Monthly Archives: December 2014

‘If you fell in a puddle, you wouldn’t call the coastguard.’

This, apparently, is the caption displayed on the side of some ambulances in an attempt to persuade people to think twice before calling an ambulance. Throughout the Christmas period, there have been reports of ambulance services in all parts of the country being pushed to breaking point by escalating demand. And they are not alone – the news coverage repeatedly described A&E departments as being swamped, and of huge waits in out-of-hours (OOH) centres.

You wouldn't call the coastguard if you fell in a puddle... (on side of East Midlands ambulance)

Why has this been such a difficult holiday period? With Christmas on a Thursday, there were four consecutive days when GP surgeries were closed, but this is not particularly unusual – whenever Christmas falls on a Thursday, Friday, Saturday, Sunday or Monday, there will be a similar block of ‘closed’ days, so it actually happens more often than not. Nor has it been unusually cold, and there have been no major outbreaks of influenza, norovirus, etc. Some of the increased activity is probably a reflection of an ageing population, with more people living longer while still suffering from several debilitating medical conditions, but there are also other factors at work.

Who tried to access care?

A colleague who regularly does OOH work tells me that those attending fall into four almost equal groups. The first group consists of people who are genuinely ill, and who probably need to see a doctor urgently. The other three groups, i.e. about 75% of those who attend, should probably not be trying to contact a doctor out of hours at all.

Of these, some people require prescriptions for their usual medication. Many simply didn’t request their routine medication before the holiday, others are away from home and forgot their medication, and some have lost their prescription or their medication. There are mechanisms by which they can obtain an emergency supply of their medication directly from a pharmacist without a prescription, and the process is clearly described here. However, as this website states, the service is not free. In many cases, obtaining a replacement prescription from OOH and taking it to a pharmacy costs the patient nothing.

The next group of patients that my colleague identified had requests for items that could have waited until their GP surgery opened – for example, sick notes. In some cases, this might have involved the patient taking time off to see their GP, whereas they were on holiday over Christmas, so why not go to OOH and see if it can be sorted out there?

And the final group of patients – at least a quarter of all those attending OOH – had trivial minor illnesses that one might reasonably expect people to be able to manage without seeing a doctor at all.

The pattern of those attending A&E is not dissimilar. Some are genuine ‘accidents’ or ‘emergencies’, but many should either have gone to OOH, or waited until their GP was available, or simply looked after themselves. Instead, up and down the country, they attended A&E in their thousands.

And GPs have also been inundated with patients before and after the holiday season with minor, self-limiting conditions. ‘It’s a virus,’ GPs explain, ‘they’re very common at this time of year. And no, antibiotics will not make any difference.’ Colleagues have reported patients attending urgently because they felt too tired the previous evening to go out with their friends, even though they now feel fine, or because they get diarrhoea whenever they go out for a very spicy curry, or because they have had a sore throat for twelve hours.

No wonder the entire system is overloaded to the point of almost collapsing.

Nor is this a new phenomenon. This Christmas might have been particularly bad, but most doctors would agree that this trend has been developing for many years. The public has become increasingly unable to cope with minor illnesses, and expects to be seen immediately – after all, you can’t be too careful, can you?

Who is to blame?

There are probably many reasons for this change in behaviour. Some commentators have blamed the breakdown of traditional families, with older generations no longer available to give advice to younger family members. Whilst this has probably played a part, it is too simplistic to blame the entire change on this. There are other mechanisms at work.

Disempowerment by media and politicians

Firstly, there has been a steady process – deliberate or accidental – of disempowering people. Constant scare stories in the media result in people feeling that they need advice or treatment now, rather than waiting to see if their symptoms sort themselves out. There is also growing intolerance of illness – I’m too busy to be ill, or I’m going on holiday next week, and I need to be better, and there must be something that can be done. Attempts by doctors to explain that the vast majority of viruses remain untreatable are met with scepticism or downright disbelief. And politicians of all parties have encouraged people to treat access to healthcare like any consumer activity, valuing convenience as they might value late opening by their favourite shops, in a system with funding at a level barely enough to cater for people’s ‘needs’ and nowhere near enough to deal with all their ‘wants’.

Complicit doctors

Doctors, too, have played a part in this process. Looking through the documentation for patients who attended A&E and OOH over Christmas, I found many who had been given prescriptions for antibiotics for conditions that did not require any such treatment. In one case, the doctor who saw the patient had even recorded that he had prescribed antibiotics ‘because of the patient’s demands and health beliefs’. Similarly, a child who was seen in A&E and diagnosed with a viral infection nevertheless received antibiotics. I can understand stressed, overworked doctors giving in to pressure, but this doesn’t help. Indeed, it positively feeds the problem by affirming the patient’s belief that they need antibiotics for conditions that are entirely self-limiting. To return to the title, it tells people that they do need the coastguard every time they fall in a puddle.

The solution: tackle demand

What can be done about this? Doubtless there will be demands for GPs to open longer, more money for A&E, etc. But all of these solutions address only the supply side of the equation, and do nothing about demand, which appears to have grown out of all proportion.

Tackling demand means telling people they are using the service inappropriately, and this is not politically popular, particularly with an election looming, but unless it is done, the NHS simply cannot survive. Patients who attend A&E or OOH inappropriately need to be told to go away should be signposted to other services as appropriate.

If they need medication because they have forgotten it or lost it or not ordered it in time, they should be directed to pharmacies – the inconvenience of paying will hopefully make them more careful in future.

And doctors need to stop feeding the monster by giving in to inappropriate demands for medication. It may be hard, it may even trigger the occasional complaint, but it most definitely needs to be done. The fear of complaints is something I often hear from colleagues, and this needs to be addressed. Doctors need to show greater self-belief in dealing with any such trivial complaint, and they should be supported in this by the entire system.

Healthcare is everyone’s business

All of us, patients, politicians and clinicians alike, need to start taking responsibility for this problem. If we don’t, we face disaster – patients with genuine needs will suffer while the system is choked with trivia.

Risk of suicide under GMC investigation

A doctor under investigation by the GMC is TWENTY TIMES more likely to commit suicide than the general public.

Αυτοκτονία με την λήψη φαρμάκου-δηλητηρίου.jpg

Of the 5,728 doctors subjected to an investigation by the GMC in 2012 AND 2013 (GMC, 2013 & 2014), 13 tragically committed suicide, a suicide rate of 227/100,000* (GMC, 2014). In the general population at that time, the suicide rate was 11.6/100,000 (ONS, 2014); amongst prisoners, the suicide rate was 65.5/100,000 (DH, 2014; MoJ 2013).

The relative risk of dying from suicide whilst under GMC investigation in 2012 was therefore TWENTY TIMES that of the UK general public (19.5 to be precise).

The GMC must urgently review its complaints-handling process to reduce stress on doctors under investigation; many are subsequently exonerated and have no chance of redress for unfounded or vexatious complaints.

Alan Woodall

*95% confidence interval: 100-350/100,000 (adjusted Wald method).

Are Human Rights Universal?

Passed in 1998 and enacted two years later, the British Human Rights Act (HRA) placed the terms of the European Convention of Human Rights (ECHR) into British law. Whilst the HRA has been the source of criticism in some circles, there can be little doubt that it is a hugely important piece of legislation.

Crucially, the HRA requires all British courts and tribunals to act in accordance with the rights defined in the ECHR. One of these rights is the presumption of innocence; article 6(2) states:

‘Everyone charged with a criminal offence shall be presumed innocent until proved guilty according to law.’

The publication of the GMC report ‘Doctors who commit suicide while under GMC fitness to practise investigation‘, written by an independent consultant, the chief executive of the National Patient Safety Agency (NPSA), therefore makes interesting reading. The report found that 114 doctors died between 2005 and 2013 while they were being investigated by the GMC. Of these, 24 were suicides, and an additional four were probable suicides. Amongst its recommendations, the report advised that ‘Doctors under investigation should feel that they are treated as “innocent until proven guilty”.

It is worth pointing out that not all of the doctors being investigated by the GMC were suspected of carrying out criminal offences. Nevertheless, the fact that an independent report’s very first recommendation should be that the GMC complies with a principle that was enshrined in British law long before the ECHR was even written – ‘the golden thread of British justice’, as Horace Rumpole frequently said in John Mortimer’s books – is an appalling indictment of an institution that has treated doctors so badly that many have taken their own lives. We can never know how many of those 28 individuals found that the stress of their GMC investigations proved to be the final straw. However, a previous study quoted in the report found that seven of 38 doctors who took their own lives between 1991 and 1993 were facing complaints.

Doctors in the UK face what the report describes as ‘multiple jeopardy’ – they can be investigated by several different bodies for the same alleged offence. As the number of bodies that can carry out such investigations appears to grow relentlessly, it is likely that the stress of this will also grow, placing huge burdens on individuals who may already be suffering from problems with their mental health.

Nine of those who committed suicide – 32% of the total – had been under GMC investigation for over two years. This is itself contrary to another principle enshrined within the ECHR, stated in article 6(1): ‘Everyone is entitled to a fair and public hearing within a reasonable time.’

It is utterly deplorable that it has taken an independent report for the GMC to face the truth: its own procedures are not compliant with fundamental human rights, or with the natural principles of British justice. In its quest to be seen as placing the protection of patients above all else, the GMC has trampled on the fundamental rights of doctors, contributing hugely – and perhaps in some of these cases fatally – to the stresses that they face. Today’s announcement that the GMC will offer ’emotional resilience training’ and further reforms to treat doctors as innocent until proved guilty, while welcome, is of no comfort whatever to the families of those who took their own lives while facing the inhumane processes of their regulatory body, or those who survived but will forever bear the scars. Those who were responsible for that regime should hang their heads in shame, and if any are still in post, should consider whether it is appropriate for them to continue. After this report, they cannot believe that the profession has any confidence in them.

Prit Buttar, GP

‘Please Sir, I want some more’

When Oliver Twist approached Mr Bumble and, with great trepidation, said ‘Please Sir, I want some more,’ he elicited the sympathy of readers who could see the manifest injustice of a system run by well-fed individuals who had the power, but not the will, to improve the lot of those for whom they cared. Today, barely a week goes by without someone asking (or often demanding) ‘more’ from healthcare – more GP appointments in evenings and weekends, more care for the disabled, more funding for psychiatric services, the list goes on and on. Much as was the case with little Oliver, many such cases earn our sympathy.

George Cruikshank Oliver Twist

Many of these demands for ‘more’ are driven by clear need. Few would argue for example that psychiatric services have been greatly underfunded in recent years, or that social care provision is patchy and frequently inadequate. Failures to provide funding in one area often result in increased costs elsewhere in the system; a disabled patient with multiple long-term conditions may require admission to hospital, which might have been avoided with better provision of social care. This adds ammunition to the argument that although these demands for ‘more’ might cost money, they will generate savings that will ultimately mean that the entire system is better off, both in health and financial terms. But these arguments hide some assumptions that need to be addressed.

There can be little doubt that additional social care for the elderly person admitted with a chest infection, who was on the correct treatment but was unable to cope at home with the limited provision of care available, would have avoided the admission. One avoided admission would pay for a considerable amount of additional social care, the argument goes, so it is self-evidently a good idea to invest more money to prevent this sort of admission. The problem with this argument is that until the admission occurs, we don’t know that in this particular case, money could have been saved by better social care. Doctors are familiar with the concept of ‘number needed to treat’, or NNT for short – how many patients do you have to treat with drug X, for example, to reduce blood pressure sufficiently to prevent one stroke? A similar argument can be applied to almost every request for increased social care funding. How many disabled individuals with multiple conditions would qualify for additional funding, and how many of these might acquire a chest infection that threatens them with hospital admission? Once considerations like this are taken into account, the projected savings from preventive measures often diminish, if not disappearing entirely.

Leaving aside the demands for ‘more’ that are driven more by convenience than need – evening and weekend GP appointments is an example of something that might be very convenient, but there is no evidence that failure to provide such services is resulting in any major hardship or illness – most demands for more investment in one particular area of care fail to identify where these additional resources might be found. There should be better provision of services for condition A, GPs should be trained better to identify condition B, the list is endless. But where will the extra resources come from? And if GPs are to do more for patients with this particular condition, what can they do less of, in order to make room for it?

It is always easy to suggest new areas of spending. In the current financial climate though, it is clear that more for X means less for Y; this is not the situation faced by poor Oliver Twist, where money was clearly available but was not being spent. Anyone who demands more for X, without identifying a credible Y that they would reduce to pay for it, is naïve at best, and irresponsible and dishonest at worst.

‘Sugar and Spice’ – are GPs just moaning?

On his blog, Partha Kar suggests that GPs are not unique in the pressures they face, and perhaps they should do more than just complain on media such as Twitter. My reply to him is as follows:

You make several good points in this piece, but also miss several more.

Firstly, I fully accept that the entire system is under huge strain. I am a GP, and my wife is a community nurse; I know how stressed and overloaded she and her colleagues are. Similarly, my many close friends who work in secondary care look as overrun as I do when I see them. However, the difference between general practice and other parts of the NHS lies in how general practice is funded. Because of our unique status as ‘independent contractors’, GP partners are the only part of the entire system who have taken personal pay cuts to keep the system alive. I have personally lost about 20% of my income in the past four years, and that’s before allowing for inflation. The last time I had a ‘pay rise’ was 2005.

Sugar cubes

Secondly, I fully acknowledge that the new generation of doctors is not the same as mine (those in their mid-50s). I see very few, male or female, who are prepared to work the long hours that I have always regarded as a normal working week. There are several consequence of this for all parts of the system. Far more individual doctors will be required than those who retire in the next few years. Just as importantly, we need to find a new generation of leaders amongst young doctors to help define the future shape of healthcare, because it is certain that we cannot simply continue as we have done in the past. Just as the attitude of younger doctors is very different from that of older doctors, so the attitude of society is very different. The growing ‘consumerisation’ of healthcare throws up its own challenges – it seems to me that the ethos of the ‘old’ NHS based upon providing care for those who need it is unsustainable when wants are regarded as having such great value, and we will need articulate doctors in all parts of the system to tell everyone – patients, politicians, and the press – some uncomfortable truths.

Old spice front

And GPs are not just sitting back and moaning about their woes. Some of us have decided to take action. From very modest beginnings, Resilient GP has developed in the past few months to try to offer younger GPs the chance to be mentored after their higher training is complete. We have organised our first courses, provided some one-to-one mentoring, and intend to build further on this in the coming year. By doing so, we hope that we will develop the future generation of leaders that the profession needs. We are also looking at sustainable ways of developing vertically integrated community-based care, to provide a higher standard of care for patients in a manner that is more sustainable for all healthcare professionals.

Rather more than 140 words, but this is an important topic and worthy of a proper response.

Prit Buttar