My story of everyday scholarship in general practice

Faraz Mughal is a GP in Birmingham and the RCGP Clinical Fellow in Children and Young People’s Mental Health. He is on Twitter: @farazhmughal

Making scholarship part of my daily practice contributes to the intellectual challenge and enjoyment of my work in general practice.

Self-harm affects 1 in 12 child or young people (CYP).1 Nearly 10% of 5-16 year-olds have a mental health illness which means in an average school class of 30 schoolchildren, three will suffer from a diagnosable mental health disorder. With increasing pressures facing young people in all aspects of their lives, the rates of mental illness are likely to rise. CYP mental health is thus a challenge for GPs everywhere.

At the frontline, we as GPs detect mental health illness; whether it presents as a physical health symptom, through parental/family concern, or simply an instinct you have when seeing a CYP in surgery. It is known that CYP with mental illness are twice as likely to attend to see their GP.1 Mental health is something we should be all thinking in every CYP we see.

But it can be an area of practice that we all find difficult, we can feel uncomfortable tackling this clinical area. Locally GPs have described, both personal issues (a lack of training) and service problems (difficulties accessing specialist services) as reasons for this.

In my own practice, I realised that there were limited resources available in this area and that accessing support from specialist services was difficult. I explored this further and realised others were experiencing similar problems. So, I began to think about how I could help address this, how I could improve my own practice while also helping the wider primary care community?

When RCGP advertised an opportunity to become the RCGP Clinical Fellow for CYP Mental Health I grabbed the chance to apply (these are regularly advertised through the RCGP so do keep an eye out!). Through this role, I have been part of an enthusiastic team developing quick-access resources for GPs and primary care staff to use in consultations with patients (accessed through the RCGP Mental Health Toolkit: http://www.rcgp.org.uk/clinical-and-research/toolkits/mental-health-toolkit.aspx). I also have the chance to influence policy through pushing for improvements in national and local services for CYP mental health. In addition, we have developed ‘TopTips’ articles for GPs on self-harm and eating disorders in CYP with more in the pipeline.

We are always thinking of how we can support GPs and if you would like to get involved with the college on working in this area, please do get in touch, we would be really pleased to hear from GPs and primary care professionals who want to work with us.

Reference:

1.     Department of Health. Future in mind: promoting, protecting, and improving our children and young people’s mental health and wellbeing. 2015. Available at: https://www.gov.uk/government/publications/improving-mental-health-services-for-young-people

 

General Practice: The Game of Inches

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

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Anybody who was a fan of movies, sports, or Al Pacino in 1999 is probably familiar with Pacino’s famous ‘game of inches’ speech. Pacino was playing the part of coach to a struggling American Football team and it was with this speech that he inspired his team before they ran out for a make or break match. Many consider it to be a paradigm for motivational speaking.

In it he describes American football as being a game that is won or lost by inches. The inches are the fine margins found everywhere on the pitch that determine the outcome of the match; the inches by which a crucial kick is made or missed, the inches by which a touch down is scored or stopped, the inches between a ball being caught or fumbled.

The general practice consultation is a game of inches or, more accurately, a game of seconds. In a world of increasingly complex patients and increasing administrative burden every second within the ten minutes counts. Squeezing every second is the difference between running to time or running late, it is the difference between satisfying the patient by dealing with their second problem or getting an unpleasant comment on the friends and family test, it is the difference between having the time to make the right decision or the wrong one.

In between looking at that funny mole and ticking the QOF boxes, it is easy to let the note taking seconds vanish from the consultation. How often is a complex and draining consultation summed up with a couple of rushed and inadequate sentences that hardly do the interaction justice as we hurry on to see the next patient? How often do these rushed entries leave us indefensible in the eyes of the law and the GMC should things turn out badly?

It seems unlikely that our patients are about to become more straightforward and, whilst we might wish it, the administrative burden of our roles is unlikely to diminish any time soon. But there are ways that we can squeeze those vital seconds, ways in which we can make that part of the consultation count.

How many of us ever learn to touch type?

For example, almost every interaction we have with patients results in typing and yet how many of us ever learn to touch type? A proficient touch typist can type as quickly as someone speaks and it is a skill that is relatively straight forward to acquire with a few minutes of practice each day over the course of a few weeks.

Of all the technology in our rooms, the keyboard is amongst the most simple and yet most of us use it badly. Data from NHS England suggests that the mean number of words typed in a GP consultation is 29.¹ This seems very little given the often complex nature of the consultations and probably reflects the time pressures involved. This data was from an audit of 200 consultations and data acquired from the same audit suggested that a GP who touch types rather than using the ‘hunt and peck’ method of typing could save 17 minutes each day, or nearly two consultations worth of time, based on 40 consultations per day.

Perhaps better yet is to stop typing altogether. Voice recognition technology is not new but it has taken some time for it to become capable of handling medical dictation. At my practice, most of the GPs now dictate directly into the patient notes, both for consultation notes and for letters, obviating the need to type at all. We use Dragon Medical which can transcribe at a rate of 160 words per minute, but there are numerous other medical transcription software packages that are capable of the same.

The ten minute consultation is bursting at the seams as is, arguably, the whole of general practice. If a seismic shift in the way we work is not soon forthcoming then, for now, we need to work in the inches. We need to find ways to make every precious second count and there are relatively simple technologies available already that can help us do that.

Reference

1. https://www.england.nhs.uk/wp-content/uploads/2016/03/releas-capcty-6-topic-sht-6-3.pdf

Self discovery with an ankle fracture

Kate Dawson is a full-time remote and rural ​GP on the Isle of Benbecula in the Outer Hebrides.

At our staff night out, I slipped on a wet dance-floor, and in a moment, fell and became a patient. I couldn’t put any weight on my foot, and my ankle swelled dramatically. As a consequence, I have learned a lot about myself, our systems, my colleagues, and about being a patient.

Our practice manager showed the most clinical acumen, and provided paracetamol and an icepack. The party continued as I watched from the side-lines,

I was on duty in A&E in our community hospital two days later and arranged for my ankle to be x-rayed. I knew there was something up when the radiologist asked me how much my ankle hurt; I had walked into the department, having done a full surgery. She confirmed that I had a comminuted fracture of my right ankle, in the run-up to Christmas, a time of year when medical locums are hard to find. I had an air-cast boot and crutches provided by the A&E nurse, and continued to the ward-round.

Three weeks later, the swelling was down but the orthopaedic surgeon was not happy, and I was admitted for open reduction and fixation in the Western Isles Hospital, adding another few weeks onto my recovery.

Firstly, I had no idea how much hard work it was using crutches. I had no problems with the co-ordination, but the strength required to walk more than ten yards is significant. My hands hurt, my shoulders were cramping up and my gluteal muscles had to learn how to balance me on my good leg. It took me quite a while to get to grips with this.

Secondly, my sisters both broke their wrists, and we have been able to compare notes about progress, the advice we were given and the progress we have made. It led me to examine the information and support we give to patients with common wrist and ankle fractures. The information that we have is quite brief, and focuses only on plaster care. Between the three of us, we have written four patient information leaflets, which are now being reviewed by a patient panel, plaster technicians, orthopaedic surgeons and physiotherapists. The aim is to adopt this board-wide.

The physios are very keen to be able to provide support with walking aids, exercises and treatment plans much earlier. We are meeting to discuss how we improve the pathway for patients with musculoskeletal injuries.

I am prone to doing everything myself, and I had to learn to ask for help.

Thirdly, the kindness that I experienced first-hand from colleagues and patients alike was wonderful. I am prone to doing everything myself, and I had to learn to ask for help. There is an art to this, making sure that your wishes are clearly expressed and the need for action described. Our wonderful practice manager rearranged the rota to cover my two weeks ‘resting’ with my leg up post-op, colleagues and locums all stepped up to fill the gaps.

Fourthly, I have learned that slowing down doesn’t mean that I do less. Instead of rushing around, sorting out everything in a whirl, I must plan my route through the day to take into account lifts, locations and tasks to be done. I have successfully ‘reabled’ myself by buying aids online, unbelievably cheaply, and remained independent where possible.

Lastly, this experience of being a patient has also illustrated very clearly how my agenda as a patient can be reframed by a few wise and confident words from a fellow professional. The orthopaedic surgeons and physiotherapists knew exactly how to motivate me into doing the right things, with good direct communication.

In exchange for a broken ankle, I have found my practice team to be kind and resilient, and I have developed the arts of patience, planning and delegation. I have started the improvement of the care that we offer patients with MKS limb injuries, anticipating better outcomes in the future.  My focus on good consulting skills is going through another cycle of improvement, and the cat is pleased too; I am sitting down more, and my lap is available more often.

Letter to Dr Sarah Wollaston – prevention of suicide and continuity of care

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

This is an edited extract from a letter to Sarah Wollaston MP, Chair, Parliamentary Health Select Committee.

Prevention of Suicide. The crux of personal continuity of care

Late in December I heard a radio discussion (BBC Radio 4, Today) about how our community and its designated services might best prevent suicide. All the participants, including you, talked with clear sense about evident truths: our need for adequate (and increasing) funding, the need for skilled vigilance in primary care and in charitable organisations, easy access to joined-up, well-trained specialist services… No surprises and no real contention.

What I did not hear was anyone emphasising the importance throughout pastoral healthcare – so particularly with the desperately emotionally anguished – of personal continuity of care. No substantial attention was paid to the harm done by serial reforms and modernisations which, generally, have made such personal care increasingly difficult, now often impossible.

Pastoral healthcare has become increasingly misunderstood, neglected and impoverished.

Yet recognising and understanding these losses is essential for any therapeutic reparation and engagement. Since my medical qualification more than forty years ago the medical technologies have undoubtedly got better, but the healthcare relationships that administer these are often worse. How this has happened is complex: the consequences, certainly, are unintentional. The result is that, overall, treatments of structural diseases continues to improve, but pastoral (personal) healthcare – that which cannot be quickly fixed by technology – has become increasingly misunderstood, neglected and impoverished. Within this rubric mental healthcare is a prime example.

In the 1970s I worked as a young psychiatrist. Mostly we were able to provide a kind of flexible and personally attuned care with personal continuity, which has since been driven out by modern systems. This erstwhile care was largely provided by consultant-led general psychiatric ‘firms’ together with family doctors (rather than ‘primary care service providers’) who then worked in much smaller practices with identified patients (‘personal lists’). Both provided cornerstones where patients and practitioners could, through repeated and easier contact, develop bonds of naturally evolving personal knowledge and understanding. Most sufferers of mental health problems and experienced practitioners agree that such personal continuity is essential to the kinds of relationships that can enable first, trust and comfort, and then healing, repair and growth. This work is delicate and nuanced so becomes much more difficult – if not impossible – where there is not the time or context to develop these bonds. It can be helpful to see the evolution and nature of such bonds – between sufferers and healers – as bearing a close resemblance to those that evolve in well-functioning families: both are held together by developing relationships of trust and affection.

Such a ‘family’ ethos of providing pastoral healthcare has been made more and more unviable by our successive reforms and modernisations. With few exceptions, such ‘progress’ is defined by increasing systemisation so that the vagaries of personal meaning, relationship and attachment are replaced by rapid devices for ‘logical’ process: diagnosis, despatch and packaged intervention. Influence by bespoke individual understanding becomes displaced by generic prescribed ‘treatments’. But with this kind of human complexity we usually find that the greater our efforts of direct control, the less our understanding. If we are heedless of this we risk killing – however inadvertently – the human heart and natural habitat of our pastoral healthcare.

Modernisation programmes have become – paradoxically – antitherapeutic.

This change of care ethos from a kind of family nexus to a factory-like complex of contracted ‘service providers’ has increased massively in the last two decades – the last half of my long career in Psychiatry and General Practice. In that time I have seen now both services have become depersonalised in proportion to their systemisation. What does this mean? Increasingly, people do not know one another: contacts more rarely become deeper relationships, not just between doctors and patients, but also between colleagues. Data storage and transfer may be rapid and complete, but the slower, subtler, human processes of growing meaningful attachment, affection and containment have been largely driven out by our reforms. So such modernisation programmes have become – paradoxically – antitherapeutic. Hundreds of conversations I have had with older practitioners and patients support this view – the exceptions are apologist colleagues in management posts.

What are the devices that have transformed our healthcare family into a factory: from understanding natural processes to driving industrial protocols?

One source is our illusion that we can treat healthcare as a commodity, utility or manufactured object. From this other things have necessarily evolved: a consumerist view, attempts to monetise and proceduralise all care so that it can be commissioned, traded and controlled. Hence the Internal Market, the purchaser-provider split, autarkic competing NHS Trusts, Clinical Commissioning Groups, commercial-type incentivisations, the Health and Social Care Act (2012) … the list continues to grow. We have been very clever at fashioning such reforms, but very unwise not to see an ineluctable flaw: their destructive human and social effects.

This dehumanising systemisation of services is seriously demoralising and has led to our poor staff recruitment, sickness, drop-out, burnout, premature retirement … and suicide.

Our corner-stoned 4Cs – competition, commissioning, commodification and computerisation – have all been much vaunted as assuring more accountable, equitable and efficient healthcare yet have rendered us general practice and mental health services with poorer human contact, engagement and attachment. This dehumanising systemisation of services is seriously demoralising for staff. The work becomes increasingly stressed and impoverished of deeper (human) satisfaction: this has led to our poor staff recruitment, sickness, drop-out, burnout, premature retirement … and suicide. How can complexly distressed patients possibly do well in a service that is itself so sick?

In the last few years of my work in the NHS I have found it increasingly difficult to offer the kind of personally synergistic, comforting, containing, healing work I used to manage so readily with colleagues. The reasons for this are largely found in our organisational reforms – the kind of thing I have outlined above. Potential suicides pose our trickiest and starkest healthcare questions and tasks. There is always more to think about, to do and undo.

HEE budget slashed – turning NHS crisis into a catastrophe

Sunil BhanotSunil Bhanot is a GP partner in Hampshire, trainer, appraiser and member of RCGP Council.

Our NHS is about to lurch from crisis to catastrophe. Our capacity to change and cope with increasing demand is going to be undermined. Health Education England’s budget is being slashed by 30% from next month. I fear that this will have a significant impact on GP training and the transformation of the whole NHS workforce in moving towards a sustainable health care service.

It is only recently that this massive reduction in funding has been confirmed, planning has begun and it is becoming apparent that there is increasing central pressure from HM Treasury for it to be implemented by the end of the next financial year. HEE staff around the country have received emails asking them to consider voluntary redundancy and reply by 6th March.

As it is becoming common place in our NHS, professional and public consultation has again been neglected. The worst day in the lives of many leading educators has been smothered by the secrecy of contractual obligations so that they have to deny even the possibility that there may be negative implications of the cuts. It is this very lack of transparency and honesty that puts at risk patient safety, the quality of care that we are able to provide and trust in everything that we do in our NHS.

Talking to many leading educational colleagues from around the country, they are shaken to the core but are unable to share their significant concerns and have to try to exude external confidence and calm and keep smiling. This is no way to treat hard-working, dedicated and committed HEE staff who are passionate about our NHS ethos.

Educational colleagues are shaken to the core but are unable to share their significant concerns.

On its website, HEE states that it exists for one reason only, “to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours”. While the CQC talks of an NHS “burning platform” which is not fit for the future and the King’s Fund about the “credibility” of the STPs, we are about to destroy any potential for regeneration. I suggest that a 30% cut in the HEE budget will harm all our efforts to deliver the promise of progress.

The “Five Year Forward View” and the Sustainability and Transformation Plans require a workforce that has enhanced training, is flexible, efficient and effective and remains motivated to continue to learn and develop, focusing on improving the quality of patient care. This needs investment in education, training and professional development not just the articulation of hopes and aspirations followed by a kick in the teeth. There is immense pressure to increase the number of doctors, nurses and allied professionals in our NHS especially with Brexit. The challenge to develop different ways of working and retain our workforce is equally daunting. And I doubt that the Chancellor will mention the cuts in next week’s Budget statement.

I am asking for an open and honest conversation, decent engagement with the profession and the public, on the challenges and opportunities to transform our NHS with our limited resources for learning and teaching. I’m asking the RCGP, other Royal Colleges, GPC and the BMA to share our concerns with HEE, our Health Secretary, HM Treasury and the Prime Minister. We need to work with Simon Stevens, Chief Executive of NHS England to explore an alternative way forward.

I am not looking for sympathy and warm words, but I am asking for a pause and some time to consider the truthful and real implications. And, therefore, please RCGP and BMA, publish and share the responses that you get.

General practice in Scotland and Australia: the experience of two GPs

Jane Gall and Derek Wooff, are both general practitioners who worked in Stranraer, Scotland for 26 years and have been working in Shepparton Medical Centre for the last 6 years.

General practice is a good job. It uses knowledge, experience, judgement and intuition to provide appropriate care and this complex process is both stimulating and rewarding. Currently with rising patient expectations and decreasing investment, solutions to workload issues may benefit from broader thinking and looking to other models of care.

We wish to reflect on our experience of translating care from the NHS in Scotland to Medicare in Australia.

We became emotionally exhausted attempting to continue providing the level of care expected by the population. 

Our background was working as general practitioners (GPs) for 26 years within the NHS model of care based in Stranraer, a small town in Scotland. We knew our patients and their families extremely well. We were truly part of a team with practice nurses, linking with district nursing staff and being part of the community hospital. This involvement provided professional satisfaction and support from a multidisciplinary team. There were many changes over the years and the team structure of General Practice allowed moulding and restructuring to changing demands. However, we became emotionally exhausted attempting to continue providing the level of care expected by the population with decreasing resources and increasing clinical governance. It was hard to manage workload and demand as well as fulfil the QOF (Quality and Outcome Framework) criteria and paperwork. It seemed the fun of the job had decreased with the doctor agenda rather than the patient agenda driving the consultations. We were concerned about moving out of our comfort familiar zone and working elsewhere without the ‘safety’ of background knowledge of patients and relationships that had developed from years of continuity of care.

Could we re-establish our professional satisfaction and feel the fun again of general practice by moving continent?

In 2010 we moved to Australia and took the opportunity of developing a medical student teaching GP clinic, which was a new development for the University of Melbourne. This challenge was growing a general practice business in Shepparton, a regional town in Victoria, Australia, within the Medicare system. When this opportunity arose for a ‘sea change’, we decided to take the plunge. Interestingly we found change and new beginnings are normal in the Aussie culture.

Adapting to a new model of care has been refreshing and interesting. Firstly, we realised that the therapeutic relationships with patients we value so much and had felt were partly built on years of continuity of care can be established quickly within a consult. This may be aided by years of experience although I do believe that active listening skills are the key. Trust can be felt at the consultation and so it can be a surprise when despite this patients do move around for care. The GP model of care in Australia allows patients to go to any GP practice at any time, so ongoing relationship care is viewed differently by both the patient and the professional.

We have considered the impact of this fundamental difference between the NHS and Australia primary care. The Australian system does encourage patients to take more ownership of their own care although it may result in over servicing and unnecessary repeat investigations. However, the GP is freed from the trapped feeling of patients being dependent on him or her as an individual. Patient autonomy and ability to seek second opinions is almost encouraged and facilitated in Australia. This can be releasing and helpful, although potentially confusing and may result in patients searching for the response desired by the patient. As there is little effective transfer of information or central data base to connect patient information, decisions can be made within silos of thinking.

Perhaps care could be considered in different contexts; acute and chronic. Acute consults sometimes including incidental task oriented requests like forms or repeat prescriptions and ‘chronic’ for more complex ongoing illness review. It appears that some patients seem to value continuity of care for chronic disease, while attending different ‘convenient’ practices for incidental or acute care. In some regard this does make sense as good background knowledge of medication tried and pathology results may be more important for management of chronic conditions.

The flexibility of provider of care allowed to each patient does alter the fundamental role of GP as the hub of the wheel and ‘gatekeeper’ that is strong in the UK model of general practice. The GP is part of the care, but not the truly essential coordinator in Australia. As stated, the care may then be inappropriate or with duplication at times but it can also provide appropriate convenient care, for example, antibiotics for a UTI in a timely and accessible manner at a consult near the where the patient may be shopping. However, there is no real way of stewardship of the public purse which will be providing Medicare back up payments for many visits.

In the NHS… some shift to patients accepting some accountability for their own care would be good to see.

Currently there are ‘care plans’ and ‘team care arrangements’ under the Australian Medicare scheme. These are used for ongoing complex illness and team care is for co-ordinating allied health referrals. This model applies well to some cases – for example patients with diabetes. It does encourage goal setting for individual patients with their ‘regular’ GP and review can be three monthly. The emphasis is focused on the individual patient in contrast to the QOF points in the NHS model which is doctor agenda and population care driven. Also there is current discussion regarding the ‘my medical home’ model in Australia to further incentivise care by one GP. This may help address some of the duplication and rationalise ongoing responsibility. I believe this may be of benefit particularly to the most vulnerable such as mentally unwell patients who may slip through the net. The responsibility by the GP in the NHS can be over-burdensome and some shift to patients accepting some accountability for their own care would be good to see, particularly given the current recruitment crisis of GPs in the UK. This requires understanding from society and a change from people feeling that totally comprehensive care is a right to encouraging capable individuals to play a more active part in their healthcare. GPs may then feel less trapped in impossible positions within the NHS model of care.

A huge learning area for us has been understanding the business financial differences within general practice in the two countries. The curious bit is considering how this affects care delivery both from a patient ‘consumer’ perspective and from the professional point of view. Our practice in Australia followed a ‘bulk billing’ model until recently. This model survived on Medicare rebate income from item of service and was effectively free to patients. Translating across from the NHS, this model fitted our beliefs of having no barriers to accessing primary care. However, we have now a deeper understanding of Australian Medicare and appreciate this government support is essentially present for those who have healthcare cards and so fit the criteria for free care. Interestingly, others often wish to pay their way as part of their expectation and own feeling of self-worth, not misusing the ‘free’ system. This seemed to us an interesting cultural shift from the British feeling of their rights as they have paid taxes to the Australian view where they feel it is appropriate to contribute and often have a higher regard of value when linked to a higher cost. However, there are some patients on the borderline for ‘healthcare cards’ which is the entitlement to free care and so are charged for consults thus may find cost a barrier to seeking appropriate primary health care. Using judgement to allow bulk billing could allow discretion to the most vulnerable but still lacks the guarantee of access to primary care for all. We do believe access to primary care is a fundamental right and it is a professional duty to manage this demand supported by broad discussion with society.

Our view is that there is value in adopting the best of both models of care.

The concept of ‘my medical home’ with continuity of care for patients with chronic illness while still allowing patients to access convenient care for acute problems may be a hybrid that could be considered. Ideally some linkage of electronic health records would support some mobility of patients and safety net patient care, while helping to reduce duplication and unnecessary investigations. This is truly a challenge for health care everywhere.

Moving to Australia has refreshed us professionally and allowed us space to reflect on and appreciate the robust system of general practice in Scotland.

Within the consultation, a focus on patient driven agenda with individual patient health goals is important. This may result in more engagement and accountability by individual patients and some of the dependency which exhausts individual general practitioners would be alleviated. One challenge is how to maintain clinical governance and standards of care within such a wide scope of work. Measuring outcomes can miss valuing the skills of navigating multiple co morbidities and providing appropriate holistic care. Knowledge and skills that are hard to define or measure are key to implementing appropriate individual care.

The engagement with individual patients resulting in improved professional satisfaction is still possible and the fun can certainly bubble up again. Recognition of the importance of primary care and managing public expectations are key to helping the bubbles rise up again. Moving to Australia has refreshed us professionally and allowed us space to reflect on and appreciate the robust system of general practice in Scotland. However, general practice in Scotland would benefit from review to alleviate the exhaustion of unrealistic patient demands and impossible society expectations. General practice is a complex job so any adjustments are complex but without recognition of the value of the job along with adaptation and changes to the job, there is a risk of loss of the essence, fun, effectiveness and professional satisfaction for the next generation.

General practice is still a wonderful job.

BJGP Open: adapting primary care for migrants

Photo by shawn at Morguefile.com

The aim of this paper was to provide some insight into how primary care is managing to offer care to migrants. In particular they were interested in looking at the challenges and the ways in which practices and practitioners were adapting to meet this need.

The first phase was an online survey. During this they surveyed 70 primary care practitioners. They then used responses to select eight case studies for a further qualitative phase. They had a mix of mainstream GP practices as well as specialist services that offered tailored services to refugees, asylum seekers and other migrants. There was one group interview (with three GPs from the same city) and seven further in-depth interviews. The descriptive analysis was structured around the principles of equitable care that drew on the framework from Browne et al.

They found that practitioners tended to focus on working with community and external agencies and adapted their own processes in order to avoid care. This was particularly evident in areas such as screening, vaccination, and health checks. The biggest barrier was the lack of funding and this was cited in 73% of cases. The organisation and partnerships were regarded as particularly important to ensure there is an awareness of wider social determinants, the impacts of trauma and violence, and all this had to be wrapped up into culturally-competent care.

Opinion: There is a small section in this paper that caught my eye in relation to burnout. Just over one-third (34%) cited personal fatigue/burnout/capacity as a barrier to developing services. The additional workload ramped up the stress for some healthcare professionals and in one of the services they had introduced life coaching. In another they had adopted debriefings that are similar to those used in conflict areas.

“I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

I’d put a positive spin on the burnout angle – it can be enormously re-invigorating to get involved with marginalised groups. As one ‘mainstream’ GP stated: “I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

There are some fine examples in this paper on how primary care can be developed to give a more “equity-oriented service”. It showcases how, despite all the appalling strain on the system, there are still ways for primary care to innovate to reduce health inequalities. More than anything we should be driven by the principle that we need to reduce health inequalities to improve our societies. And sometimes we need to hunt these people down. Whether it is people with learning disabilities, or the mentally ill, or people who inject drugs, the homeless or as in this case migrants and refugees – these are the groups of people that need our attention.

ResearchBlogging.orgSuch, E., Walton, E., Delaney, B., Harris, J., & Salway, S. (2017). Adapting primary care for new migrants: a formative assessment BJGP Open DOI: 10.3399/bjgpopen17X100701

“Too big to talk about”: Organisational momentum and its paralytic wake

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

Corporatism often enlarges and entrenches itself by increasing demands for compliance. Eventually though, unchecked, this will sicken any organisation. Such is now evidently ailing our NHS. A brief glimpse from a small conference provides a sample.

November 2016, London. A small conference of (mostly junior) doctors. The brief: to better survive the increasing stresses of their work. They are being mentored, guided, enabled and reassured by evidently concerned and sympathetic senior clinicians and cohort managers.

Supportive, ventilatory and distracting strategies are suggested: these may palliate, encourage and help endurance.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are. An older patrician-clinician, Dr O, is able to reassure with statesmanlike knowledge and know-how. Yes, appraisals are an unpleasant, inordinate and major stress for many doctors, Dr O agrees. But he can personally help with this: he knows how the system operates, and who operates it: Dr X, for example. Dr X is very senior in the appraisal hierarchy and wants to be helpful to our many needlessly and haplessly struggling doctors. He can pass on many tricks, feints and shortcuts to neutralise the formidable administrative obstacles and find easier ways to demonstrate the compliance now essential for professional survival. Yes, Dr O continued, these are testing and perilous times but there are those – like Dr X – who will provide sanctuary, ‘a safe house’, help with ersatz documentation. The important thing is that we find ways to tender what we must: to survive.

As I listen to these exchanges I recall heroic stories from World War II: of resistance movements stealthily sheltering, then smuggling to safety, downed allied airmen; of Oscar Schindler duplicitly providing false documentation and work to protect those otherwise doomed. Dr X seemed, to me, like Schindler and Dr O his discrete emissary.

All these efforts, albeit unintentionally, perpetuate a bad and destructive system.

I admired all these caring and protective seniors and the responsibility they showed for the welfare and survival of their juniors. Yet I was doubtful of the larger benefit that would come from these sincere and substantial efforts: to help these tired and craven doctors to pass muster, comply to regulations they experience as draconian, and then survive-by-adaptation with the mandatory documentation. All these efforts, albeit unintentionally, perpetuate a bad and destructive system. Adaptation via obedience can easily turn to collusion.

I attempted, with respectful diplomacy, to say this. I summarised briefly: “I really like the comforting care, support and healing that’s being offered between you. But something much bigger is being ignored: the unsustainable, toxic and oppressive environment we all have to work in. These forces overwhelm and fatally undertow all our attempts to mitigate or repair…”

I had wanted to offer a brief profile of the component-agents of our pathogenic healthcare culture: how the 4Cs – commercialisation, commodification, corporatisation and computerisation – are driving out the human and vocational heart of our work; how our erstwhile (mostly) humanly gratified professional ‘families’ are displaced by managerially driven and depersonalised systems of ‘factories’; how our health services’ administrative devices all drive the larger system that is so ailing and alienating us. The entire Internal Market, Commissioning and Inspection cultures, in their many guises, all contribute: autarkic NHS Trusts, financially-based competitive commissioning; burgeoning performance-related targets with their necessary machinery for monitoring, data, negotiation and penalties; the resulting, ever-increasing need for compliance, surveillance, policing, documentation and (to mop up any surviving outliers) strictly regulated professional appraisal and validation …

But the chairperson arrested the beginning of this flow. She judged it well beyond the scope of this meeting: how may clinicians now best survive?

***

During a short break a veteran manager approaches me. “I know what you want to say. Almost everyone here would agree with you. But there’s nothing we can do about these things: they are far too big for us to influence them”, she says with fraternal commiseration. “In any case, this is not the right forum”, she adds with cautioning advice.

“Well, there never is a ‘right forum’ for discussion of these crucial things now. This recurrent exclusion is not accidental. It is the tip of a systemic iceberg: it tells us much about the size and nature of our problems. Paradoxically, our lack of open discussion indicates why we must talk candidly. And if not now, when?”, I replied.

The manager seems attentive to this but says nothing. She meets my gaze and offers me a brief smile. To me this seemed unjoyfully complex: contrition, appeasement, fear, alliance, apology, irony and respectful pity. I smiled back, wondering what she saw.

She turned to join Dr O. They re-entered the conference room.

—–0—–

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com

 

Saving the NHS – the struggle to manage increasing anxiety

Peter Aird

Peter Aird

Peter is a GP in Bridgwater, Somerset.
Peter Aird

Photo by hotblack at Morguefile.com

On the eve of the 1997 election, the year I became a GP partner, Tony Blair declared that the nation had ’24 hours to save the NHS.’ Twenty years on, like those who advised the emperor who paraded about town in his nonexistent new clothes, some politicians pretend they cannot see that the NHS is in the altogether perilous state of near collapse. One wonders if they have completed a DNAR form for the NHS without the agreement of those who love it most.

One wonders if they have completed a DNAR form for the NHS without the agreement of those who love it most.

Be that as it may, what is certainly true is that the NHS cannot do all that it is being increasingly asked of with each successive year. This is for at least two reasons. Firstly, as science advances, more things become theoretically possible. But as Isaac Asimov once said ‘The saddest aspect of life right now is that science gathers knowledge faster than society gathers wisdom’. This is still true – not all that can be done should be done. The second reason, I think, is more fundamental. We live in an increasingly anxiety ridden society. Henry Thoreau wrote: “The mass of men lead lives of quiet desperation, and go to the grave with the song still in them.”

Undoubtedly some of our patients are, indeed desperate. Lacking the fulfilment that they desire, but don’t quite know how to realise, they are desperately anxious not to miss out on whatever it is that would give them satisfaction. Idolising absolute health, anxiety rises as their desire for the elimination of every problem, big or small, real or imagined, cannot be met. The constant endeavouring to solve every problem is exhausting and counterproductive, for both those with the problem and those trying to do the solving. As Leonard Cohen sang: ‘There is a lullaby for suffering and a paradox to blame’. Facing our weaknesses and accepting our suffering can be, I believe, paradoxically, comforting.

However this is a difficult philosophy to convey and one that is harder still to convince people of. So anxiety persists, together with its lonely companion, its accomplished accomplice, depression. Anxiety in all its forms is now so pervasive that I think it easily represents the most common problem presented to me at work.

Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

Firstly there are those patients who present with frank anxiety- by which I do not mean to suggest they have an irrational fear of Frank’s be that Sinatra, Zappa or D. Roosevelt. Rather I mean those patients that present with up front anxiety symptoms – panic attacks and the like. Then there are those patients who present with symptoms that they are anxious represent serious underlying disease. They are often hard to reassure, so twitched are they by the twitches that they experience. And then there are the patients whose symptoms generate anxiety in us – the doctors. We can be left concerned that we are missing something serious and fear what that might mean both for the patient and also for our own reputations – reputations that we cherish, perhaps, more highly than we ought. Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

I wonder how much of this is tied up with the current postmodern notion of relative truth and its recent spawned offspring ‘alternative facts’. Many have remarked that 2016 was a particularly bad year and perhaps, with all the terrorist outrages, natural disasters and political upheaval the year brought, not to mention all those celebrity deaths, we do all have good reason to be uneasy. But also concerning, perhaps more so, is the fact that the Oxford English Dictionary made ‘post-truth’ its word of the year – a decision that reflects that public policy is being decided based on appeals to personal emotions rather than objective facts. Paul Weller and ‘The Jam’ sang, ‘The public gets what the public wants’ and it seems today the public is at least sometimes promised what it feels it wants, independently of what it needs, because it is politically expedient so to do. I am left wondering if all the anxiety we see, and feel, stems from the fact that, with the throwing out of the still clean, clear bathwater of objective truth, we have thrown out the baby of any sense of assurance.

If nothing is certain, how can our patients be anything but anxious about everything? How can they be reassured that their symptoms are not concerning when the opinion we hold can never be more than what we feel to be true? Our feeling, that their symptoms are not worrying, can never counter their feeling that they are, since their feelings are no less valid than ours. I was surprised once when my assurances, that a lesion on a patient’s scalp was a harmless seborrheic wart, were not accepted by the patient because her hairdresser had felt it was a skin cancer. But then, if truth is relative, an expert’s opinion (and I use the term lightly) has no more authority over that of a non specialist.

Another patient once challenged a consultant cardiologist’s opinion that her ECG was normal as she felt her symptoms were consistent with what she had read of Wolf-Parkinson-White syndrome. The objectively normal ECG, and the expert opinion of the consultant on that ECG, was contrary to the patients feelings. And so a second opinion was requested and, when this was declined, the patient chose to write directly to the consultant expressing her belief that her concerns were being ignored.

This notion extends to the anxieties we experience as doctors. If truth is relative, how can we have any confidence in what we feel to be true, and, if the patient feels differently to us, how can we say that we are right and they are wrong? I am aware, of course, that there are, inevitably, times when a diagnosis is in doubt, when the truth is uncertain, but it sometimes seems we are no longer confident that we know anything for sure. In a society suspicious of intellectualism, the learned are themselves suspicious of their learning. Too concerned that our patients be happy with our opinion, our clinical diagnoses have to be malleable, tempered to acknowledge the validity of the patients’ opinion regardless of how lacking in objectivity that opinion might be.

Is it only me who, knelt at a patients feet and examining their sylph like ankles, has reluctantly murmured; “They are a little swollen I suppose”?

Is it only me who, knelt at a patients feet and examining their sylph like ankles, has reluctantly murmured: “They are a little swollen I suppose”. Of course it is no wonder we sometimes behave like this since we have had it driven into us that we be ‘patient centred’ when all along we really should have been urged to be ‘truth centred’. But it’s arrogant to claim to be right about anything these days – facts prove nothing. In a consumer society, the customer is always right. Is it any wonder then that, as medicine was opened up to market forces, the result would be that the patient is always right too?

And if feelings are what are important, then what others feel about me are every bit as much an indicator of who I am as what I feel about myself. After all, a satisfactory satisfaction survey is sacrosanct – I’m OK, if you’re OK with me. But if everybody’s feelings are different, how can I be OK, since how can I be OK with everyone? How can I make everybody feel positively toward me when they all have different criteria for what it is that would cause them to feel in such a way?

Anxiety is, I think, largely, a fear of unhappiness in the future which leads inevitably to us being unhappy in the here and now. That’s why anxiety and depression are such common bedfellows. With, to a great extent, the loss of religious belief, and with it the hope of a better time and place to come, society no longer is prepared to accept that we must sometimes wait for happiness. In an age when everything is instant, waiting is not an option – we must be happy now. But in a materialistic, consumerist society, which daily advertises to us our discontentment by displaying what it insists we need, but do not have, to be happy, it is no surprise that we are anxious that life is passing us by, that we are missing out on being fulfilled today.

And so the National Health Service has become the National Health Slave.

And of course it’s not just material goods that our society consumes. We consume health – it is the ‘must have’ we assume and insist upon. No suffering, however small, ought to be tolerated. We must have health and we must have it now – not next month, nor next week, not even tomorrow. The doctor will see me now – be it Tuesday morning or Sunday afternoon. And so the National Health Service has become the National Health Slave even as the NHS itself, colluding with society that it can meet its greatest needs if it would just do as it was told, slavishly insists patients behave in ways current medical opinion deems appropriate. Don’t smoke, don’t drink, don’t fail to exercise, don’t eat just four of your five a day, and whatever you do, don’t forget your Vitamin D. Don’t, don’t, don’t, don’t, don’t – and you might just live forever.

And so it seems to me that what this all ultimately boils down to the existential question of death. It is the one thing certain about life but we, increasingly perhaps, try to pretend that this too is uncertain as we pursue, and push, eternal life through medicine, lifestyle adaptations and sentimental and fanciful notions of how those who undeniably have died, somehow live on. In a world where nothing is certain, the certainty of death is above all to be doubted.

But we need to face facts, and so must our patients. Despite how much money is pumped into the  NHS to fund all that medicine increasingly can do, despite how long GP surgeries are open or how short waiting times in A&E departments become, and despite how much we heed medical advice and adjust our lifestyles accordingly, we, and our patients, will all one day die. Regardless of what we may or may not believe about life after death, if we are to find any happiness in this life, we need to stop pretending otherwise. We must stop believing that our interventions could ever prevent the inevitable. Rather than doing more for longer, if we want a population that is healthy in the fullest sense of the word, we need to do less. Yes the NHS must be funded adequately but it must be funded adequately to do what a long hard look determines is objectively thought to be important rather than subjectively felt to be urgent.

We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship.

We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship and we must stop suggesting to our patients that life is all about attending to our cholesterol, BP and vitamin D levels so that future suffering is prevented. Why? Because a good life is not solely determined by the absence of suffering – now or in the future. Unrealistic attempts to deny the inevitability of death all too often serves only as an expensive and time consuming distraction that compels us to look down at the temporary and trivial and leaves us neglecting to look up at the significant and satisfying.

We and our patients need to learn to ignore the mundane and consider instead the transcendent. Only then will we, and they, instead of enduring an existence weighed down with anxiety and depression, enjoy a life buoyed by contentment and joy.

Arclight: a new ophthalmoscope and otoscope

John PorterJohn Porter recently completed his GP training and is enjoying living in Bath and working as a salaried GP in Bristol.

There are items of equipment without which a GP in clinic cannot function. Top of this list comes a stethoscope. Closely followed by an ophthalmoscope or otoscope.

As I neared the end of GP specialist training the time was nearing to hand back the practice supplied equipment and to put a hand in my pocket and buy an ophthalmoscope/otoscope of my own. A few hundred pounds, this tends to be the most expensive item needed to get started after training.

With my credit card about to take the hit I got talking to a friend who had returned from working as a doctor in Uganda and was continuing to use a novel ophthalmoscope/otoscope designed for use in developing world environments in his work as a NHS hospital doctor.

After giving it a once over my initial impression was that the Arclight device worked well. (www.arclightscope.com). I could see the benefits the novel lightweight device would have when used in areas of the world where its inexpensive price and the lack of need for batteries is an advantage, and wondered if it also had a place in the bags of GPs in the UK.

Out of personal interest in low cost and innovative technology I acquired and distributed 36 devices to both qualified GPs and final year trainees to find out more (mean clinical experience was 11 years).

I started with questionnaires to gain insight into what GPs thought of their current kit. What I found was that the vast majority of GPs who took part used their ophthalmoscope between 5 to 10 times per week. Their confidence in ophthalmoscopy using their regular devices was 6.4/10 (mean), with a range of 4/10 to 9/10 (1 being no confidence and 10 being very confident). In otoscopy confidence was 7.8/10 (mean) and ranged from 6/10 to 10/10. Problems with batteries and bulbs, being cumbersome to take on visits and expense were widely shared complaints.

Arclight devices were trialled in clinics for 6 weeks. End questionnaires found confidence in ophthalmoscopy using Arclight scopes was 6.9/10 (mean), a range from 3/10 to 9/10. Confidence in using the Arclight scope for otoscopy was 8.1/10 (mean) and ranged from 6/10 to 10/10.

Users found that the Arclight scope’s light weight and small size was beneficial to them in general practice, as were the bright LED lights which were found to stay consistency bright. Suggestions for improvements in the device included making USB charging less fiddly and improving the stability of the otoscope ear pieces when fitted. 75% of users said they would continue using this device after this trial and 92% would recommend the device to a friend.

Outcome

It would appear that the Arclight ophthalmoscope and otoscope device would be very welcome in GP bags (and I would anticipate around the necks of hospital doctors and medical students).

Interestingly I found user confidence with the Arclight scope better than that reported from the traditionally used more expensive and cumbersome devices without their frequently encountered battery and bulb problems.

Dr John W Porter, GP, Kingswood Health Centre, Bristol & Dr Keir EJ Philip, Core Medical Trainee, Barts Health NHS Trust.

Of note neither I nor my friend Keir Philip have interest invested financially or otherwise in Arclight ophthalmoscope/otoscope devices, we’re just intrigued by this sort of thing!