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Priorities & Pedicures

I’m a part time GP and full time mum to a 2 and a 3 year old. Last night the 2 year old kept me up most of the night – that’s parenthood, and I was just grateful that today was one of my days ‘off’. Since she decided to catch up on her Zzz’s in the buggy on the nursery run I decided to treat myself to a brief moment of relaxation and a pedicure.

Half way through another customer walked into the shop. A woman in her 50s, very overweight with the unmistakable growl of a heavy smoker. She wanted a mani and pedi. It’s a Friday so they are busy and explain she will have to wait. “Oh” she says, “I’ve got a GP appointment in an hour” the technician shrugs, all the staff are busy, she’ll have to come back another time. “Alright” says the customer, “I’ll get the doctor to ring me instead. I mean she rang me last night already, but it was 7.30, who wants to answer a call from the doctor at that time?”. I watched aghast as she rang the surgery and claimed she couldn’t get out the house this morning and could the doctor ring her instead.

Five minutes later I watched as she reached in her handbag for a salbutamol inhaler. “That doctor hasn’t given me the antihistamines I asked for a week ago” she told her neighbour with a put-upon sign. “Two days I’ve been without them! I can hardly breath! It’s not good enough.”

So I sat, lip firmly buttoned, I’m not in the mood for another debate, I have enough of those at work. I thought about that GP, making phone calls late into the evening. I wondered if she had worked the 12 or 13 hour day many of us now consider standard. I wondered how many patients she had seen to face that day, 30? 40? 50? How many phone calls? How many lab reports? How many letters from hospital colleagues to read and action? I wondered if she had slept well last night. Had she laid awake struggling to unwind from the stresses of the day? Did she worry that the work load meant she couldn’t do her job as well as she wanted, couldn’t do what was needed for her sickest patients? Did she fret that so many decisions made in one day made mistakes inevitable? Did she pray that she hadn’t made a mistake which harmed a patient or left her open to complaints, litigation or even criminal charges? Did she continue working at home completing a portfolio of educational ‘evidence’ to ‘prove’ she is still fit to do her job year after year? Did she see her kids that night? Did she wonder where those headlines about super-rich GPs come from when her salary seems to pay for her childcare and not a lot else? Did she wonder if her physical and mental health could survive working at this pace for the 30 odd years until retirement? I know I do.

As GPs we have become used to being undervalued by government and bashed by the press. We know the headlines about £100k salaries and 9-5 working are nonsense, we know that primary care has been chronically underfunded and over recent months we have done a better job of getting this message across. At the end of the day very few of us do this job for the money, for an easy life, or for political ambition so we often fail to be our best advocates. Most of us do the job for the patients.

The patients. ‘Think of the patients’ the juniors are told when they dare to strike over imposition of an unsafe and unfair contract. ‘Think of the patients’ GPs are told as we are asked to open our doors seven days a week despite being stretched to breaking point already.

Well sitting next to me was one of these patients. A patient who preferred to miss an appointment at the doctor than one at the spa. A patient who would happily pay £40 to get her nails done but wouldn’t dream of paying two quid for an over the counter antihistamine she was ‘entitled’ to on prescription. A patient who wants her doctor to call, but only at a time that suits HER (even though she can’t be bothered to keep her appointment). A patient who would rather have tablets and inhalers than pack in the fags to improve her own health. And perhaps worst of all, a patient who despite being called by her GP late in evening to help her with her health concerns doesn’t miss a beat in slagging off that same GP because she hasn’t got her tablets exactly when she wants them. I will accept that it unusual to witness this extreme level of selfishness and disrespect in a single patient, but I’m pretty sure that everything I have described above has been experienced by most GPs on a regular basis.

I am a fervent believer in the NHS. I consider it a privilege to work in a healthcare system that is the envy of much of the world for it’s quality and cost effectiveness. I believe in primary care as the cornerstone of our NHS. I have always argued passionately that primary care must remain free at point of delivery because, you guessed it, I’m thinking of the patients.

Today I was reminded that for too many patients a service with no charge is also perceived to have no value. Cancel your solicitor, accountant or hairdresser at short notice and expect to be charged, cancel your GP in favour of a manicure and then complain that they haven’t made you better! Ha!

All the while the GPs are seeing more patients than ever before, patients who are more complex and more demanding by the day. They are working longer hours, shouldering greater risks, earning less money and facing ever greater challenges to keep their practices afloat. In doing so these GPs are propping up a system on it’s knees. A system broken by underinvestment and constant use as a political football, and now damaged further still by a government and right wing press that stoke ever greater patient expectation and demand, whilst failing to provide the funding to meet it. It’s almost as though they want the whole thing to crumble….

Today I’m not thinking of the patients, I’m thinking of those doctors exhausted, stressed, anxious, overburdened and ploughing through the endless 10 minute consultations on this sunny day. I’m wondering how long they can keep primary care afloat for the sake of the patients. I’m wondering how long they should.

Dr Laura S

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

 

Open letter from Grassroots GPs to Junior Doctors

AN OPEN LETTER FROM UK GRASSROOTS GPs TO JUNIOR DOCTORS
5th November, 2015
Dear Colleagues,
We are writing to you as your trainers, colleagues, former junior doctors and most importantly as your GPs to express our support at this testing time. We have been watching the events unfurl in the Junior Contract debate and have been appalled by the misuse of statistics, untruths and spin being uttered by the government about this unfair, unsafe new contract and the refusal of the Secretary of State to return to the negotiating table without pre-conditions.
Junior doctors work very hard. We have all been Junior Doctors at various times over the past 30-plus years, and consequently we know how unsafe working once was. The Government is refusing to negotiate on vital safeguards; putting patients and staff at risk and now suggesting that the CQC should be put in charge of hospitals adhering to their agreed working times. A somewhat misguided plan would be a charitable interpretation of this move.
The training you need to become the GPs of the future will be threatened by this contract.

General Practice benefits from the wealth of experience you have and will most effect:

• Those who may transfer over from other specialities to join General Practice.
• Those of you who wish to spend time doing research.
• Those of you who wish to take time out to have children.

This life, clinical and academic experience should be welcomed and encouraged, not
undervalued and underfunded. Although there have been reassurances that the GP supplement will not be removed, we are uncertain as to the validity of this reassurance until proper negotiation can take place without preconditions. Mr Hunt’s new offer via the media yesterday does not reassure us.

We know you work long hours and anti-social shifts that affect your lives, your relationships and your families. We know when you are not at work, you are studying for exams and attending courses. We know you do this for a fraction of the income the public believes you earn. Strike action may compromise care in the short-term, but we firmly believe the long-term effects of this ill-conceived contract are far more damaging. As GPs, we will try to support you through the stress that this contract change is having on you all as individuals. Please talk to your clinical supervisor or registered GP if things become too much.

We will support whatever decision you make.

Signed on behalf of UK GPs by the Committee of GP Survival,  the Committee of
Tiko’s GP Group and the Partners of Resilient GP

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

Empty Promises & Disenfranchised Doctors

Resilient GP strongly condemns the actions of DoH and their bulldozing of the negotiations of the junior doctors’ contract.

The Government made an election promise to find 5000 new GPs. The first move has been to cut the pay of doctors training to be GPs by up to an estimated 31%. The imposition of an unfair contract will ultimately result in the loss of the best and brightest that are already paid less than comparable peers in other industries. It will become unaffordable to be a doctor in England.

This move will ultimately harm patient safety. Prompt and decisive action is needed by the Government to rectify this travesty.

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.

We really must meet again Mr Hunt

Dear Mr Hunt

Eight months have passed since I challenged you at the RCGP conference in Liverpool and I think we still have some unfinished business. The elephant in the room is now a stampede.

In the time that has passed between then and now, it has become increasingly unpleasant to work as a GP in the UK. This is a real shame; General Practice used to be a really fulfilling job, and on some days, it still is. The majority of my patients are wonderful and providing them with high quality professional medical care is incredibly satisfying. I love that part of my job; I know that I make a very positive difference to the lives of many people.

So, what’s the problem you may ask?

When did you last visit a GP Mr Hunt, as last time your kids were ill you bypassed the system and took them to A&E. Perhaps this was a publicity stunt to prove a point. The reason I ask is that I and many others have realised that you have absolutely no idea what a GP actually does. I don’t say this lightly, I know you aren’t a stupid man, but the fact that you think that we can be replaced by physicians assistants who will have done a maximum of 82 days training in general practice as part of a 2 year postgraduate course and who even then will be unable to write a prescription makes me wonder?

Becoming a GP is the end result of a minimum of 10 years of training. I use every year of that experience to do my job properly. We see people who may have something serious or who may have something minor, but both presenting with the same symptom. Deducing the cause takes knowledge, skill, time and experience, not a computer algorithm. I spent 6 years teaching people how to be GPs too. I have seen very capable clinicians fail at becoming a GP because it requires a very precise and highly tuned set of skills, both clinical and communication based. This simply cannot be achieved in a shorter amount of time, in fact, it probably needs longer training based in General Practice, not in hospital.

Instead of valuing this professional expertise, you currently seem hellbent on denigrating it. Not all GPs are going to be perfect, we know that, we are human, but every negative headline suggesting that we don’t know what we are doing, or that we earn too much, or that we don’t work hard enough or don’t diagnose enough of this or that, eats away at public confidence in us and makes patients distrust us. This is leading in turn to an increased number of complaints (in fact, the GMC and ombudsman are encouraging people to complain). This causes a further loss of morale and wastes an inordinate time to answer. Some complaints are justified, sadly more and more are about patients not getting what they want, rather than what they need. This is fuelled by your consumerist approach to the health service.

What on earth you are you up to? There is now a petition with more than 100,000 people calling for your resignation. You are attacking consultants, GPs, in fact anyone involved in the delivery of the health service (with the notable exception of your pal Simon Stevens at NHS England). One must ask oneself why. My guess is that it is a well considered plan to set the medical profession up as the scapegoats for the NHS collapsing. You have absolutely no intention of helping it survive. This clearly cannot be seen to be your fault though; that doesn’t make good politics, so why not make it the fault of the GPs trying to run commissioning groups, the consultants or GPs who won’t work 7 days routinely. We aren’t stupid either Mr Hunt. If you were to resign, someone else would simply step in and do exactly what you are doing, because this is the policy your government has decided to implement.

Whilst I am a GP, I have worked in hospitals too. I have trained GPs (I resigned because the evil cousin of NHSE, HEE made that job too unpleasant to do too), I work for the local CCG and I am a GP appraiser. I have 2 young children. It would be easier for me not to care about all of this and just plod on and do my job. But I can’t because your actions have made my job almost unbearable. I have the CQC, the GMC, NHSE and the ombusdman all waiting for me to make a mistake and pounce. I have patients coming in ready for a fight because you have raised their expectations and they think I am basically an antibiotic dispensing machine who earns too much and they know better than me (some do, I am not that arrogant).

I have watched colleagues flounder and indeed I have had to take time off due to the anxiety all of the above creates.

With lovely colleagues around the country we set up ResilientGP to try to educate GPs in sustainable ways of practicing that will enable them to not burn out and to support each other. We have 2726 members as of today and running that forum means we see and hear about the daily struggles and thoughts of those who post. They are frustrated, fed up and many are planning their emigration or retirement as I write this.

Why does this matter? It matters because without good quality primary care the population of the UK will suffer. At the moment, thanks to your rhetoric, they don’t really know this. They don’t appreciate that their surgery is probably only one retirement away from shutting, they don’t really understand that the shortage of GPs in the country means that they may not have one soon. This is the inconvenient truth and so instead of having a grown up discussion with the population about using the NHS in a responsible way, you instead make us out to be the incompetent baddies.

I could emigrate. My husband is a GP as well and we could be financially better off and probably happier in another country, but we aren’t, because I want to stay here and look after my patients and help General Practice in the UK to survive.

We know what you are up to, we know why you are doing it. We ask that your party stops and has a sensible discussion with the professionals who know what is happening at the coalface (not some of the yes men/women who you use to give credence to claims you have consulted the profession). There are ways of fixing this. Lets discuss them.

You were too busy to visit a GP practice who invited you to spend some time with them “due to prior commitments” until September. May I politely suggest Mr Hunt, that you and your ill-advised staff shift your priorities and in your words “get real” about the perfect storm you are currently overseeing.