What’s working life really like for a doctor? What does John do when he's at the GP surgery?A short, light-hearted guide to
- what John would really be doing as locum GP (besides falling asleep),
- the kind of patients he would see
- the amusingly bizarre problems him might encounter
- A realistic limit to John’s knowledge
An accurate resource for fanfiction writers but an entertaining read even if you don’t intend to write.
General Practioners - The Gate-Keepers of the NHS
John Watson is a fully qualified GP (for the reason why read Exploring Dr Watson’s Army Career). A GP in the UK is the equivalent of a family doctor in the US.
In the wonderfully convoluted hierarchy of the NHS, GPs are the gate-keepers. Anyone with a non-emergency health problem will go to see their GP as the first port of call (and plenty of people with emergency problems turn up too). GPs are usually able to diagnose and treat about 90% of all patients who come through the door. The vast majority of health problems are simple and self-limiting. The other 10% get referred onto a specialist doctor at the hospital for further tests and an expert opinion.
Because GPs see such a wide variety of people, they become very good generalists in dealing with common problems. They are not always particularly good at spotting rare conditions but they are good at knowing the limits of their knowledge.
All GPs partners in a GP practice are self-employed (it’s a bit like lawyers in a law firm). The government gives them grants to provide healthcare services to a geographic area and from that money the GP draw their own salaries. This is why some GPs can earn very large sums of money.
A locum GP is not a partner of the practice – they are basically temps. Some are paid on a per hour/per day basis if their contract is very short term. Otherwise they are paid on a monthly basis if they work regularly for several months at one practice (i.e. if you are covering for maternity leave). There is great demand for GP locums. The reason Sarah didn’t sack John for falling asleep during clinic was not just because she liked him – GP locums are also thin on the ground.
There are always GPs going on maternity leave, sabbatical, study leave or just really long holidays. In a large GP practice the other partners can split the extra workload, in smaller practices is often no feasible so a locum is needed.
GP run things called “surgeries”. This does not mean they are performing an operation. A surgery is basically the same as a clinic. There are usually two clinic sessions: morning surgery and afternoon surgery. Some GP practices have a late surgery in the evening so that people at work don’t have to take time off.
A typical day goes something like this:
John arrives at the surgery logs into the computer system, has a quick preview of booked appointments and tries to second guess why they’re coming in (it was certainly a favourite pastime of mine in GP)
09.00 – 11.00
Morning surgery typically back to back 10 minute appointments and most doctors inevitably run late.
11.30 – 12.00
Morning meeting: some GP practices have this once a week, others have it every day. During the daily meetings doctors will sign the (massive) pile of repeat prescriptions and divide up the home visits.
12.00 – 14.00
Doing home visits. The night before or during the morning patients will call requesting home visits, they are normally the elderly and housebound. Sometimes it may be that the person just wants some company. The doctor may be the only person they will see for several days. Other times it can be an emergency as the elderly can deteriorate very quickly.
14.00 – 17.00
Afternoon surgery: more back to back appointments
17.00 – 18.00
If John is covering for a regular GP who is away for a quite some time he would probably work at least 3 full days a week but this depends on how much the practice is willing to spend. He may work 5 half-days or just 3 half-days. However when he works is not really flexible if he’s on a long term contract: if he has a surgery at 9.00am on Monday, he needs to turn up.
To fit in Sherlock’s shenanigans, I think John has taken a series of short term posts cycling around different London GPs or alternatively he could just work for the out-of-hours GP service.
Sirens and Flashing Lights
One service that is even more desperate for locums than normal GPs is the out-of-hours GP services: a point of call for urgent problems when the GP surgeries are closed i.e. nights and weekends. Working purely for the out-of-hours services gives John the ultimate flexibility. Depending on the service, John can decide to turn for a shift (usually 7 hours) the night before and, though it won’t make him popular, cancel his shift at short notice.
John would get to whizz around London in a car with flashing green lights and he has to deal with a myriad of different emergencies. Although more often than not, the patient has nothing life threatening, there are frequent episodes of intense adrenaline fuelled action. For example: a cardiac arrest after a heart attack. The patient/their relatives often phone the GP first because they don’t realise it’s a heart attack.
Some rather amusing situations I’ve ended up experiencing in out-of-hours practice include: a lovely young man with a turnip stuck in his bottom. When we finally managed to extract it with the help of some suppositories, he refused to allow us to throw it in the bin…apparently it was still good to eat.
Another one was a sweet old lady who had covered her entire body with kitchen foil because the North Koreans were trying to steal state secrets out of her ovaries. We had to refer her to the emergency psychiatric team.
Other situations include: people running naked through the streets (yes their “sensible” neighbours phoned the emergency GP instead of the police) and a poor teenager who got his reproductive organs trapped inside an inflatable toy. I have no idea why neither the boy nor his mother deflated the toy before we arrived, it would have at least preserved some of his dignity.
The drunks and drug overdoses usually get taken straight to hospital by ambulance but sometimes people still call the emergency GP and we end up having to ventilate (breath for) the patient until they come out of respiratory arrest. More often than not we see people who are in withdrawal from alcohol and or illegal drugs. These can be serious and life threatening situations which require transfer to hospital.
(If John was a Kitten, he's so be Dr Cat)
What kind of patients would John see in GP?
Well I can tell you now GP is not like Grey’s Anatomy or House. Most patients have very straightforward problems that a senior medical student could diagnose.
Lots of patients don’t need a new diagnosis – up to 50% of all patients have a chronic disorder of some kind: diabetes, high blood pressure, back ache, depression, anorexia, drug and alcohol addiction. There are patients on medications that have to be frequently monitored like drugs for hyperthyroidism. Babies need to have regular development checks and women frequently change/start contraception.
In any given day – John probably spends most of his time chatting with the patient, making sure they are well as they can be and then maybe make some minor tweaks to their medication.
In terms of inner London, this area has a high incidence of tropical disease (from travellers and immigrants). TB is very common, so are STDs like gonorrhoea, syphilis and Chlamydia, and other infections like hepatitis B and C and HIV. So I assume that John probably sees more of these problems than his more rural colleagues.
Some GP practices also offer minor surgery – including stitching up wounds and cutting out (non-cancerous) moles. I imagine it would be a nice break from the monotony for John and as an army GP he would know how to suture.
John’s area of special interest (most GPs have one) would probably either be musculoskeletal problems (he would have seen lots of these in the army) or in minor surgery. A special interest just means you see more of these types of patients than the other GPs in the practice, perhaps John runs a special muscle and joint clinic once a week.
GP is not all dull and repetitive, occasionally something truly interesting/amazing/horrific/bizarre appears such as a man who lost all his skin, the poor lady whose throat bulges like a bullfrog every time she swallows, the child who sees musical notes as colours and the guy who was too embarrassed to go to A&E when his penis turned purple.
The National Health Service (NHS)
When writing a fanfiction: please do not have John billing his patients. He is not legally allowed to do this, healthcare in the UK is free. Doctors are also very cautious about accepting presents and definitely will never take any cash from their patients.
For everyone who does not live in the UK, it's very important to remember that health care in the UK is free at the point of delivery. This means when you see any type of doctor it is always free, doesn't matter if it's your GP, a hospital specialist or in Accident and Emergency. You do not have to pay anything for the consultation, any procedures or operations, any drugs prescribed in hospital, or the cost of the stay in hospital.
The NHS does not work like many other government funded healthcare systems around the world, where you and/or the government contribute to your own government health insurance pot. All the people who are working pay a tax called National Insurance and the money raised funds the healthcare treatment for everyone.
On the NHS everyone gets the treatment that they need regardless of their contributions to the state. NHS care covers just about every conceivable aspect of medicine (but not dentists or opticians) except procedures/treatments that have no medical purpose i.e. cosmetic procedures.
If you want something that is not funded by the NHS, you will not get it on the state system regardless of how much you have contributed to the state in National Insurance. You have to physically go and see a private doctor and the insurance contributions you have made will not be returned to you if you choose to opt out of the NHS and use the private sector.
The only thing some people have to pay for are prescriptions from the GP which you collect from a pharmacist (community prescriptions). However drugs for all chronic diseases like hypertension, diabetes and cancer are all exempt. Only people who are aged between 16-60 have to pay this prescription charge. The unemployed or people on disability allowance are also exempt.
Because the NHS is essentially free - it pretty much has the monopoly on healthcare of any kind. It also has the monopoly on training doctors. All doctors must train on the NHS in order to reach the top of the career ladder (i.e. become a consultant).
As a locum GP John does technically work for the NHS. He's not got a full time contract, but he is indirectly employed by the NHS. All of his patients would not have to pay anything to see him.
I have had several questions regarding private doctors in the UK. Yes, private doctors do exists but they are not a separate pool of doctors – they are the same doctors you would see on the NHS. Everyone has to train on the NHS. You cannot set up your own private practice until you become a fully qualified GP or consultant specialist (this takes between 5-15 years after finishing medical school).
Nearly all doctors work for the NHS, even if it’s only part time. The state provides a very generous pension and job security which the private sector cannot.
Private doctors are NHS doctors on their days off – it is in effect a form of moonlighting. The market for private healthcare is very small in the UK compared to other countries with a dual state and private system e.g. Australia.
Comparatively few people ever buy health insurance in the UK. Although large companies like BUPA and Virgin have managed to make some headway into this market. Firstly, you would be paying twice for healthcare because you have already been paid your contribution to the NHS as part of National Insurance. Secondly, like any insurance, there is always the fear that when the times comes they won’t pay up. On the NHS you don’t have to worry about this problem. The joy of private healthcare is that you usually don’t have to wait very long. This is why cataract surgery, joint replacements etc have a big private market because their waiting lists are horrendously long. Other specialities like plastic surgery can offer people operations that just won’t be funded on the NHS like breast and bum enlargements.
Private GPs do exist – there are some people with enough money to spend £60 on a ten minute consultation. There are also some very misguided people who think the quality of doctor on the private system will be better than on the NHS. Private GPs will also do home visits, and these don’t have to be assessed on a need, so if you can afford it you can have the doctor visit your house like in TV series private practice.
Generally private practice does not make that much money for the doctor – you have to pay very high medical insurance fees. For an eye surgeon it can be up to £10,000 per year. If you work purely on the NHS, the NHS provides legal cover and the medical insurance companies will charge you much less.