Tumbleweed sighted in the Surgery
‘Confirmation bias’ is the tendency to search for, interpret and favour evidence to support one’s pre-existing beliefs.
It has been brought to the attention of your PPG that when it might take three weeks to book a routine GP appointment, there are times when our waiting room looks somewhat empty of patients. Why might that be?
Long gone are the days when your GP did nothing but see patients. Health care has become more complex and more demanding. There is evidence that doctors consulting patients for more than seven half-day sessions each week are prone to burn out. I frequently work an eleven hour day, so can clock up full-time hours before Thursday lunchtime! Worn down doctors don’t provide safe or compassionate care.
We have most hands on deck at the busiest times of the week – Monday and Friday. On other days some of us will be fulfilling the other roles the NHS expects of us – commissioning local healthcare, teaching and training, managing this surgery and other care providers, pursuing specialist clinical roles or representing the needs of GPs and their patients on a county stage.
We are only a medium-sized GP practice and team. A trickle of patients in the waiting room does not reflect a dearth of activity. Whilst one GP may be seeing booked appointments, our duty doctor will be doing telephone consultations and triage. The Advanced Nurse Practitioner or a GP will be undertaking a ‘ward round’ of care home patients. Although it is good to stagger appointments across the working day, it is also necessary to create protected time for team meetings to discuss, plan and improve patient care. Every hour spent consulting patients face to face generates another half hour of administration; reading letters, dictating letters, completing forms and reports, requesting tests, interpreting tests, making phone calls to patients and colleagues, chasing up stuff that other parts of the health service should have done but hasn’t …
Please remember that a quiet waiting room in no way reflects the volume of care and the intensity of work in General Practice.
I have become complacent in thinking that only elected politicians and their lickspittles undermine GP services. This week I was reminded that doctors are sometimes their own worst enemies. A big ‘thank you’ to Flemish researchers and their study of the treatment of sore throats, published in the British Medical Journal. I fear it will be in the health pages of the Daily Wail before you read this.
The authors – in their own words – offered the ‘weak recommendation’ of prescribing a single dose of steroid to patients with a sore throat. This made the pain go away a whole 11 hours sooner, but didn’t reduce time off school or work. They wrongly concluded this is ‘likely to be offered in the context of a consultation that would have taken place anyway’.
The researchers totally ignore what is called ‘opportunity cost’ – the important jobs we can’t do when we are tied up doing trivial tasks. UK primary care is already in crisis. Look at the waiting time for a routine appointment. We have a finite number of doctors and nurses. We (only) have ten and a half hours in the working day. There is only so much we can safely do. If we are talking to patients with a sore throat, we can’t spend an extra few minutes with someone suffering a mental health crisis, or visit a terminally ill patient.
So if you are a normally fit patient with a short-lived sore throat (they typically last 5-7 days) please don’t expect a prescription for steroids. Take painkillers from the pharmacy or supermarket. Seek advice from the nhs.uk website or a pharmacist if unsure. Speak to us if your sore throat may have a bearing on another illness, or if the course of the sore throat doesn’t pan out as expected.
Excessive doses of steroids cause side effects including shrinkage of your gonads. If you think you need a doctor or nurse’s prescription for a simple sore throat, this is precisely the opposite effect to what you need.
Computer Virus/Hack – 16 May 2017
When the Care Quality Commission visited Spilsby in November 2016, their Lead Inspector complimented us on our website that sought to explain transparently how the NHS works and how it sometimes struggles. This is our take on the NHS cyber-attack debacle.
GP computers are owned by the NHS and the Windows operating system is managed by the NHS. On Friday afternoon, Lincolnshire CCGs rang all 100 Lincolnshire GP practices and told them to shut their computers down immediately. We were informed that our secure ‘N3’ internet link had been compromised. This, thank fully turned out to be incorrect. The ‘malware’ affected both healthcare and non-healthcare organisations worldwide.
Over the weekend Lincolnshire CCG’s Gold Command convened several times to discuss the ensuing crisis. We invoked our own disaster recovery plan in order to overcome our local issues.
We were provided with a software ‘patch’ for our computers on Monday afternoon which we were able to apply and start the process of overcoming the issues that had been caused by the virus.
There is no safe pen-and-paper fall-back position for patient care in the 21st century.
Spilsby Surgery has a finite number of staff and the working day isn’t elastic. Over the remainder of the week we’ll have to prioritise patient care (both clinical and administrative) for the most sick and vulnerable. If we don’t respond with our usual speed, effectiveness and good grace we apologise, but hope to be able to resume our normal service very soon. Thank you for your understanding.
There isn’t enough general practice to go around
The British Red Cross charity rightly reports NHS hospitals and ambulance services are in a state of ‘humanitarian crisis’. At the same time, the chair of the Royal College of General Practitioners voiced concerns that urgent care – often of minor illness – threatens the care of patients with serious long-term conditions. ‘Something has to give’ she concluded.
Next we heard Theresa May blame GPs. She said the reason hospitals aren’t coping is because GPs aren’t open seven days a week and just aren’t working hard enough. This is demonstrably not true.
A few months ago we received a letter from Victoria Atkins MP asking what we were doing to reduce waiting times for routine appointments. We replied that our doctors and nurses couldn’t work any harder without risking patient safety. We pointed out that it was in her Government’s power to allocate more resources to primary care. Her response suggested we had evaded the question, and repeated the Department of Health line on investment in the NHS. Our second reply is posted here for you to read. Our second letter remains unanswered.
The GPs at Spilsby love our work; talking to people, helping them with their problems. We love that we get to know our patients so are best placed to understand their needs. We feel our patients’ joy when they get better from illness or overcome adversity, and that we help them do so. We also feel our patient’s pain when life kicks them. And we don’t take this for granted; we feel privileged to be in that position. Up until recently, General Practice had very high job satisfaction. But no longer, as evidenced by GPs leaving the profession in droves and fewer doctors wanting to take their place.
The alleged £10 billion investment in the NHS won’t even keep pace with inflation in the cost of healthcare. At the same time, local Sustainability & Transformation Plans demand £26 billion of savings. A saving where there is little saving to be made is a cut. We fund the NHS less than any comparable European country. We have less hospital beds than most; fewer doctors too. Germany has nearly three times as many hospital beds and twice as many doctors. France is similarly well resourced. Yet we expect more than any of those other countries. And the result is the current mess.
Details of cuts in GP services in Lincolnshire will be made public in the coming weeks. We will no longer be able to request MRI scans. Expect long waits to see a specialist first if we think you need a scan. Hip and knee surgery won’t be allowed by the CCG if you are overweight. (You may be overweight in part because you struggle to exercise because you need a hip or knee operation). GP referrals to certain specialities may be vetted, although such referral management schemes have never been shown to make cost savings. There’s more to follow. GPs who work for the CCGs were largely bypassed in this decision-making.
What new resources might exist appear tied to promises of seven day GP access. We explained our thoughts and fears about seven day opening in November 2015 (see below). No other country has their surgeries open 8-8pm seven days a week. They don’t need them to and couldn’t afford such a service. Neither can we. We already have a 24-hour GP service already for emergencies – Out of Hours.
There have been 18 pilots for seven days working in pilot sites (These were generously funded by the David Cameron’s ‘Prime Minister’s Challenge Scheme’. This isn’t what Mrs May is suggesting – she wants us to do more with the same funding or less). These pilots have mostly been unsuccessful and are considerably less cost-effective than the appointments we currently provide.
The idea is not that your local surgery opens seven days a week; simply a group of surgeries having a service on one site (in Lincolnshire likely to be many miles away from you) offering appointments for a whole area. The GPs would take it in turn at these weekend ‘hubs’. You can have a weekend appointment, but it’s unlikely to be with your own doctor and there will be less regular appointments at local surgery because we’d be doing shifts at the ‘hub’ instead. At Lincolnshire East CCG the plans are presently at the ‘how in god’s name are we going to commission that with the ongoing financial and staffing crisis’ stage.
- Out of 35 studies European Countries studied by the Euro Health Consumer Index in 2015, the UK came 28th in terms of number of doctors per head of population.
- A GP practice is funded only £136-157 per head of population for all that years care. Some people pay as much each year to insure their pet rabbit’s health!
- The World’s most influential health think-tank, The Commonwealth Fund last year found that the UK’s GPs are the most stressed out of the 11 leading western nations.
- GP appointment numbers have increased from 310 million in 2010 to 370 million last year. This means we spend less time with each individual patient than many other countries.
- More than 20% of GPs suffered work related illness in 2015. 30% of GPs plan to leave the NHS in the next five years.
- 201 GP practices closed in the last year.
We fund our NHS to levels lower than virtually all first world countries and expect it to do more than those comparator countries. The government tells you not to believe the people on the frontline, the evidence and the experts. They tell you there is no lasting problem which can’t be solved by increasing efficiency and the staff working harder. Don’t believe them. General Practice is in real danger now of extinction, and with it the NHS as a provider of equal care to all free at the point of delivery. Please don’t let this happen. Please protect the care you value. You might consider writing to our MP as a start.
In the past, many GP practices upgraded their phone systems with providers who used 0844 numbers. The systems provided new capacity and functions to improve patient care, but at an extra cost to callers.
Six years ago the Department of Health asked GP practices to review these arrangements for patients calling from landlines, and Spilsby Surgery duly did so. It would have cost the practice at least £60000 to break our contract – £60k less to spend on patient care. It would also have reduced the capacity of our phone system – more patients would have met an engaged tone at busy times. Our staff might be unable to dial out. We didn’t think this was safe or acceptable.
We renegotiated with our provider to add 01790 numbers to our existing contract – a change discussed with our Patient Participation Group. Since then we’ve actively encouraged callers to contact us on these new numbers. Patients dialing the 01790 number do so at no extra cost.
Our 01790 numbers ‘piggy-back’ on the existing 0844 contract, which means the 0844 number has to remain active. The 0844 number will be shown if your phone has a caller display. People who use the 0844 number found on old documents, or web pages that haven’t been updated by third parties, will still get through to us.
The practice has taken the ‘reasonable steps’ required of it by Department of Health regulations in renegotiating this contract. If you’re one of the few people still using the old number, please update your records to save yourself further unnecessary expense.
KEEP TAKING THE TABLOIDS
Two recent and related news stories have caught our attention. Locally the press has reported that patients in two Lincolnshire CCG areas are the least likely in the England to receive an early cancer diagnosis (‘Lincoln and Boston GPs worst in the UK for early cancer diagnosis’, Lincolnshire Reporter online). Nationally the BBC reported ‘Receptionists put people off seeing GP’ – Cancer Research UK stating that patients disliked reporting their symptoms to office staff in order to get an appointment. Demoralising stuff. Demoralising staff.
Are GPs in Lincolnshire less competent than their colleagues in the rest of the country? Probably not – though we declare a conflict of interest in making this assertion. Is Lincolnshire short of GPs? Undoubtedly there are problems attracting doctors in speciality training to the East Midlands, and retaining them once they are fully qualified GPs. If you can’t recruit enough GPs you’ll struggle to see one, delaying diagnosis of serious illness. Those of us who remain can’t work any harder without risking patient safety in other ways. That’s the story behind the headline. It’s a problem that Lincolnshire Local Medical Committee is trying hard to address, with some early success for patients and GP practices. However we need more resourcing from NHS England, and less blame from the Government and sections of the media.
The job title of doctors’ receptionist has probably been obsolete since Janet was housekeeper and receptionist to Dr Findlay. If you can come up with a new one for the complex and busy job they do in 2016 please let us know. Like many GP practices in the UK, Spilsby Surgery operates a tested and trusted version of ‘Doctor First’ management of both urgent care and problems you worry need addressing before the next available routine appointment. At busy times of the day, our duty nurse or doctor may have more than a dozen telephone calls pending. How do we know who needs to receive a call first? Who might be having a heart attack? Who might have stubbed a toe? Answer: you need to give a little information to our trained ‘care co-ordinators’. You wouldn’t ring 999 and insist on only speaking to a police officer. You don’t go to a restaurant and demand it’s the chef who takes your order! And whilst we’re on the subject, ‘It’s personal’ is synonymous with sticky genitals – you’ve immediately gone to the end of the queue. Please help us to help you, and make an imperfect world work a little better.
SEVEN DAY OPENING
You may have been invited to complete the national postal General Practice Patient Survey.
In 2014, some 880 000 patients did. At a time when the Department of Health is championing 7 day opening in the NHS, the GPPS asked patients for its views on primary care availability. An analysis of the results, published in the British Journal of General Practice, make interesting reading.
The research authors found that over 80% of respondents had no problems with existing primary care opening times. 15% of the total participants thought Saturday availability would help them. Less than 1% of the 880 000 patients had a strong preference for Sunday opening. The authors conclude that Sunday opening is unlikely to improve GP access. The study confirms the findings of an independent analysis carried out for NHS England of patients who did have access to sites offering 7 day opening.
Spilsby Surgery has for a long time provided ‘extended hours’ availability with pre-booked appointments on a Saturday morning and one weekday evening. The research findings strike a chord with our own experiences. Whilst evening and weekend appointments may benefit younger people and patients in full-time work, there is no way to police who attends these appointments. Many of the patients we set outside our normal 8.00am to 6.30pm working day could also attend ‘in-hours’. Extending surgery hours provides little improved access for those it was anticipated to help most.
One of the strengths of British General Practice is the Primary Health Care Team. Spreading our team more thinly across a full 7 days makes for less effective team working. A GP without a health care assistant, chaperone or a secretary working alongside them in an evening can achieve far less for the patient sitting in their consulting room. An increasing part of our work involves co-ordinating your care with hospital and community colleagues. If our working hours overlap less, it makes a conversation with your Health Visitor, Community Nurse or hospital consultant more difficult.
New Department of Health investment in GP services is increasingly tied to promises of 7 day availability. The British Medical Association warns that this has resulted in ‘precious NHS resources being wasted on keeping near empty practices open and staffed’. GP practices who believe in the strengths and benefits of tried and trusted ways of working are disadvantaged. So are their patients.
JUNIOR DOCTORS AND YOU
You may have noticed that General Practice has an image problem.
And a recruitment problem. The national picture is worse in the East Midlands. The East Midlands problem is worst in Lincolnshire. Only 15 out of 37 GP training posts were filled in Lincolnshire this year. So Spilsby is very fortunate at this moment to have a full complement of GPs and GP Registrars. Many of you will be familiar with our Registrar Dr Divya Kuttappan, and we look forward to being joined in December 2015 by Registrar Dr Liz Marchant.
Dr Kieran Sharrock, when he’s not at Spilsby Surgery, is Medical Director for Lincolnshire Local Medical Committee, which in the last year has launched an innovative recruitment drive promoting the benefits of training and working as a GP in Lincolnshire to doctors nationwide and beyond.
Spilsby Surgery is therefore very concerned to see these efforts undermined by the Department of Health’s initial proposals that GP registrars – qualified doctors undertaking specialist training to become GPs – risk a 31% cut in their total pay. The British Medical Association describes a subsequent DH offer to increase their basic pay by 11% as ‘misleading’. Their junior hospital colleagues face changes to working hours that they fear will harm their patients and their family lives. This poses a new and greater threat to the future of GP and hospital services in Lincolnshire.
In the three years that Spilsby Surgery has been a GP training practice, our patients have benefited from the skills and motivation of a number of excellent junior doctors. As our patients’ care needs and our workload increase year on year, it’s difficult to imagine how the Surgery would function without them.
Junior doctor members of the British Medical Association are being balloted on industrial action. It’s not a decision that these dedicated doctors will take lightly. Spilsby Surgery hopes that the Department of Health will offer all junior doctors the assurances they seek to avoid industrial action and agree a negotiated contract settlement.