All posts by Russell Brown

About Russell Brown

GP East Sussex, Chair of East Sussex Local Medical Committee and on GPC, co-founder of @ResilientGP. Birdwatcher when I get the chance...

General Practice Forward View

LWLMClogoRGP logoGPSlogo

A Joint Response to the General Practice Forward View

  • Urgent measures are needed immediately to prevent the collapse of general practice
  • Long overdue investment and a long term plan, but will practices last until 2020?

Whilst no one can dispute that it is good that the importance of General Practice within the NHS has been recognised, looking behind the headline £2.4 billion doesn’t instil most of us with the enthusiasm it seems to be causing elsewhere.

The money

  • It is not clear if this money is going to have to come out of the £8bn already promised to the NHS by 2020. If this is on top of the £22bn savings that have to be found, that doesn’t add up. Who is potentially losing out to give us the funding?
  • £2.4bn would take us BELOW 2010 levels of funding for general practice. Surgeries need money now.
  • Come 2020, we will have more complex patients, more GPs and allied healthcare professionals to pay (if they can be found) and more work to do. To get the full amount promised, GP surgeries will need to open every evening and 7 days per week. This is on top of the existing urgent care and out of hours service; a duplication which makes little sense.
  • There is a £322m primary medical care allocation mentioned for 2016/17. Isn’t this what we had already been told we were getting or is it additional? We need urgent clarity.
  • We are led to believe that the £508 million transformation fund is a one-off, and depends upon CCGs being able to fund much of it. CCGs have no spare money, many are overspent and/or having to prop up secondary care trusts. There is no mention or explanation of the context in which these headline figures translate into real investment for practices.

The workforce

  • NHSE and the RCGP have supported the creation of 5000 new GPs by 2020. Again – this is never going to happen.
  • The GP returners’ programme (which was created by workforce planning at the GPC) is good but simply isn’t enough. The Parliamentary Select Committee Report released today calls for Government analysis and tracking of leavers and their reasons for departure – but it’s GPs leaving practices that are key – not a simplistic head count of those entering/leaving the profession. Not all GPs see patients in the classic surgery setting.
  • Recruitment from abroad is an extraordinary plan when we can’t seem to tackle getting UK GPs back into the workforce without major difficulty.
  • The significant challenge of medical indemnity fees is not addressed when this would make an immediate difference to the number of sessions GPs can work both in and out of hours. A chance to maximise the current workforce has been missed here. Funding needs to go directly into GP practices, so that they can keep the GPs they have, and recruit more.
  • With regards to pharmacists and paramedics, when they work well with GP practices, it is good for everyone and we can be pleased that this may be expanded.
  • The army of 1000 Physicians Associates however is somewhat less helpful. There are currently 35 working in general practice in the UK, with no regulation and no career structure. Today’s Select Committee Report calls for the regulation of physician assistants.
  • The medical assistant role may however be something that actually makes a positive difference to the day to day lives of GPs.

The organisational structure

  • Current surgeries need money now. This forward view is based almost entirely around large collections of GPs working together. Whilst this can work well in some areas, it by no means for everyone and, in fact, there have been recent thoughts that the Vanguard model may not be the panacea that it was once touted to be, again as iterated in today’s Select Committee Report.

In summary

This plan is very short on detail, and detailed immediate plans are what we need. There is a recognition of the issues, but a lack of urgency in a dire situation. We collectively are worried there won’t be a General practice to fund in 5 years’ time. If there is, it will be one that is not recognisable to our patients. Patients must be clear they will not be seeing a GP very often in the future, but other healthcare professionals. Has that been adequately communicated to them? Our funding is being taken away from other areas of the NHS and takes us back to less than we had in 2010. If the government and NHSE were serious about maintaining high quality General Practice for the rising population of the UK, this plan would include immediate emergency measures alongside the longer term vision. We look forward to seeing the GPCs next step in light of today’s report.

Why PMs can be the saviour of GP surgeries

 

During our recent survey, Practice Index, a group set up to support practice managers, helped by promoting the survey through their networks.  We asked them if they could write a blog for us on the role of Practice managers in GP.  Read on….

 

At a time when hundreds, if not thousands of practices, are facing the very real threat of closure, now is the perfect time for GP partners to allow their practice managers to become the saviours of surgeries everywhere.

 

Unlike GPs, practice managers tend to come into the profession with a variety of skills and experiences, which can help primary care move into the new, service-focused world we all exist in. This means practice managers can be leading advocates of new ways of working and therefore well-placed to establish truly patient-focused, efficient services.

 

Practice managers also have a true understanding of what goes on across the whole practice, both front of house and behind the scenes. They’re the chief executives of practices. They know the practice budgets, have knowledge of where capacity is in the practice, can see where additional services can be added, understand where additional resource is needed and they’re also the conduit between practices and the never-ending dump of administration from the NHS and CCGs.

 

Now’s the time

 

So, it’s therefore time to utilise the skills of these experienced professionals, allow business skills to be brought into play and free-up practice managers to utilise the full range of systems, tools and resources available at the front line to the benefit of businesses; because that’s exactly what practices are.

 

For example, could technology be used to improve efficiencies and cut expenses concurrently? Many surgeries will still have a receptionist to book patient appointments, but their time could be better spent elsewhere. Communication takes many forms these days so why not let patients book their appointments online and by telephone.

 

Keeping up with the latest technology can also help practices to become more efficient and ultimately reduce expenditure. For instance, practices can save both printer ink and paper by sending invoices and statements electronically. Also, small changes such as switching to energy efficient light bulbs will go a long way for cutting your expenses too. While clinical staff concentrate on that side of the practice, it’s practice managers who can effectively implement changes, whatever they are.

 

Change is needed and inevitable and with the support of partners – and that is the key here – practice managers can drive practices forward, update processes, streamline operations, cut costs and boost revenues. They have the skills to save general practice so now’s the time to let them do just that.

 

Author: Practice Index

 

A Rescue Package for General Practice

In a collaboration between Resilient GP, GP Survival and Londonwide LMCs, we invite your collective wisdom.  We have generated a series of ideas which we think might go someway to forming a rescue package for General Practice.  Please complete the survey and tell us what your priorities are.

Rescue Package survey

Message from Lesvos

The following message was sent to our Facebook Group By Dr Bob Sangar.  With his permission, we reproduce it here to inspire colleagues to help in any way they can.  He got involved through Mercy Worldwide.

“Dear Resilients,

Please forgive the long post. I am currently 3 days into a week on the island of Lesvos. I was offered by a friend to do relief work here as there is a humanitarian crisis on the doorstep of Europe. I am working mainly at Moria, a former prison camp currently used as a registration centre for refugees. There are constant riot police on site and refugees all over the island. Circa 7000 arrive daily.

I have seen Immersion (trench) foot, acute stress reactions, URTIs, wound infections, asthma, gastritis, malnutrition, hypothermia and fractures amongst other problems. Almost all these people are fleeing conflict, terrorism or persecution (or fear of). There are many children. These are people who desperately need help and even a smile and courtesy are like manna from heaven for them. The people of Lesvos are amazing. They have little but are ready to share it all with the refugees. Like a lot of GPs I feel quite fed up at times with our job. I wanted a holiday but I left my wife and kids on half term to come here. My wife insisted I come as she knew this camp had no medical cover. However, though I miss them, I have never felt so needed professionally. I am so grateful that I’m a GP. There is no other profession that could see a feverish child, assess a woman with possible pregnancy loss, assess a knee sprain, treat a paronychia, manage infected eczema, diagnose a confusing rash as insect bites, treat scabies, manage hypertension or advise on switching antidepressants when a patient can’t find their current one. Possibly only a GP can manage this case load.

I have been near tears at hearing these patients’ desperately sad stories of drowned children or lost husbands; I have had to make spacers with a pen knife and a plastic cup; I’ve walked over crowded sleeping refugees resting in a dark condemned sports complex at 3am reaching people needing help. I have worked with people from Sweden, Iraq, USA, Norway and Germany (all unpaid volunteers) and felt like we’ve all made a difference.
Please don’t be scared to come. There is literally something anyone can offer. It can be harrowing but I have seen such selfless humanity this week that amongst the carnage of baton injuries, death, illness and hunger I have seen hope for all of us. I’ll leave you with a picture (obtained with verbal consent) of a beautiful baby whose parents crossed from Afghanistan to Iran (over mountains) then were smuggled to Turkey and then came by dinghy to Lesvos. His Mum said he never let’s anyone other than her and his dad hold him and that he really liked me. She was just being polite but he made needy old me feel like a million dollars for a few minutes!”

Lesvos

Reflection on inspection, by Prit Buttar

As some of you know, my lovely daughter is a pastry chef in an upmarket restaurant-cum-hotel. Yesterday, environmental health officers sprang a surprise inspection on their kitchen.

Bear in mind that this is a restaurant that aspires to a Michelin star. The inspector asked the chef to explain precisely how he knew the meat was cooked enough to be safe. She was unwilling to accept his experience and skill, and wanted him to be able to prove that he had checked the temperature of the meat (which for her requirements would have been far too high for most fine food dining). The refrigerators in the kitchen all have thermometers, and a log book is maintained of readings every morning – the first person in the kitchen checks the temperatures, but they are often put in the log later in the day when time allows, as morning is dominated by getting breakfast ready. Apparently, this delay was not good enough. Nor, apparently, was a sign above the sink used for rinsing vegetables and salad that read ‘Now wash your hands’ – the inspector was concerned that it did not make it clear that people are meant to use a different sink to wash their hands.
As my daughter told me these anecdotes (and several others), you will understand that my thoughts turned to CQC inspections, which are generally marked by a similar gulf between those who inspect and those who are being inspected. Next week, I am meeting officials from CQC about concerns raised by my GPs in Oxfordshire, and their preliminary responses to our concerns show a lack of understanding of just how absurd some of the questions are. The meeting is unlikely to end with universal understanding and enlightenment.

What have we done, to allow such a state of affairs to arise? It seems to me that there is widespread distrust of professionals in all walks of life, resulting in inspection regimes by organisations and individuals who are frankly too ill-informed to understand what they are inspecting. Anyone working in a professional kitchen has already passed suitable health-and-safety regulatory standards to make many of yesterday’s questions irrelevant, but the inspector either didn’t know this or insisted on measuring things that had already been measured. Similarly, CQC inspectors ignore the fact that our GMC regulations already require us not to discriminate, to follow professional standards, etc.

To an extent, all professions have been let down by individuals who have fallen short of the standards that they should reach. But the solution surely isn’t to create another tier of inspection and regulation. Far better to get the existing regulations upheld appropriately. Instead, we have allowed – and in many cases colluded with – the creation of new quangos that ultimately will fail to achieve anything other than their own self-perpetuation.

I am always reminded of the old cliche – what matters is rarely measurable, while what is measurable rarely matters.

A tragic death due to overdemand and undercapacity

I am writing from the bedroom of my parent’s house, having arrived here late at night. I wish it was in pleasant circumstances, but sadly my mother has just died, at 69. A life cut short, a husband bereaved, a son without a mother. Today I join the ranks of those who have been let down by the NHS, the professional leaders and academics, the government, but also a community of Britons. I’m breaching her confidentiality, because I know she would want lessons to be learned from her death. Some will simply decry this as grief speaking, but if we cannot express our frustrations in grief, then I fail to understand where our compassion comes from.

My mum died of biliary sepsis and hepatic encephalopathy after a month in a coma, on and off ITU. The care she received by the doctors, nurses and other workers was exemplary, both in primary care and hospital. I have nothing but admiration for them. But all are overworked, underresourced, and this was as preventable a death as I’ve ever seen.

My mum became generally unwell a few days before my dad found her in a coma. Being a working class miners’ family, who grew up in a spirit of solidarity and community support, and taking only what they really needed from the state, thy did not want to bother her GP. A day before she was admitted to hospital, they tried to get her an appointment with the GP, but not knowing how to press the buttons ahead of those more savvy consumers well trained in claiming emergency need for their complaints to get what they wanted (as a patient said to a colleague, ‘Well doctor, it might not have been an emergency for the NHS, but it was to me’), there were no appointments available until the next week. She retired to bed and never properly woke up again.

I am a GP. But I’m not the usual kind. I am solid working class in attitude, speak like it, would not be described as posh in anyway, believe in a strong welfare state, and grew up as a child through a year long miners’ strike during which I ate at soup kitchens. I lived in a community on our street (I grew up on the street where Billy Elliot lived in the film) where families supported and relied on each other, where help was provided with the sick and, the needy, and the doctor and state bothered less for the chronic illness that is prevalent in that community than should have been the case. I grew up with people who valued the founding principles of the 1945 compact to use the precious resource of the Welfare State responsibly, many having sacrificed sons, brothers and fathers in a war to create a better place for us. But that community is gone, destroyed by ‘progress’.

I have watched as the NHS I loved has been decimated, packaged for sell off, and consumerised by a succession of governments, Labour, Tory and Coalition alike, who claim to be ‘supporters’ but have done everything to destabilise the system to breaking point. I’ve watched as our medical leaders have colluded with this, sometimes for their own political or career gains, at the expense of patients and colleagues. I’ve seen academics push self-serving agendas that are unrealistic, claiming those at the front line need to do more without any additional resources or genuine understanding of the reality of the situation. As a former postdoctoral scientist and public health researcher who worked tirelessly to get the smoking ban enforced, I’m ashamed by the behaviour of some of them who tell overworked front line staff how to do better from the comfort of a computer desk and SPSS spreadsheet. Good officers lead from the front, and check their men’s feet before asking them to march into battle. Many have forgotten to do that. Others never understood such principles in the first place.

But mostly I blame the government and media. I blame the government for stoking demand and creating health anxiety and fear in our nation at every turn, at destroying our communities’ resilience to cope with illness, so that the ‘clinical iceberg’ model of care that once suggested 90% of illnesses were managed In the community without professional input has defied physics and paradoxically risen above the surface such that demand is swamping services. I blame the media for the constant barrage of 24/7 health scare stories, of ‘get your GP to check it’ being the legal backstop for everyone under the sun to pass on responsibility, and a culture of entitlement that has become the norm – ‘rights without responsibilities’ – in a very small, but massively overusing, section of the population

My ResilientGP colleagues were recently criticised for daring to raise these issues. Some argued that we were all right wing, and simply didn’t care about our patients. I and the rest of the ResilientGP team are hugely insulted by that sweeping assumption. I’ve given my life to patients who needed me, been there round the clock for them, and still intend to be in the NHS until I retire. The suggestion that inappropriate demand has become the focus of what ResilientGP is about is incredibly incorrect. We acknowledge it exists, and for once I agree with Dr Clare Gerada – in not blaming patients – but this is a factor, one of many, that needs debate. Explaining not blaming was our aim, and that is what we intend to do. Some may not like the methods, but I challenge them to find the methods to do so if they have the expertise, resource and academic freedom to do so, not pretend the problem does not exist. We all know it does – just some of us are prepared to put our heads into the shooting gallery to raise the issue.

ResilientGP is campaigning for a health service where we have the resources to do the job, safely and in a timely manner, for patients who need our care. The big reasons we cannot do this are the dismantling of the social contract between state and community, chronic underfunding, power brokers in the medical elite and government who have colluded to deliver their own agenda for their own gains, and not for patients. Many patients are scared and clueless where to turn, given that any ‘community’ beyond a daytime talk show really no longer exists for many. We do not have the capacity to meet all ‘wants’ anymore, and as much as I would like to, I have to be realistic in that I can only give so much of my time in a finite system to those who are ill and whom I can help influence their health. Give me the resources to do more, and I will. But I haven’t right now, and to pretend otherwise is to collude with those who have created the problem. By standing up and shouting ‘enough’ we are raising the problem and throwing the gauntlet at those who have created the problem in the first place, and that is NOT patients.

My mum died, too young, due to an uncaring government, a medico-political elite who debate in committees but have rarely experienced poverty themselves as I have, and yet profess to understand it better than I do, and a community who have not had to make sacrifices and no longer understand that a precious resource like the NHS should be used carefully, responsibly and should be cherished.

I hope that ResilientGP can work with others in both government, academia, Royal Colleges and the BMA to change the situation. My lifelong work in research, teaching and clinical practice has been dedicated to serving my patients, and trying to rebuild a community that has been lost, so it is resilient enough to fend for itself in days of need. I now dedicate my efforts in ResilientGP to my mum, so that she would be proud once again of an NHS able to respond and care when needed. She was proud of me becoming a doctor, and said ‘go get em son’. I won’t rest until we get a service for our patients that we can be proud of, despite whatever opposition is thrown at my colleagues and me. The battle is too vital not to win.

Rest In Peace Catherine Woodall (1945-2015), from a loving son and husband.

Alan Woodall

Ethical considerations

We feel that is is not unethical to raise real life examples of inappropriate appointment use. No one has identified any patient and sharing information on the misuse of resources and opportunity cost involved denying someone else more in need of an appointment is both worthy, ethical and necessary. The ethics of utilitarianism are equally important here and it is a duty of doctors to challenge inappropriate use of resources. It is, to us, highly unethical that the leaders of the profession have done nothing to challenge this elephant in the room.

We understand some might feel uncomfortable, but these are examples happening every day in the NHS, which occur solely because we are free at the point of use. The public have a duty to use services responsibly, or be educated in where they are not. The problem is now we are so overregulated and time stretched that for a doctor to challenge such use simply invites a complaint which then takes hours to respond to, so many NHS staff lack the courage or resilience to challenge. So we have to be brave, as a group of healthcare workers desperate to improve access for patients in need, and stand up to defend the NHS, profession and other patients who cannot access healthcare by raising this vitally important issue.

Inappropriate demands to GPs

Introduction

General Practitioners in the UK (GPs) have been contracted since 1948 by the National Health Service (NHS) to meet the reasonable healthcare needs of their patients. Each GP has registered with them on average 1,700 patients, any one of whom can request an appointment to be seen by the GP, giving no information in advance other than whether they need to be seen routinely or as an emergency.

To become a GP, one must study for a minimum of 4-6 years at University, work for 3½ years in hospital and then spend 1½ years training in General Practice before being allowed to practise independently – a total of 9-11 years of training and significant personal and taxpayer investment.

Every effort is made to encourage the ill to consult their GP in a timely fashion to receive whatever treatment or reassurance they need. Indeed, no GP ever minds reassuring someone worried they might be unwell.

Increasingly, however, many GPs feel that what is expected of them exceeds what might reasonably be considered fulfilment of healthcare need, or that it might reasonably be expected to be met by friends, family or other trusted sources of advice.

The real danger is that if NHS time is taken up dealing with matters that could be dealt with by someone else, the ill will find it harder to access the medical treatment they need that only doctors can provide. This important concept is known as “opportunity cost”.

We have latterly been raising this issue in public and been met with bemusement by those who never face (or acknowledge) the demands that are presented to GPs on a daily basis.

The conventional response by GPs to such requests is to seek to understand and even sometimes address what lies behind such enquiries, whether it be inadequate education or family support, concealed anxiety about a possibly underlying health condition, poverty or simply the need for an advocate.

In the face of unprecedented demand for NHS services in general and the skills of GPs in particular, it is now time to ask whether General Practice is being used appropriately, or whether society could meet some of the needs a GP routinely encounters without recourse to the NHS.

Survey Method

We conducted a survey on a large, private online discussion group composed entirely of GPs. We asked for examples that were considered by that GP to be an inappropriate use of their time and skills. We received over 200 unique responses. We excluded very similar responses or those we considered might have conceivably have been a presentation of underlying illness.

Another large closed group was consulted about how best to present the findings, which were then published on our website in the prior to a general election.

All responses have been anonymised.

Survey Responses

For ease of reference, and to help stimulate ideas for alternative solutions, we have divided these into six categories: cosmetic, normality, trivia, requests for prescriptions for everyday items, administrative and miscellaneous.

  1. Cosmetic

    – Concerns apparently relating entirely to cosmetic issues

    1. “I have stretch marks on my thighs”
    2. Cream to make breasts bigger
    3. Anti-ageing cream
    4. “Is my nipple too hairy?”
    5. “Is there a pill so I can have a baby boy?”
    6. “I have ugly feet”
    7. “Do you have something to make my nails stronger & hair shinier before my holiday tomorrow?”
    8. 19 yr old girl: “My chin looks too fat in photos on Facebook – I need an operation”
    9. “My iPhone camera makes my face look wonky”
  2. Normality

    – Concerns that in the opinion of the doctor are closely related to normality

    1. 6 week pregnant woman attended out of hours because she felt her tummy was “too flat”
    2. “My cat scratches my furniture and it upsets me because I love him”
    3. “I went to the gym yesterday and now my arms are hurting”
    4. I want to find out about my son’s ying and yang”
    5. “I have cockroaches in my house”
    6. “Doctor, please tell my son to study harder so he can get into Eton.” The child was 6
    7. Mum booked an appointment to ask the doctor whether she thought it was Ok if an 11 year old daughter went on a planned, overnight school trip that all the other children are going on
    8. “My sleepy baby keeps rubbing her eyes”
    9. “I seem to urinate for ages after drinking X pints of beers with mates”
    10. “A bird pooped on me”
    11. “My skin is too soft”
    12. “Can my child get red eyes from chlorine in the swimming pool”
    13. “What normal 15 year old boy doesn’t have porn on their computer?! I’ve looked and looked but he really doesn’t! That’s not normal!”
    14. “My daughter has a brown rash on her leg”. (felt tip pen ink which was rubbed off with an alcowipe pad)
    15. “My son has a rash on his ankles every night” (sock marks)
    16. “How do I get an eyelash out of my baby’s eye”
    17. “Can you stop my 11 year old daughter from only eating pizza and chips for dinner.”
    18. “I’ve bought these fancy anti ageing face creams. Can you look at the ingredients and tell me which order I should use them in?”
    19. “My son’s shoes are rubbing him”
    20. “I dreamt a few times my 12-yr-old daughter had stopped breathing. I was terrified I couldn’t help her”
    21. “Doctor – my stomach makes this weird rumbling/gurgling noise whenever I haven’t eaten. Its starting to affect my work!”
    22. “Hi Doctor. I booked this appointment 2 weeks ago but the problem has gone now. I didn’t want to waste the appointment so I thought it best to come anyway.”
    23. “I have grey hairs….I’m nearly 40….have I got a medical condition?”
    24. “I’m worried about a white lump in my baby’s gum.” The receptionist suggested it was a tooth. The irate mother suggested only a medically qualified person should judge that diagnosis. She demanded urgent appointment. It was indeed a tooth.
    25. “I get a static shock when touching the banister.”
    26. “Drinking coffee makes me urinate more & it’s affecting my quality of life.” Patient drank 5-6 cups a day.
    27. “I need some advice as I want to break up with my boyfriend and I don’t know what to say”
    28. “I have had a mouth ulcer for 2 days”
    29. Man in mid 20s “why when I drink certain types of beer I vomit and have a headache the next morning”
    30. “My child has something dangling at the back of his throat” (This is called a uvula and almost all people have one).
    31. “I get sore feet when I dance in high heels”
    32. “I can’t stop eating sweets and chocolate – I think I must have diabetes.”
    33. “I would like to undergo fertility testing as I have not become pregnant for 2 years now”. The husband had been away for 18 months.
    34. The other Dr told me I’m overweight but I really think it’s fluid and a water tablet would help don’t you Dr?” The patient had a BMI of 49 (morbid obesity).
    35. “I’ve lost my spidey-sense and need a test to find out why”
    36. “I had an insect bite last week and it itched like hell. It’s gone now, but wondered if it will itch if I get another one?”
    37. “If my body gets cold, I sneeze. This doesn’t occur if back in my hot home country.”
    38. “How do I guarantee a boy baby?”
    39. “I’m addicted to crisps “
    40. A man drags his partner in to surgery “He’s been talking to other men on the internet!”
    41. “What is the best way to cut my baby’s fingernails”
    42. “My wife is 30 , I am 50. I can manage sexual intimacy only 2 times a week. Do you have a pill to reduce her libido?”
    43. “My penis gets cold when I go outside.”
    44. “My 10 yr old daughter won’t eat vegetables. Can you refer her to a hypnotherapist?”
    45. A man presents with a yellow lump on his leg which had come up suddenly. This was triaged from a phone consultation to be an appropriate GP consultation. When the man attended, the GP pulled a gummy bear from the patients leg.
    46. “I’m allergic to avocados, if I eat 8 I’m sick.”
    47. “Doctor, my skin went a little red in the sun this past weekend”. “Did you use sun screen?”. “No”.
    48. “My testicles swing too much.”
    49. “I am allergic to cats. I am getting a cat. Can I get a vaccination”.
    50. “What do these grey hairs on my head mean? Is it normal?”
    51. A 24-yr-old lady attended GP worried as she got butterflies in her tummy when she was around a man she liked.
    52. “I have had a runny nose for the last half hour”
    53. Patient attends after a heavy night drinking with a headache.
    54. A middle aged man attended clinic wanting to know if it’s normal to have to blow his nose after washing his face.
    55. A patient with no symptoms attends to demand the doctor sends her for an X-ray “to make sure I am OK”
    56. “My pubic hair is too curly”
    57. “Please can you remove this pubic hair from between my teeth”
    58. “Doctor, please help. My partner has a fetish for silk scarves”
    59. “Doctor, I cannot fart without making a noise”
    60. “Doctor, I can’t face a bikini wax while I’m pregnant (it’s more painful than usual) so can you advise me how to tell my husband that I don’t feel sexy at the moment.”
    61. A patient consulted as they were concerned their feet sweated when they wore trainers.

3. Trivial

  • Concerns that the doctor felt could have been addressed by any sensible adult
    1. “Can you settle a marital dispute? My wife thinks paracetamol is better, I think ibuprofen is. Who’s right?”
    2. “I have sneezed twice in the last hour”
    3. “I have a scratch on my arm” (tiny 2 millimetre scratch. No infection).
    4. “My child has turned blue” -the child had blue dye on him from a duvet cover which had not yet been washed.
    5. Two emergency appointments for a cold sore. The first to tell the patient the diagnosis, the second (later that morning) because the grandmother (a nurse) disagreed with the original diagnosis.
    6. Out of hours prescription request for skin emollient (like a moisturiser).
    7. Patient called 999 and attended A&E because they had broken a FALSE fingernail.
    8. Man requesting a contraceptive pill
    9. “My child smells like yeast….”
    10. “My poo smells this morning and it doesn’t normally” with said excrement wrapped in tinfoil in a carrier bag.
    11. “I burnt the top of my mouth on pizza 5 days ago…”
    12. “I have blisters on my hands since I started in the rowing club”
    13. “I had a rash last week…it’s gone now. But seeing as I had an appointment I thought I’d come anyway!”
    14. “Tap water makes me ill. I can only drink mineral water but my decreasing benefits mean I can’t afford it anymore. What should I do?”
    15. “My cat has IBS – I just wondered if I could catch it from him?”
    16. “My lodger is annoying me because he’s spending too much time in his room.”
    17. “Can you fix my sprained ankle before I go out tonight as I want to wear heels.”
    18. “My 3 year old daughter’s poo is bright blue! Look!!”
      (Mum takes out a sample of excrement in the surgery in a Tupperware container).
      “Has she been doing any drawing with crayons lately?”
      “Yes? I suspect the blue one is missing!”
    19. “I’m really worried my daughter has a splinter… can you get it out? We haven’t tried by the way, because we were so worried”
    20. “I broke my nail”
    21. A patient brought in divining rods connected to a computer. The computer concluded the patient was allergic to eggs. The patient then requested an allergy test to eggs.
    22. “I sucked a bit of old baler twine a week ago and still have a funny taste in my mouth.”
    23. “My husband was snoring last night – I recorded it so you could hear”
    24. “Please can I have sleeping tablets as I live on a noisy street?”
    25. “My child vomited once this morning” – but was otherwise entirely well
    26. “I have had a sore throat since this morning” (30 year old man)
    27. “I have had a runny nose”. “for how long”, “the last 30 minutes”. (No other symptoms).
    28. “My baby’s poo is a funny colour and smells offensive”
    29. “My wife isn’t interested in having sex with me. Please can I send her to you so you can give her something for that.”
    30. “I’ve tinted my eyelashes but now there is pus everywhere and I can’t see. This has happened before when I had an allergic reaction when I dyed my eyelashes and I had to go to hospital. Can you stop it happening again?
    31. A man presents to the GP on Friday and voices his anger about not being able to get an appointment until then despite the fact he had a sore throat 4 days earlier. His throat was now better. He continued to moan to the GP about the system, despite the fact the GP attempted to reassure the patient he had had a self-limiting illness as was evidenced by the fact he was now better. The patient left unable to appreciate he had not only wasted an appointment, but that he would have never needed to attend in the first place.
    32. “I’ve just run my first marathon. My knee now hurts. I have not taken any pain killers but would like an urgent referral to physiotherapy.”
    33. “When I clean my ears with cotton buds, it makes me cough. Why is that doctor?
    34. A patient attended an appointment to tell the GP they had had diarrhoea in the last week which had now resolved. They felt it was important to let the GP know their self-limiting illness had settled.
    35. “Doctor, my farts smell very bad”.
    36. “I get indigestion when it’s cloudy and my child has ear discharge when there is a full moon”
    37. A male patient who had been diagnosed with irritable bowel syndrome reattended the GP concerned his symptoms might actually be due to ovarian cancer.
    38. “My baby’s snot is just too green”.
    39. A patient attended as they had stepped on a “slimy creature” the night before. This turned out to have been a slug.
    40. A patient attended with symptoms of a blocked nose for 12 hours. The doctor advised some saline spray as a decongestant. The patient then angrily said to the GP “You are useless” and waved a hand in the GP’s face patronizingly saying “bye bye”.
    41. “Doctor I have a cold, and I want to get well before marathon in 4 days. What can you do”

3. Requests for prescriptions of everyday items

  • Another very common experience for GPs, borne largely of the fact that those on low incomes pay nothing for items which are prescribed for them
    1. Paracetamol or ibuprofen (extraordinarily common request, especially for children)
    2. Sunscreen
    3. Toothpaste
    4. Anti-aging cream
    5. Sudocrem
    6. Shampoo (“to make my hair shiny”)
    7. Chapstick (“because my lips are chapped”)
    8. Bra (because of breast pain)
    9. Multivitamins
    10. Talcum powder (for sweating)
    11. “Everything I need from the chemist: nappies, toothpaste, toilet roll and my shampoo”
    12. “We are going on holiday so I would like a (free NHS) prescription for paracetamol, dioralyte, emollient and antibiotics just in case”.
    13. Fortisip drinks (because “I don’t like cooking”)
      • these are fortified drinks for patients who are deficient in nutrition. They are often given to chronically unwell patients such as cancer sufferers who cannot eat properly. They are very expensive to the NHS. They are also frequently demanded by intravenous drug addicts who will not pay for food over drugs. They are often traded by drug users for drugs because of their value.

4. Administrative

  • A longstanding burden for GPs (see the 2001 Cabinet Office paper Making a Difference: Reducing GP workload). This work falls outside a GP’s NHS contract. Many GPs apply charges for this work, as they are entitled to, to attempt to recoup some of the costs relating to their own time and that of their staff in meeting these requests.
    1. “Please sign my passport form”
    2. “Please sign my form so I can do my parachute jump”
    3. “Can I have a Letter for housing” “But you received one just last week”. “Yes but that was from another doctor, if I get two letters I think it’s a more convincing argument. Can you say the corridor is too narrow for 2 people to walk through at once? I will wait while you write it, I don’t mind”
    4. “Please fill in my (medically unrelated) work forms”
    5. Patient brought in a picture of mould in a teacup for a letter to be written to the council in order that she be rehoused into a bigger bedroom flat with more windows.
    6. “I would like a referral for my daughter to become a doctor”
    7. “I need a sick note because I don’t speak English well enough”
    8. “The school require the GP to write a note to allow a child to wear swimming goggles for swimming lessons”
    9. “Doctor, I was in France last week. Could you give me a sick note to cover please”
    10. “Can I have a note to say it’s ok for my child to eat food on a TV show”
    11. “Do you know how I can get into the furniture design business?”
    12. “If you’re giving me a sick note for 1 week, you might as well extend it for 3 weeks since I’m going on holiday and then I claim back the annual leave.”
    13. “We don’t have the same travel channel on our cable TV as our neighbour. What are you going to do about it?”
    14. “My 9 year old daughter cries and cries because we can’t get a dog” (pets not allowed in block of flats). “Please write a letter saying she’s depressed so we can get her one”.
    15. “Can you write a letter to get me a new flat. Mine is really dirty.”
    16. Patient who was pregnant for 10 weeks and otherwise well. “I can’t work anymore, could I have a sick note to last till end of pregnancy.”
    17. “Can I have a sick note for 6 months because I am nearly at retirement age”
    18. “I need a GP referral to get a free eye test”
    19. “Which college should I enrol in?”
    20. “Please can you help me write my CV”
    21. “Please can you fill out my driving licence application as I’m not sure how to”.
    22. Can’t decide whether to emigrate to Australia or not. The doctor in question received a complaint relating to this consultation. Apparently the doctors was: “bloody useless GP, no help whatsoever”.
    23. “I need the bus stop to be closer to my house”. “I have to walk past too many homeless people on the way to the station”
    24. “I need a letter for the council so they will box in my pipes”
    25. ”I need a letter to get reconnected to the electricity.” Apparently the patient had allegedly “fiddled” the meter and had not paid the fines.
    26. “Can my 12 year old (perfectly healthy) daughter have a note to say she can go horse-riding?”
    27. “Can I have a letter to get a better mattress from a charity”
    28. “Can you write a letter for the nursery to say my son can go outside with a coat off.”
    29. “Can you write a letter today to say you think I should go to beauty school. In Costa Rica.”
    30. “I’ve just been on holiday with my mistress. I’ve just got back and work want to know where I’ve been. I’d like a sick note to cover me.”
    31. Appointment for a lady requesting a letter from the GP for a washing machine as the communal one in the flat was not convenient.
    32. Letter stating patient is unable to attend their tribunal or ATOS assessment (a very common request)
    33. “Doctor, I need a new referral for my hospital appointment”
      “I thought I had already referred you for this and you had an appointment”
      “Yes, I forgot about it”.
    34. Letter request from a patient to verify that they are now vegan so a study bursary could be claimed.
    35. A patient requested a letter of good standing for her dog because a neighbour had complained about said dog to the council.
    36. “Doctor, I’m very stressed. I work hard and have to pay my rent weekly, pay for my food and I am left with no money at the end of the week”
    37. A patient attended for a letter for her travel insurance as she wanted to cancel her holiday to Spain in December. She was worried she will catch Ebola.
    38. “Doctor, please can you write a letter to my daughter’s school to say I’m finding the school run tiring and can they arrange transport to and from my house?”

5. Miscellaneous

  • ranging from the treatment of pets to the downright fraudulent
    1. “I would like an ECG, so that I’m medically cleared to go and take hallucinogens for a week in a Spanish private clinic to treat my depression” (Patient had never presented with symptoms and never been diagnosed with depression).
    2. Home visit to an elderly lady who “could not get warm and was shaking”. (Requested by her daughter). When the doctor arrived, there was no medical problem with the patient. It transpired the pilot light had gone out on her boiler. The doctor attempted, but was unable to relight this.
    3. Home visit request – turned out to be a request to change batteries in a satellite television remote control and advice on how to use it.
    4. “Can you cut my sons toenails as he doesn’t like it.” (He was 17 years old).
    5. (Phone consultation) “Dr my baby has just woken up and is crying. I’ve run out of milk. Can you pop over and bring me some.”
    6. “Doctor, I have toothache”. “Have you seen a dentist”. “No”.
    7. Patient attends for a repeat alcohol blood test after the one done by the police following a drink driving test (to try and cheat the DVLA).
    8. “Doctor, I have cheated on my partner and now I don’t know who to choose”.
    9. A heavily pregnant woman attended the GP and asked that GP to phone her husband to remind him of his “responsibilities”.
    10. A lady attended to ask the GP why there was one viagra tablet missing from her husbands packet.
    11. GP called to a home visit because the patient couldn’t open her tablets.
    12. Young lady attends and shows the GP pictures of herself and her sister asking the GP who they think is more beautiful. The GP told the patient this was an inappropriate request for a GP. The patient was shocked and upset by this.
    13. “Doctor, can you ‘make’ me diabetic (ie. on the records), so that I can qualify for free viagra”
    14. “Doctor, can you tell my husband to stop buying food that’s near it’s ‘sell by’ date as he’s wasting money.”
    15. A patient attended wanting to discuss her guinea pig’s health and whether the GP could prescribe medication on the NHS as she doesn’t want to pay the vets bills.
    16. A patient attends as they want to stay on sickness benefits longer and is worried that the doctors are making him better too soon.
    17. “Doctor I took some of my epileptic dog’s diazepam to help me sleep but now she has run out. Can you prescribe us BOTH some more?”
    18. “I am pregnant, and want an early scan because if the baby is a girl I want an abortion”
    19. “I don’t know why I’m here doctor, my wife made the appointment.” “Well shall we bring your wife in or telephone her perhaps?”
      “We can’t. She’s in Portugal.”
    20. “I have a broken tooth”

Footnote

These may sound like extreme examples, but they are all genuine events. GPs report that whilst such requests are not new, they now occur far more frequently. At a time when there are more patients with long-term conditions requiring care from their GPs, and when the population is ageing, it is increasingly difficult to justify spending so much time dealing with matters such as those listed above.

Resilient GP Facebook Group

“Why should I join the Resilient GP Facebook group?” This is what one of our 1,000 members said:

I feel like you are all so knowledgeable and I have lots to learn about how things ‘really work’ as I’ve just been a salaried GP for a few years and never really had much to do with the ‘inner workings’ so therefore it was easy to just ‘leave it to the others’ in a way. But I now feel more understanding and empowered and am grateful to Resilient GP for opening my eyes and encouraging me to look at the bigger picture and support each other in this fight against the powers-that-be. So thank you all!