen and treated on the basis of mutual trust and respect and on a continuing basis that lasts far longer than individual episodes of illness. We still treat our list of patients and act as their advocates within an increasingly complicated NHS system. Most doctors and their patients still believe in personal care, a lifelong, confidential medical record and the virtues of treating people in the context of families and loving relationships.

Why, then, is all this now in great danger? For the answer, we have to look south of the border - paradoxically under a Prime Minister brought up in Fife, educated in Edinburgh and elected to Westminster by Scottish voters. The English NHS is set to dismantle the very basis of personal care by doctors serving a defined list of patients on the grounds of fashionable competition and privatisation. The key vehicle for this change is dilution of the confidentiality of the personal medical record, recklessly allowing its details to be automatically sucked from practice computers on to what is known as "the spine" - an electronic database to be available to anyone within the NHS "family".

Connecting for Health, the latest massively expensive governmental IT disaster, is promoted as essential for the emergency care of any patient who turns up unannounced at a hospital, but the dangers of information incontinence within the NHS, the largest single employer in Europe, is conveniently forgotten. Already there are instances of illicit access to the records of celebrity patients. The real reason for this dangerous innovation, of course, is not patient care, but so that the English Department of Health can offer general practice contracts to alternative providers - commercial companies that propose to offer primary care through the same supermarkets and high street outlets that seem to have captured the imagination of the spotty adolescents who populate the No 10 Policy Unit.

General practice has changed over 30 years, and most of us recognise that as welcome and appropriate in a maturing society. What must not change, however, are those enduring principles that have served the NHS and its patients so well since 1948. A personal service, provided by well-trained doctors and their teams, based locally and on families and one where there is trust that what is said confi-dentially in a consulting room on a Monday will not be on a government database on Tuesday. A service where there is recognition that historically one could never phone for instant advice out of hours for the least discomfort, but one where there was always help in an emergency. A ser-vice that is based upon the best virtues of British medicine, not one modelled on the musings of a Prime Minister determined to preserve his popularity in Labour marginal constituencies, especially where those are English.

  • Dr Brian Keighley is a GP in Balfron.