Category Archives: General Practitioners

Some tips to avoid waiting to see your doctor……. but it is going to get worse, and more expensive whatever.

A relative had to call the doctor for a urine infection. It was painful, they had a fever, and yet no treatment was available without an appointment, and a sample of urine for culture. The urine was lost, and they went privately because there was “no other way” to get treatment! This cost time, energy and £65, but to the English Health Service it has cost another disillusioned taxpayer. Stories abound about poor access, delayed investigations, and subsequently poor outcomes. The shortage of doctors has been predicted for more than a decade, and the poor manpower planning that has led to those doctors we do have being “part time” is understandable for all of us close to the profession and the service. Disillusion is not confined to the public, but is endemic in the caring professions…. hence early retirement and emigration, and changes of career. Poorer parts of the UK will be more affected, as when there is undersupply doctors will choose to work in more affluent areas with better schooling and infrastructure. These areas will also have more people prepared to pay for the private option. Just as dentistry has “gone private”, so Primary Care (G.P.) is facing the exact opposite of the National, fair, mutual service(s) that Aneurin Bevan enabled in 1948. We are bringing back fear, rather than replacing it.

Some tips to avoid waiting to see your doctor…….

Write your symptoms down on headed paper and deliver it ( by relative if necessary ) as the doctor will have to read the letter, have it scanned into your notes, and act on it accordingly. The envelope should be addressed to your preferred or normal doctor, but make it clear that any doctor will be adequate. If you think it urgent mark the envelope as such, but be aware that GPs have been excused form being an emergency service. ( A true emergency, as defined by the state(s) and not by the patients, needs a 999 call, and attending A&E. ) Verbal messages over the phone are not recorded in a standardised manner, so recording is different in each practice. Emails either direct to a practice, or from receptionists receiving messages, are not necessarily copied into notes.  Access is going to get worse, and more expensive whatever: there are just not enough doctors for the next 15 years..

The “ideal” concept, as originally envisaged has died. We have to ration health care, so better that rationing is overt rather than covert. It must be universal for big expensive services such as cancer care, and heart surgery, but it may have to be local (post coded) for smaller items and services which are not expensive or life threatening. My personal preference is for means tested health care in the same way as we have means tested social care. This would allow combining budgets without internal argument. All that remains is for the press and the politicians to reach this conclusion. The bad news is that this will take decades, and many deaths.

The prospect of a “telephone app” doctor does not convince me at all. Advertisements in London have small print saying that, to access this service, you will need to re-register. The old adage of History, Examination and Investigation is being replaced by History, Investigation and then possible examination but by a different doctor. I predict: No continuity of care. No trust. Waste by over investigating, and then by litigation costs. What better incentives to go privately if you can afford it? What better way to destroy the health services by making them unofficially “two tier”?

Sarah Baxter reports that: “Doctors are quitting and surgeries are threatened. Services need radical reform” in the Times 11th December 2018.

Scary news. More than 350 GP practices may close next year and millions of patients face a three-week wait to see their doctor. To be frank I thought everybody in Britain, like me, was already obliged to book an appointment three weeks in advance. So whenever my children, say, need prompt attention for an ailment that might be serious but probably isn’t, I send them to one of those private walk-in clinics for £65 that you can find around the back of central London railway stations.

Not everybody has that opportunity, but I felt ashamed about running to the A&E after my son was prescribed a couple of Nurofen for a neck injury on the football pitch that turned out to be nothing. Equally, I’m not prepared to wait three weeks for an examination. I did try to change surgeries, but was told by a nearby GP practice that its situation was far worse……….

My NHS clinic is Theresa May‘s ideal – if only I could see a GP (The original Times article)

Correspondence:

Sir, You report that, in the past year, 9.3 per cent of patients waited more than three weeks for an appointment (“Millions of patients face three-week wait for GP”, Dec 7). While it is undeniable that there are serious resource shortages at GP practices, there is much that patients can do to improve the performance of their GP service. In my local practice, patients fail to turn up to 5 per cent of booked appointments without giving prior notification. During the course of 12 months this wastes 50 per cent of the time of one whole doctor.

In the case of minor ailments, patients who agree to accept an appointment with a clinical nurse or agree to visit a pharmacy directly can improve the availability of doctors for more urgent appointments.
Richard Harvey
Oakham, Leics

Sir, Tony Blair made two big errors in his dealings with primary care: allowing GPs to opt out of 24-hour care and interfering with appointment systems that practices had fine-tuned to meet the needs of their patient population. As a result of being embarrassed on national television in a Q&A session with voters, he introduced a “one fits all” system incentivising practices to deal with all requests for an appointment within 48 hours. The only way this could be achieved was for practices not to allow booking in advance so the appointment book was empty at the start of each day. This created the rush hour at 8.15am and a lucky 30 got an appointment.

Any service where demand outweighs supply inevitably has a pinch point and in this scenario the bottleneck is at about two to three days. Urgent cases can still be seen on the same day and chronic conditions can wait a couple of weeks with no detriment to the patient. Illnesses such as sore throats, viral illnesses, diarrhoea and vomiting, etc get better without the need to be seen at all.
Dr Andrew Cairns
Petersfield, Hants

Sir, Maybe the delays in being able to see a doctor are not caused by, as you report, “the chronic shortage of GPs”. Out of the seven GPs in my doctor’s practice, six only work part time.
Douglas Stuart
Guildford, Surrey

Sir, It is not just general practice that is under enormous strain; patients across the country are also struggling to access NHS dentistry. More than half of NHS dental practices are closed to new patients and some people face a 90-mile round trip to get to their nearest surgery.

As chief executive of the largest provider of NHS dentistry in the UK, I see first-hand the acute shortage of NHS dentists, particularly in remote areas, and the impact this has on patients. The government urgently needs to train more dentists and, most importantly, allow high-quality clinicians from around the world access to work in the UK.
Tom Riall
Chief executive, mydentist

Sir I am lucky enough to be registered with a GP practice in west London which operates a system that ensures that medical advice can be easily accessed. Each weekday morning and four weekday afternoons a walk-in clinic is on offer where, as often as not, a patient is able to see the doctor of their choice without too long a wait. As well as this facility, an appointment — perhaps for a lengthier consultation — can be arranged using the phone, sometimes subject to a week’s delay. If this busy practice can achieve such a service, then why are not all practices aiming for such a system?
Sheila Keating
London W2

Image result for two tier service cartoonWorkload pressures and the GP shortage forcing practices … to close

GP surgery closures ‘will see 3 million patients lose out in the next year’ 

 

 

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Late cancer diagnosis… and poor cancer care. Let GPs have access to tests, and when there are enough, involve them in key treatment decisions.

Its not only the late diagnosis of cancer, influencing outcomes, which annoys NHSreality, but also the pretence that cancer and terminal care are under control in an ageing population. The opportunities to improve quality of life in the last few weeks and months is a great one. The subject of “advanced directives” or living wills is hardly discussed in society. This desperately needs to change… Teams of clinicians involving oncologists, GPs and Palliate Care consultants need to review far more cases together, and much earlier.

BBC News 26th November 2018: Cancer care: England still lagging behind the best

GPs need better test access to improve cancer diagnosis
OnMedica27 Nov 2018

Cancer patients wait more than a year for diagnosis
The Times22 hours ago

Early cancer diagnosis rates drop in several areas
Health Service Journal26 Nov 2018

Cancer care still falling behind in England

Letter in the Times 28th November 2018:

CANCER DIAGNOSIS
Sir, As senior academic GPs working in cancer research, we agree that the UK’s performance in timely diagnosis of cancer is distressingly poor but contend that the solutions proposed in your leading article (“Catch Up on Cancer”, Nov 26, and letters, Nov 27) are flawed. Patients with possible cancer are often older, most have at least one pre-existing long-term health problem and many have complex medical histories. These are the very patients that the providers of online diagnostic services prefer to avoid. A straight-to-specialist service will shunt the workload of sorting out patients with non-specific symptoms on to NHS specialists, whose capacity is under at least as great a pressure as general practice and who generally lack a broad expertise outside their own discipline.

GPs are highly skilled at making diagnoses, despite the pressures they work under, and their referrals for suspected cancer have doubled in number since 2009. However, they need the same access to sophisticated diagnostic tests as their counterparts enjoy in other high income countries and they don’t need the downward pressure on referrals being increasingly exerted by our NHS. At the same time research is urgently needed to develop new diagnostic tests that work well for ruling out cancer, and to translate them into clinical practice, so that GPs can more efficiently select those patients who do need specialist assessment.
Professor Greg Rubin, FRCGP
; Professor Willie Hamilton, FRCGP; Professor Richard Neal, FRCGP; Dr Fiona Walter, FRCGP

In a celestial world as outlined by the old NHS, there was universal, cradle to grave cover, with no barriers to access, free at the point of delivery, and without reference to means. Funny that we have so many medical charities then. And the greatest number of these charities is in the Hospice (Palliative and Terminal care) sector. These charities are mostly run from physical buildings, and hospices, but in the poorer areas of the country they are “Hospices at Home”. The idea to help elderly at home is a good one, BUT it overlaps so much with charitable providers. The perverse incentive for Trusts and Commissioners to offload as much as possible to these charities will inevitable mean there are large post code voids in cover. NHS reality does not object to this IF it is honestly discussed. The solution is a means based insurance based system, and since most of the assets in the UK are held by the elderly this would be more progressive.

Chris Smyth reports November 22nd in the Times: Rapid response teams will help elderly at home

NHS “rapid response teams” will be on call 24 hours a day, seven days a week to help frail and elderly patients who fall or suffer infections, Theresa May will say today as she promises to use extra health service cash to keep people out of hospital.

GPs will also get to know care home residents personally in an effort to keep them well at home. Such services will get an extra £3.5 billion a year by 2024 as part of a £20 billion boost promised to the NHS in the summer

Experts welcomed the ambition but questioned whether the NHS would have the staff to provide the services, and warned that such top-down initiatives often backfired…..

…Simon Stevens, chief executive of NHS England, said that guaranteeing the money for local services would help to make the plans a reality.

“Everyone can see that to future-proof the NHS we need to radically redesign how primary and community health services work together,” he said. “For community health services this means quick response to help people who don’t need to be in hospital.”

Sally Gainsbury, of the Nuffield Trust think tank, said: “This money will simply allow GPs and community services to keep up with demand over the next five years. That’s important but it means the new money announced today is not going to lead to a significant change.”

She added that there were “serious questions about whether the NHS has the right staff in the right places to carry this out”. She warned: “We would agree the NHS needs to focus on helping people more outside hospital and getting them home more quickly. But the idea of telling every local area to do the exact same thing has often backfired in the NHS, as it is bound to be less well-suited to certain places.”

Plans for state-backed indemnity scheme for GPs in Wales

This is a piece of good news for GPs in Wales, but it should be National, not regional, and the ultimate solution is a “no fault compensation” scheme as in New Zealand. The scheme may give Wales an added attraction, which along with the inducement payments may help recruit and retain GPs.  There is a net 20% loss of graduates from Wales annually, and this may help correct, but it alone is not enough. Education is the big issue for doctors and their families, and addressing this is a longer term problem. Perhaps it will be extended to Hospital specialists as well?

Adrian O’Dowd for “onmedica” reports Friday 16th October in the BMJ: Plans for state-backed indemnity scheme for GPs in Wales

he Welsh government has announced its preferred partner to deliver the new state-backed scheme to provide clinical negligence indemnity for GPs in Wales from next year.

A medical defence body, however, has criticised the move, saying this was an untested scheme with insufficient detail and could remove GPs’ ability to choose an integrated indemnity and advice product instead.

Welsh health secretary Vaughan Gething announced yesterday the NHS Wales Shared Services Partnership’s Legal and Risk Services, who currently indemnify GPs working out of hours, is the preferred partner to operate the Future Liability Scheme from April next year.

Mr Gething, speaking in Cardiff at the Primary Heath Care Conference, organised by the Primary Care Hub and 1000 Lives Improvement in Public Health Wales, said the scheme, which would be aligned to the scheme announced in England, would ensure GPs in Wales were not disadvantaged and that GP recruitment and cross border activity would not be adversely affected by different schemes operating in the two countries.

Mr Gething said: “This new scheme will provide greater stability and certainty for GPs in Wales. It will support GP practices and primary care clusters in their delivery of sustainable and accessible health care.

“The Future Liabilities Scheme will cover the activity of all contractors who provide primary medical services. This will include clinical negligence liabilities arising from the activities of GP practice staff and other medical professionals such as salaried GPs; locum GPs; practice pharmacists; practice nurses; healthcare assistants.

“I will make a final decision on the delivery of the Future Liability Scheme in Wales following further engagement with medical defence organisations.”

Medical and Dental Defence Union of Scotland (MDDUS) chief executive Chris Kenny was sceptical, saying: “We are concerned that this untested state-backed indemnity scheme will be implemented in April 2019 when so little detail has been shared with MDDUS or GPs in Wales.

“We have been pressing the UK and Welsh governments to provide comprehensive operating and funding details of the new scheme for some time now yet little has been forthcoming.”

The existing medical defence organisation (MDO) model worked well, he argued, adding: “Writing MDOs out of a claims service is a false economy – and a threat to GPs’ professional standing.

“That’s why we expect the state-backed schemes in Wales and England to preserve these principles. If government want to offer a simple claims only service, then GPs should be able to choose the integrated MDO service at no financial disbenefit.

“We believe this is a high-risk approach which fails to protect GPs’ professional reputation, removes choice and, as independent contractors, GPs should have the option to choose an integrated indemnity and advice product as compared to the state-backed scheme.”

Dr Charlotte Jones, chair of the British Medical Association’s GPC Wales, said her organisation supported the Welsh government’s choice of preferred partner.

“The proposed scheme will address one of the biggest financial pressures on GPs and will help enable all GPs, practice teams and wider cluster healthcare professionals to work more closely together taking forward the transformation of Welsh primary care.”

Dr Peter Saul, joint-chair of Royal College of GPs Wales, said: “Indemnity is a real issue for GPs, which can affect the time they can spend in practice treating patients. The college campaigned for and supported the announcement of a state-backed indemnity scheme and it’s encouraging to see steps being taken to create a sustainable solution.”

Asbestosis report: BMA – Medical indemnity for GPs in Wales

2012 (6 years ago and it’s worse now!) : Medical negligence costs rise in Wales – NHS News

See the source image

 

The decline of suicide (except for the USA). No GP should avoid psychiatry training..

It is a worry to professionals who have an interest in “systems” that so much government time is spent getting advice from the USA. In mental health especially, but life expectancy as well, America does worse than most other countries. On Saturday the Economist (this week) publishes a report: Staying alive – why suicide is falling. 

It is socialised medicine, and especially universal care/cover which really addresses Mental Health, but it has to be properly funded. In the UK some 40% of what a GP sees has a psychiatric element, and yet not all GPs do psychiatry in their postgraduate training. Psychiatry is so unpopular that there have been “doctors” discovered practicing who are not trained…. This needs to change, and it is only by training all GPs in psychiatry, and with ongoing Balint support for these GPs, that psychiatry will get the professional backup it deserves.

“Around the world, suicide rates are falling as a result of urbanisation, greater freedom and some helpful policies. America is the notable exception: since 2000, its suicide rate has risen by 18%, compared with a 29% drop in the world as a whole. It could learn from the progress made elsewhere, and more lives could be saved globally with better health services, labour-market policies and curbs on booze, guns, pesticides and pills”

Jamie Ensor on Newshub 20th November 2018: Investigation into Kiwi woman’s fake psychiatry qualifications leads to 3000 doctors being inspected in the UK.

GPs on the press/media rack. The Balint approach.

Mental health still surviving on the crumbs

Lets train GPs properly in 6 week rotations. None should avoid psychiatry..

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If Nurses fill the gaps left by the shortage of GPs, this will be the start of private practice in many towns..

Most GPS will be too busy to read or reply to Mr Darzi. As a retired GP I feel I have to reply. The letters from the Times’ replies are in the pdf below.

It seems a little ironic for a surgeon, who deals with operations and definitive outcomes, to comment on General Practice. The good GP uses time as a diagnostic tool, lives with uncertainty and handles patients with multiple symptoms and often multiple diagnoses.

Failure to train enough doctors is one problem. Training a disproportionate number of females to males is another. Making the job more and more desk bound and administrative is another. The shape of the job has changed a lot, but given time, appropriate training, and backup of a good team it would still attract. GPs need broader training especially so that all of them have the same opportunities in Paediatrics and Psychiatry, and Old age medicine and rehabilitation.

Doctors are trained to think laterally and make a diagnosis. The training takes a long time but why has only 2 out of 11 applicants been successful over the last two decades? Rationing places at medical school has now killed the goose that laid the golden eggs of efficiency. Nurses will probably refer more, request more tests, follow up more, and may well make more mistakes. The litigation will follow…

And will this mean that unpopular areas retain GPs, whilst unpopular ones have Nurse Practitioners? A health divide if ever there was one, and an encouragement for private practice.

Ara Darzi opines in the Times 9th October 2018: Nurses can fill the gaps left by the shortage of GPs

Primary care and public health are becoming even more important as the population ages, diseases change and the need for long-term community care grows. Yet at the same time, this work is becoming increasingly unpopular with doctors.

To add to the problems of retaining GPs, a survey of general practice trainees carried out this summer by the King’s Fund, a health think tank, found that only a fifth planned to be working full-time a year after qualifying. The proportion planning to be working full-time after ten years was the same.

This is an astonishing vote of no confidence. Like many of their generation, young GPs want a portfolio career. They want to be involved in research and education; the prospect of owning and running the same practice for the next 30 years is a million miles from what most hope to do with their lives. They are not alone. Surveys show a similar trend across the world, with fewer than 10 per cent of physicians choosing family medicine in some countries.

Here, then, is an opportunity for nurses. Advanced practice nurses, also called nurse practitioners, are as effective as doctors at many tasks and, according to one study, could take on 70 per cent of GPs’ workload. Their main areas of expertise are in the management of long-term chronic conditions such as diabetes; they can diagnose, treat, prescribe and refer patients to hospital, and admit them if necessary. There are limits to their responsibilities (they don’t treat children under five or expectant mothers and they can’t sign sick notes) but they are acceptable to the public, take less time to train and cost less than GPs.

A report by a group of international experts, to be presented at the World Innovation Summit for Health in Doha next month, which I chair, will argue that nurses are poised to become the dominant force in primary care. They tend to live in the communities they serve, understand the local customs and culture and are well placed to detect early signs of disease and help tackle the wider social determinants of health.

There is a growing recognition that nurses are well suited to provide the sort of patient-centred care that is needed to look after the rising numbers of people with chronic diseases such as cancer, heart failure, diabetes and dementia.

There are barriers. Improved education, recruitment and commitment from employers will be required. But if we are to solve the crisis in primary care, we must urgently look to positioning nurses as the new gatekeepers of the NHS.

Professor Lord Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London

Doctors to see groups of patients – is probably madness. The fox is waiting..

Letters in reply to Mr Darzi

Image result for filling the gap cartoon

Image result for filling the gap cartoon

 

Doctors to see groups of patients – is probably madness. The fox is waiting..

The one thing a Doctor does, which others don’t do, and for which he is indemnified for mistakes, is to make a diagnosis. The first consultation is the important one, and afterwards, follow up can be done by many others. Physiotherapists, psychologists (or cheaper and less trained nurse counsellors) , Parkinson’s or Macmillan nurses etc.  The achievement of a diagnosis involves examination, usually physical, but often psychological as well. Many patients present with “vague” or multiple symptoms, and some poor practices have demanded only one symptom per consultation!

The follow up rate of GPs differs according to their ability and willingness to live with uncertainty. Achieving a full diagnosis in physical, psychological and spiritual dimensions may take more than one 10 minute consultation, but this is unusual in todays accelerated world. All GPs need to know their follow up rate compared to their peers, but remember it needs to be adjusted for age and complexity of patients, and older GPs see older patients. Not many practices know their follow up rates, and very few GPs know theirs.

One technique to reduce uncertainty is to refer everyone. Nobody complains, but they do wait! Consultants used to know the GP, and after reading their letter, would often prioritise the referrals from those who sent patients infrequently. This unofficial form of rationing was reasonable. What happens today? Are letters sometimes handled by administrators and then treated equally?

Wriggleing on the hook of rationing health care in different ways, means that we will see many experiments until the numbers of diagnosticians increases. if a GP is needed for a 2 hour group surgery he could have seen 12 new 10 minute appointments in that time, along with the opportunity to examine and personalise the consultation. The old definition of a GP giving “personalised continuous care to patients and their families” has been abandoned in the modern world, but this does not mean we should not aspire to it. But if a GP practice follows up so many patients that they personally need to see groups, then that is not good use of resources. Others can do the follow ups. Leave doctors to diagnosis…

I found several current definitions (I have excluded those that focus on the negative (a doctor who did not specialise) and none of them mention the ability to live with uncertainty or to use time as a diagnostic tool. The GP was the goose that laid the golden eggs of efficiency in the original health service. No longer, and the fox is at the door..

Image result for jemima puddle duck

The RCGP 1977 definition is here and

WONCA updated it’s definition in 2011

Others are:

a medical doctor who attends to the everyday medical needs of individuals within a community.

a doctor based in the community who treats patients with minor or chronic illnesses and refers those with serious conditions to a hospital.

A physician whose practice is not oriented to a specific medical specialty but instead covers a variety of medical problems in patients of all ages. Also called family doctor.

A fully registered medical practitioner in the UK who provides general medical services to a particular group of patients or “list”, either in partnership with other GPs, as a salaried GP in a group or, less commonly, as a single practitioner. GPs may also provide inpatient care in community hospitals. A GP will refer patients “forward” to a consultant (hospital specialist) when the patients’ needs cannot be addressed locally. GPs in the UK are not NHS employees, but rather contract independently with the NHS.

Both the Telegraph and the Mail last weekend reported on the shortage of GPs, and that they were looking at solutions whereby GPs see patients together. Obvious confidentiality issues – but also a group support ethos…. GPs to see groups

Hannah Mays in the Times 8th October reports: GP surgeries to see 15 patients at a time.

Group consultations of up to 15 patients are likely to be made “the default” for the NHS in its ten-year plan to tackle waiting times, it was claimed last night.

The scheme has been promoted as a strategy to ease the strain on family doctors and cope with growing shortages of GPs, and been piloted in areas including London, Birmingham, Manchester and Sheffield.

Doctors involved in the pilots said that they had reduced the time spent repeating advice and that patients were given as much as 90 minutes to discuss their condition with fellow sufferers. The longer sessions could also help doctors to develop closer relationships with patients and their families. They said that the consultations had proved more efficient at tackling health complaints including obesity, diabetes, arthritis and erectile dysfunction.

NHS England describes group consultations as medical appointments provided by a clinician in a peer-group setting that “potentially doubles productivity and access to routine care”. The clinician may be a receptionist, clerk or healthcare assistant with one day’s training who would be able to direct the group towards advice on their condition. Patients are asked to sign confidentiality forms to ensure that what is discussed remains within the room. In some sessions test results are posted on a board and a consultant, GP or nurse leads brief discussions with each patient.

However, Joyce Robins, from Patient Concern, said: “This is a ghastly idea. GP appointments are supposed to be a private matter where you can openly talk about your most personal health issues. If you’re discussing things in front of a group of strangers, you might as well tell the local town crier.” Rachel Power, of the Patients Association, said that the sessions would be helpful in some cases but added: “We are concerned that these group consultations are said to replace traditional appointments, apparently without exception.”

Any GP you want: so long as you’re healthy

The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

Letter in the Times 9th October:

SHARED GP VISITS
Sir, I thought my eyes were deceiving me when I read your article “GP surgeries to see 15 patients at a time” (Oct 8). I was also surprised by the Patients Association being reported as saying that this move “would be helpful in some cases”.

Are we now all to believe that Samuel Butler’s work of fiction, Erewhon, is likely to become a reality? He wrote about an imaginary visit to a topsy-turvy country where it was a punishable offence to be physically ill but where criminality and immorality were looked kindly upon as treatable diseases.
Ken Mack

Wrexham, north Wales

Sir, In deeply rural villages, we all have the same doctor. Now I love my neighbours, but do not yearn to know the condition of their nether regions, or to recount my symptoms to the butcher, the baker or the gossip maker.
Sylvia Crookes

Bainbridge, Wensleydale