For a combination of work, family and leisure reasons, I travel a fair bit and, until their recent efforts to improve customer service, I used to try hard to avoid budget airlines. It was the sense of contempt for my custom and their inflexibility in the face of passengers' problems that I disliked.
So it was with some horror that I realised recently that the changes we are making in my GP practice to cope with rising demand, falling income and increasing contractual and regulatory requirements risk pushing us into a budget-airline-style modus operandi.
General practice is acting as a safety valve for growing deficiencies in the wider NHS. Alongside those who need an appointment for acute illness or chronic disease management, others now pile in. Frustrated by repeated calls that reach hospital answer-phones, patients default to their GP for help with hospital services. Schools demand proof of professional advice for absences due to minor illnesses, so parents who can competently manage childhood illnesses are contacting the surgery.
Operations are rescheduled repeatedly, so symptoms worsen and a holding treatment is required. In each of these situations, the most direct access to professional help is through the GP's front door.
In response, we are redesigning our services. We have launched a morning walk-in clinic to improve access for people with acute problems. We have introduced email consultations and web-based-options for requesting medical certificates, repeat prescriptions and re-referrals.
But we are also wary of supply-induced demand: research shows that as more health services are provided, people make use of them who might otherwise have coped without professional help. If we open the doors wider and longer, we need to ensure that precious, easily accessible slots with GPs and nurses are not swallowed up by patients who don't need face-to-face medical care.
So we have introduced 'triage' guidance for receptionists, which determines who should be added to the GP's appointment list. Who should be steered towards the computer in the waiting room? Who should be asked to book in with an alternative member of staff? This risks toxic comments on our website about nosy and intrusive questioning, but we are giving it a go. Equally, to cope with demand and in order to keep our own mental health in order, we are introducing rules and limits to what we will and won't do in our walk-in clinic.
This is where the fear of budget-airline-style general practice looms ominously. We will not issue repeat prescriptions because past experience tells us that appointments will be used by people who forgot to request them in advance (via a phone app, if wanted). We won’t do pill checks (these can be done online, with a visit to the self-service blood pressure machine in reception). As demand grows and it becomes harder to recruit GPs, such changes feel inevitable, but also defensible. They will enable us to direct the skills and experience of the GP to those with the most complex problems.
But I nevertheless fret about the potential impact on patients of the rules we are creating in order to manage demand and to reduce the stress our clinicians are feeling about the changes. So I sound people out about the plans: "Is it just too awful to refuse to issue a repeat prescription when a patient is sitting in front of you?", I ask other GPs. "My surgery has done that for years", says one colleague. "And mine", says another.
And there's the problem. General practice is hugely diverse. Many other highly regarded practices are making similar changes. For some, a face-to-face consultation has to be preceded by a phone call. In others, it is getting harder to reach the surgery without first making electronic contact. Telephone numbers are buried deep in practice websites, stoking the blood pressure of those with limited IT skills who try to find them.
My own inner-city practice is staffed by clinicians who have self-selected to work there; who are interested in the health challenges of deprived populations and empathic with the difficulties faced by patients with complex health and social challenges. We have been proud to adjust the way we practise to accommodate these things and have seen it as an element of our professionalism.
But we are facing the reality of austerity funding, rising demand and ever-more stringent demands in the GP contract. Survival is forcing us to cut out the frills and flexibilities; to create 'rules' and 'boundaries' and stick to them in all but extreme circumstances - for experience also tells us that unless we all do the same thing, patients learn to 'shop around' until they get what they want. One could argue that these changes represent a shift towards the cold inflexibility of budget travel. Or might it be be seen as extending the reliability and consistency of high-performing organisations into a GP setting?
However you interpret it, we are trying our best to mitigate the effects of these changes on patients. Revisiting our values and scrutinising how the changes we are developing fit with them. Working closely with our patient group to test out emerging plans. Identifying areas where it remains too central a part of being a professional to curb individual judgement and focusing on clinical services where standardisation is least likely to affect outcomes.
But the reality remains that we feel we can’t avoid working in ways that fundamentally jar with our expectations of ourselves. Friends and former colleagues have found this shift so intolerable that they have retired from clinical practice. The University of Manchester's 2015 GP worklife survey describes an increase since 2012 of GPs who describe 'having insufficient time to do the job justice' as one of the factors creating job stress.
But for now we are pressing ahead, monitoring patient and staff feedback and measuring access. We have joked that if we can't offer business-class services, then perhaps we should aim for EasyCare (the medical equivalent of EasyVet, perhaps).
But the impact of not being able to live up to one’s own expectations of oneself is corrosive. Add to this a range of other stressors identified in the University of Manchester survey including long working hours, recruitment problems and ‘adverse publicity by the media’ (which has seen the biggest growth in impact since 2012), and the drivers of international workforce migration and early retirement become clearer.
I still see the job of a GP as a huge privilege, and I find enough job satisfaction in every clinic to keep me going. But I never expected to practise 'budget airline style'. I’m hoping I can continue to cope with doing so in future.
Rebecca is a General Practitioner in Greenwich and a Senior Fellow in Health Policy at the Nuffield Trust.
A version of this blog first appeared in BBC Health's Scrubbing Up.