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Jeremy Hunt

Responding to the Secretary of State’s announcement on the junior doctors’ contract, Dr Maureen Baker, Chair of the Royal College of GPs, should have said:

Jeremy Hunt is unfortunately a politician. All utterances that come from his mouth should be treated with extreme caution as they may contain comments that are not entirely based in truth. He has the mainstream media eating from his hand. I don’t trust him and neither should you. We are stuck with him as our Secretary of State, but we at the RCGP will support our juniors despite his every effort to undermine the great work of not just our junior doctors, but all our members.

The End

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Forward Planning

Do you want to know what the future of primary care holds? So do I. This is how the future is being shaped at the moment:
Appointments
We will provide non urgent appointments within 48 hours (under one proposal). That’s non urgent. Urgent appointments presumably within 48 minutes-unless it’s an emergency in which case obviously (or not) A+E might be better.
If they are open.
You stand roughly a 92% chance of being seen there within 4 hrs of attending as an emergency.
If you are not sure which A+E to go to then please ask a friend. Or your family. If you are really still not sure, you could always go to the nearest one. Or go to your GP (then repeat the process ad nauseum or until feeling better).
If you have had an accident or have an emergency then please do not attend your GP as they are trying hard to reach targets. The main target is the desk-aimed at by their head. Fortunately the blow is frequently cushioned by paperwork from NHSE/CCG/CQC etc etc.
Development
Primary care services are looking to integrate-with anybody who will have them. Applications must be submitted with details provided of exactly how many extra votes this will provide for the relevant political party come May 2015.
All applications will be considered-if looking to include alternative non NHS providers then those that pay a modicum of tax in the UK will be given greater priority. For example-Café Nero over Starbucks, Butlins Health over Amazon etc.
Applications must be submitted by hand, and should be signed in original ink on the back of the Elgin Marbles by Aneurin Bevan. Must be with NHSE by 3pm this afternoon to access part of the £2.54 extra initiative, cost cutting, vote winning, frail and clueless political party fund. This fund is not ring-fenced and can also be accessed at the House of Commons bar so please apply early.
Retention
The workforce is clearly under pressure and the government is trying to work out why this might be. They are going to ask people nicely if they would consider a career in General Practice. To help lure them, they will slag them off in the press, fiddle around with their pension, reduce the overall primary care budget, ask them to spend hours each week trying to commission services whilst running a business and trying to see patients, and help them to maintain focus by ensuring they spend as little time as possible at home. Interested? Please fill in the 26 page wellbeing assessment form which you can obtain from your GP and ask for an appropriate referral.

Oh well-you can only do your best, even in the most testing of conditions. The majority of GPs I know simply want to get on with the core work of caring for patients. I admire (and feel sorry for) those that have the energy and will to engage with the political process of organising primary care.
I for one will be eternally grateful when that boutique coffee shop finally opens beside the Citizen’s advice bureau office just along the corridor from me…
Richard Cook
January 2015

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Medical, Uncategorized

What’s in a name?

“Before you go Mrs Jones-just to let you know that I am your named doctor as of 1st April.”

“What do you mean?”

“Well, I’m going to look after you-care for you medically and all that. I will be working with associated health and care professionals to deliver a multidisciplinary care package to meet your needs.”

“Eh? Isn’t that what you’ve been doing for the last 20 years?”

“Well, yes, but that doesn’t really count-I wasn’t officially your named doctor. The point is, I’m really going to take control now and care for you.
Look, I’ve even got a new badge-do you like it?”

“But didn’t you care when I lost Albert? You seemed to care for him, you organised the hospice team and you looked after me when I got upset and couldn’t work for a while ?”

“Of course, but…”

“What about when I had my heart attack-you sent me down to A+E and you even came and saw me in the hospital as well. Surely you were looking after me then?”

“I know, but the point…”

“And when I had my lump-you sorted out all the treatment for me, arranged for the nurses to keep an eye on me, and chased up the specialist when they lost my records and I didn’t have an appointment?”

“Yes, I know but..”

“What is this-some kind of April Fool joke? You’ll be telling me it’s some ridiculous political idea to boost votes soon!”

“Ah, well, there is this idea floating around that GPs should, well, look after their patients and act responsibly.”

“Who’s idea is it?”

“Um, Jeremy Hunt’s.”

“Jeremy Hunt? The racing driver? I thought he was dead?”

“No, no-the politician Hunt. The Health Secretary. Our named leader of health.”

“Oh-I don’t worry about politics. He’ll probably move on to education in the next reshuffle. I know that you will be here for me-I can rely on you. I trust you.

And I like your badge.”

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Pharma

One of the great things about our work is that rarely a day goes by without learning something new.This knowledge can come from many different sources including patients and colleagues, and is not just related to things medical, but life in general.

Over the years I have discussed numerous non medical topics with patients including holiday destinations (campsites in France),photography tips, cycling apparel and Jeffrey West shoes to name a few.I have no doubt that, on occasions, these discussions have shaped my ( and my patients’ behaviour) in a very conscious manner.

Back when I was a house officer over 20 years ago I still remember the rich pickings of free curry and handouts provided by the drug companies.The Frumil green tourniquet was a thing of beauty, and to have one dangling from your white coat pocket really was a status symbol of the mess, to be used time and again,creating veins from nothing in the dark of the night.Did I unconsciously take on board the subliminal tourniquet message? I don’t remember ever prescribing Frumil, but I do remember sinking back in to bed after another successful venepuncture.

photo

We no longer maintain these relationships with pharmaceuticals of course-slowly over the years we have moved away and rely on our CPD, reading and practice or CCG formularies to help guide our prescribing habits.Health and safety has removed the reusable tourniquet too-I am now forced to bin any old catheters instead of putting them to good use.

Fast forward to a wet and windy day nestling under the South Downs as an 87 year old giant of a man slips in to my room, leaving his tractor in the car park and trailing mud behind.

“How do you stay so fit?” I ask, knowing he still works long days and rises early.

“It’s all about breakfast” he says,”bacon,sausage,eggs and black pudding every day-always leave the fat in the pan and reheat it each day for the best flavour”.

“And your cholesterol ? ”

“Oh-bugger that,I don’t mind if I die young”.

And so I have learnt again, how to cook bacon and die happy.

The secrets of Big Farmer.

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The doctor, the patient, Skype.

It is over 50 years since Michael Balint wrote about the consultation model, and there have been many other worthwhile contributors to education around this area since then. It is an area of our day to day work that can always improve, and will develop and change over time as we acquire new skills and learn more about our patients. The vast majority of our consultations take place face to face, but over recent years we have made increasing use of the telephone to triage and consult with patients. Some doctors like this more than others-and patients feel the same. But what of Skype? How does this fit in to current consultation models?

I like technology- smartphones, gadgets, touch screens and all that, but I really don’t like Skype. Socially, I view the phone as a means to an end-a communication tool, bullet points needed, a minimum of conversation. Texting is great for me-I can do it when it’s convenient, short quick messages, get the points across and move on. I have never been a great conversationalist (just ask my wife…) so prolonged phone calls are not really for me. 100 free minutes on my mobile phone contract-that will last me the year not the month. I can see why others feel differently and use the phone to keep in touch with family and friends- and Skype for many will be an extension of this. For me-I find it awkward and stilted with the worst bit being the goodbye. Is it OK to hit the end button now? Are they still looking at me? Shall I let them do it first? I have used it a few times to talk to the kids when I’ve been away without them (rare in my line of work)-and I can cope with the social indecision with them. But patients? What will it add?

 I spend a lot of time consulting face to face but also over the telephone-especially in the out of hours setting and I feel comfortable with the processes involved. Much of what we learn from patients is from the narrative itself, with any examination needed a supplement to that. I am left wondering what Skype can add to this from a doctor’s perspective and can really come up with only a few examples. Will it aid us in making a diagnosis or should we look upon it as a system that might help patients (and politicians) more than doctors? Is it possible that patients will be reassured by simply “seeing” their doctor-I doubt it.

As with all things new, no parameters of normal have yet been developed-so knowing whether we are doing it “correctly” is going to be difficult to judge. When mistakes or complaints are made-who will judge what a “normal GP” would be expected to do? It is possible to record Skype calls but it does not look terribly straightforward so this may be an option for some and could be useful to both patients and doctors.

 I am struggling to think of a long list of conditions that I might be able to deal with over Skype that I would not otherwise deal with over the phone. Confirmation of minor skin conditions maybe-urticaria, viral rash or even shingles spring to mind. Cellulitis ? A vague swelling somewhere? External thrombosed  piles? It may be that the only way forward is to suck it and see (not the piles), embrace the technology if it works, tread carefully, safety net and, if in doubt, arrange a face to face consultation.

 The next step, of course, will be a daily skype update from the care home staff….

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Need a job?

My senior partner has just announced his retirement after 30 odd years working at the frontline of primary care . Before the ink is even dry on his letter to us, our thoughts turn to how to replace him. Who, in this day and age of political meddling of the highest order, restricted budgets and the promise to work for longer and longer hours, would want a job in primary care?

A friend of mine is involved in opening a new café in Brighton which has a strong cycling theme (http://www.velo-cafe.co.uk/). What a great idea-cycling and coffee have always been a perfect match so to bring them so close together seems obvious (especially as it is virtually on my doorstep).So what will he look for when employing new staff for this exciting venture and how will he sell his project to them? Presumably attributes such as an interest in cycling, coffee or both  would be a good start? An interest in people? A believer in good customer care? This is beginning to sound like my perfect replacement partner-substitute patient for customer and we’ve got a deal!

In reality of course, there are lots of attributes that we look for in a new partner, and there must be many ably qualified doctors out there to fill such a role. It seems, however, that many of them are not looking for a partnership role, but choosing to bide their time and see how the political landscape settles down over the coming years before committing themselves to a permanent post.

Well-my message to them would be…don’t be put off primary care. The nation will always need GPs, and we need good ones. The organisation of healthcare is changing, but there will always be a requirement for good primary care teams. We also need interested doctors to be involved in shaping the future of primary care-this can be done alongside our daily work if you are part of a good team. We need Queen Bees and workers-you can develop your role over time and there is huge scope now in primary care to take up interests in a variety of clinical and non clinical areas.I feel you would be best supported in this as part of a good partnership-one in which you can rely on your colleagues, and they can rely on you.

I suspect in 20 years time our health care assistants will be performing coronary bypass surgery in the basement as a daycase, but we will still need someone to look after individuals and their families in the community. Despite the chaos around us, we can still focus for 10 minutes at a time on the patient in front of us-this will always be our prime objective, and is what makes our core job so special.

Come and join us.

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qof-a conflict of interest?

8:30 Monday evening and Mr Jones walks in to the consulting room. He and the doctor are new to each other. What could possibly go wrong.

“Good evening Mr Jones”.

Silence is the answer. No verbal response, downcast eyes and a flickering of the lip.

The doctor watches and his diagnostic feelers start to quiver-albeit slowly as it has been rather a long day. Mr Jones has arrived halfway through his third surgery of the day, 12 hours after the start of the first. Gordon Brown has certainly left his mark on primary care-extended hours surgeries a boon for patients?

So what next-the doctor starts to think, what goes through his mind? What should go through his mind? He tries to focus-on the patient in front of him, not on the distracting forces around him. What are those forces-what can distract him from the single most important aspect of his work?

To understand how best to help the patient, we may first need to understand how best to help ourselves as doctors. To clear the mind, to remain alert, psychologically well, and concentrate our efforts during those sacred 10 minutes. This is not easy, especially when some factors are out of our control. We find ourselves making working, lifestyle and financial choices which can all affect patient care if not handled carefully. We work within a practice, and have obligations to our partners as well as our patients. We may be part of a family and must also fulfil our role at home. We have bills to pay, maybe a mortgage, as do our partners at work and this also hovers in the back of our minds during the working day. How do we ensure that we separate the patient’s needs from our own? There has been much published over the years about the doctor/patient relationship-much of it very good at the time, and many aspects of it still relevant today. I would argue that this relationship is under threat by external factors-particularly QOF, and we will have to concentrate our efforts to preserve it in its natural form.

I can’t say that QOF has had no beneficial effects for patients-I think that it has and has probably helped to improve some aspects of our care, and highlight some deficiencies as well. However, it is a blunt tool, and it was never designed with the consultation in mind.

I don’t like QOF now. In fact I resent it. Moving goalposts and adjustments year on year soak up efforts and resources from the practice that should be focussed on patient care. I dread to think how many hours we put aside to discuss QOF targets/exemptions and how many staff we have working on this. The practice machine works away slowly at this over the year-but the focus is never really on good outcomes for the patient, it is on the financial implications for the practice.

Let’s go back to Mr Jones. Our first thoughts are to try to engage with him and untangle his problems. Depression? Migraine? Bereavement? In to which domain, if any, will he be categorised by QOF?  When I am trying to help a patient with possible depression, I don’t want to be trying to remember which template to complete, or whether I have remembered every component of said template. I want to be listening, watching. I was glad to see the passing of PHQ9-some found it helpful but I cannot remember it ever helping in a treatment decision. Why did we do PHQs? Why do we spend time completing templates? For patient care? I’m not convinced. If our primary interest is patients, then QOF=finance= possible conflict of interest.

So where to next? Are we, as physicians, able to manage and treat patients without being contaminated by financial or practice affairs, and is this a reasonable expectation? I hope that we are, but I don’t think that QOF helps us. We should look for alternatives, and pursue these in any future “negotiations” with DOH. I am not naïve enough to believe we can ignore the financial constraints within the NHS. I do believe, however, that we need to minimise the impact of this during the consultation.

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