Kessler Syndrome and primary care: have we reached tipping point?

Thursday, January 5, 2017
Dr. Jon Stanley


Primary care really is in crisis.

We have all at some point wished upon a shooting star, but it's not always easy to tell them apart from satellites and space stations.

This might seem like possibly the most bizarre introduction to discussing the state of primary care in the UK but satellites and GP surgeries are both at risk of a very deadly disease: Kessler Syndrome.

Donald Kessler predicted back in the late 1970s that if there are enough satellites in Low Earth Orbit, a single collision between two would result in thousands of sharp, high energy fragments that could go to destroy other satellites. This would cause a chain reaction that would obliterate LEO satellites for centuries, every time a new one was launched it would be near-instantly destroyed by high velocity debris from previous satellites.

Fast forward to 2016 and we see time and again reports of GP surgeries closing due to being simply overburdened by patients, by paperwork, by a loss of new GPs to foreign lands and worse - a massive inability to entice doctors into GP training.

So what happens when a practice is full, barely coping, and a neighbouring one closes? In one word: Cascade. This is Kessler Syndrome and personal off-record discussion with many GPs I went to medical school with suggests this is happening.

A GP surgery in Edinburgh closes, in the city centre. 13 out of 18 practices in Fermanagh are closing soon with patients left over 30 miles from a practice. They are closing too in London and in rural Wales. This is happening everywhere. 

Common sense would suggest that at least part of the cause is central. Why are GPs doing professional appraisals in the middle of winter? Why are they doing them at all? Why do juniors laugh at their seniors who suggest they become GP partners rather than locum? Why is the ever rolling juggernaut of "doing more in the community" not being politically challenged by MPs who simply need to say:

"There is no capacity to do this anymore, the cupboard is bare, it's creaking and we just need to stop".

650 MPs cannot be wrong in unison but they are near all silent on specifically why primary care is in essence collapsing within the UK. This is not the fault solely of the SNP, Sinn Fein, Labour, or someone once called us, the Effing Tories.

It is bigger than this. It threatens emergency care too. If you can't be seen quickly by a GP, you go to A&E where the NHS, in essence, pays twice for your care. First, it pays the GP a capitation fee, and then it pays a fee per service when this GP contract fails.

The solutions are not easy. But they are simple.

1. Put a handbrake on all non-essential clinical work done by GPs. Completely stop it. No insurance claims, no occupational medicals, no appraisals. 

2. Direct all hospital specialties to avoid routine GP follow-ups. The idea that a patient seen in A&E should go home but "see their GP if it gets worse" is absurd and distressing to patients.

3. Offer resolution talks with any GP practice where closure is imminent. Bespoke PMS contracts are going to be better than a GMS practice that has vanished, never to return.

4. Take all primary medicine out of competitive tendering. Stop it. The boutique "cornershop" model does work despite the musings of some think tanks. Economy of scope is crucial for an ageing population and system redesign isn't the answer.

5. Accept the drive to have as many female GPs as possible has been a disaster. Female GPs quit in huge numbers and do so very early in their career. The reasons are complex and warrant a full article but until we have formula for addressing this then recruiting more male GPs seems obvious.

6. Remove GPs from out of hours commitments formally, bring individual GPs back into the system and cover them with crown immunity. This protects GPs from exorbitant insurance fees, which are the reasons their out of hours work appears so lucrative; nothing could be further from the truth.

7. UK qualified pharmacists who have seen their profession and incomes decimated by migrant pharmacists from the EEA should be supported professionally to share clinics with GPs and be the first port of call for many skin and ear nose and throat issues that can be handled by simple prescriptions.

We need to give GPs a break and get real about the very high attrition rates of female GPs. Then we need to either formulate a plan to slow this down or conclude we cannot. Either way going forward a move away from equality and to equity would encourage more men to enter the profession and by extension primary care.

We are not in position to have a full, rational, evidence rich debate on the future of primary care. We were ten years ago but it's too late now. The priority has to be on the demand side, cutting their workload as much as is possible and not adding anything to it. On the supply side the priority has to be on recruiting and retaining GPs who have been trained.

Dr. Jon Stanley is Health Research Fellow at the Bow Group, a Junior Doctor and a Member of the Royal College of Surgeons