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:
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.
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.
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


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….


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.


The decline.

I was out cycling with a friend recently when he told me about the comments of an ex professional cyclist. When asked about how he enjoyed cycling after his retirement, his reply was, “it’s all about managing the decline”. We chatted about how difficult this must be, to reach the peak of a sport, and realise that your time is up and how to deal with that recognition. As I watched my friend disappear in to the distance, I mused over my own peak-had I reached it yet?


It was later in the day, on recovering my breath, that I began to draw an association with our role as primary care physicians and the “management of decline”. We see many patients every day, of all ages, some ill and some not so ill. With the ever increasing age of the population, we are of course seeing larger  numbers of  patients who are past “their peak”, whose health is declining, and many of them also struggle to come to terms with this, and will frequently seek help in how to manage it. More specifically, it got me thinking about those patients whose health is deteriorating, for whom there is no prospect of improvement, and coming to the realisation that we perhaps should be focusing our efforts jointly with patients on “managing decline” rather than cure. One difficulty is accepting this, or understanding when that point is close to being reached, or has already been passed.

I am not talking about the patients on a clear cut pathway of treatment and transition into palliation. The oncologists and palliative care teams will be seeing a lot of these patients, and of course usually manage this transition well. I am talking about those suffering a gradual decline and being managed mainly in primary care-perhaps living with dementia, heart failure or simply old age.

A few years ago I heard of a patient living with alcoholic liver disease. His GP advised him during a consultation-“look, we’ve discussed this before, if you don’t stop drinking then you are going to kill yourself”.
The patient paused before answering-“I know that doctor. You have told me before, but you didn’t tell me it would take this long”.
The penny dropped, the doctor realised at this point that the patient understood his predicament. He was not going to stop drinking-he wanted help and support in “managing his decline”. The relationship changed, the doctor stopped looking for a cure, and they worked together with a shared understanding of the management plan.


So what can we learn from this? As a doctor, I have learnt to keep listening, asking questions and to constantly revisit the management plan to ensure that wherever possible patients, carers, families and doctors are all singing from the same hymn sheet. We perhaps should consider this more readily, even in those patients without an obvious “terminal illness”, helping patients accept illness and to manage their ill health. We should not be afraid or surprised of what patients might tell us-offer them opportunities to discuss their fears and expectations, encourage them, allow them to voice their darkest thoughts . Above all, support them in that difficult journey from health, through their peak, down the inevitable decline towards death.
Patients may have formed their own conclusions about their health well before we realise, and discovering this sooner rather than later will help them and doctors alike.

Richard Cook
August 2013