Sick leave in general practice

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Ahmed Rashid

Ahmed Rashid

Ahmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He also writes the regular monthly column “Yonder” in the BJGP: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature.
Ahmed Rashid

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On my journey to being a grown-up GP, I completed placements in four different practices as a junior doctor (FY2, ST1, ST3 and ST4). As you might imagine, each placement introduced me to a host of intriguing colleagues – both clinical and non-clinical – who each taught me something different and between them, showed me what good (and bad) healthcare teams look like. Above all, over the course of these placements, I became convinced that the ‘independent contractor’ model of general practice needs to change. One important reason for this was the way in which practices struggled to cope with GP sickness.

Perhaps by coincidence (and perhaps not, given the huge pressure on NHS general practice at present) but on each of these four placements I encountered situations where doctors were away on long term sick leave. The causes of the sickness varied from cancer to coronary heart disease to mental health problems but in each situation, doctors were left to cover for their colleagues. This meant considerable increases in workload and often, due to the partnership model, it also had repercussions on doctors’ personal incomes due to the need to pay for locum doctors.

Team members were openly insensitive about their missing colleague


As I look back at the four practices, the ways in which the doctors reacted to sickness in their colleagues were in many ways a barometer for how effective and cohesive the teams were. Amidst a lot of genuine care, there were often glimpses of dark humour, curt looks among colleagues in meetings and forced smiles. In the surgery I least enjoyed working at, team members were openly insensitive about their missing colleague and in the surgery I liked best, they were deeply concerned and committed to offering support in any way possible.

I don’t believe, though, that those who were less sympathetic were necessarily bad doctors or even team members. Rather, their organisations were simply not set up to be able to absorb the pressures that come from unavoidable sick leave and were systematically unable to be as compassionate as they would want to be.

Of course, the factors causing doctors’ ill health and the general financial strains on practices are broader issues that have political origins and federations and practices working at scale may help to alleviate some problems. Nevertheless, though, it is ultimately the independent contractor status that is responsible for doctors’ incomes to be linked to their colleagues in this way. If GPs were to become salaried to the NHS like hospital doctors, their income and workload would not be affected by their colleagues’ sickness in the same way and they could focus on being the supportive and caring professionals that they invariably are.

Integration and true collaboration to develop primary care

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Cat Roberts is Clinical Lead GP involved in developing and delivering primary care services within an acute trust, including a GP-led frailty service

You can read Cat’s first post: Challenging the norm: GPs as innovators here.

I vividly remember one of my first consultations as a general practice registrar. The patient had a list of complex problems and I did not have the skillset to deal with the multitude of issues or her expectations. The consultation became strained, and as she pressed me for answers and solutions I became more defensive. The defensiveness manifested itself in the use of medical jargon, hiding behind guidelines and explaining resource limitations.  This was a subconscious attempt to assert authority and establish a clear balance of power. It ended rather comically with me leaving the room as I was fearful she never would.  My supervisor emerged from his room, looked over the top of his glasses and inquired:
“Is everything OK?”
“I don’t know how to make her leave my room…”
“Why is she still there?”
“Because I haven’t helped her.”
I perceived she wanted an answer, and whilst trying to find an answer I had stopped listening.  All empathy and rapport had left the room. I returned to the room with some new questions which were able to facilitate meaningful conversation.

These are all symptoms of a floundering relationship and a dynamic that makes sharing management a challenge.


Why did that all go wrong?
Is it possible that this dynamic exists on a larger scale with our colleagues in secondary care, community care and social care? With limited resources and time we may become defensive and confrontational towards one another; too quick to assign blame, judging each other’s skillset and capacity. Do we subconsciously imply a balance of power in the wording of a discharge letter, when referring a patient to a bed manager, or in our tone in a referral form?  Are we creating boundaries, relinquishing responsibility, being fearful of blame? Are we angered by perceived unfair allocation of time and resources? These are all symptoms of a floundering relationship and a dynamic that makes sharing management a challenge.

Tell me about yourself
One of the six principles of our Integrated Frailty Service is Culture and Education. We host joint educational events on topics relevant to frailty and multi-disciplinary team members frequently present. GPs run sessions on managing uncertainty and other strategies that are intrinsic to consultations in primary care. Hospital clinicians present the latest evidence based practice, reawakening our love of clinical medicine and allowing us to cast our net of differential diagnoses wider. These sessions are attended by both clinicians and non-clinicians so we request that anyone attending avoids jargon and tailors content appropriately. Rapport between clinical directorates and across providers is restored, stories are exchanged and challenges are viewed from all perspectives. Myths and misunderstandings surface and are addressed and a true empathy of each other’s skills and constraints develops. This principle, despite being impossible to quantify in data and Key Performance Indicators, has the most tangible benefit and has the biggest impact on patient care.

Both camps are fearful of change, repercussions, impact on patient care and sustainability.


Maybe we both want to achieve the same thing?
Another core principle of our service is Integration. This broad term refers in part to practical challenges such as shared electronic records, imbedding the service within the directorates of the Trust and helping align community services to best respond to patient needs. It also underpins another vital relationship needing bolstering – that of the clinician and the non-clinical manager. Sometimes frustration, exasperation and being overwhelmed by a problem can manifest as apathy, indifference and a reluctance to engage with any system improvement drives. Both camps are fearful of change, repercussions, impact on patient care and sustainability. Perceptions are sometimes tainted by behaviours and the balance of power fluxes between clinicians and managers. The result can be systems which are fragmented, dysfunctional and hinder clinical care and positive patient experiences. The potential gains in true collaboration and understanding result in seamless transitions of care for patients – with experts in clinical care optimising their time and skills, and experts in strategy and operations facilitating this change.

The consultation no longer feels overwhelming or hopeless.  We may have reached a middle ground in terms of mutual understanding and empathy. The complex problems still exist but the management is starting to feel shared.

Read Cat’s last blog: Challenging the norm: GP as innovators

Challenging the norm: GP as innovators

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Cat Roberts is Clinical Lead GP involved in developing and delivering primary care services within an acute trust, including a GP-led frailty service

Following a few years of basking in the ‘delicious ambiguity’ of general practice we returned to the hospital wards to try to fully understand patient care pathways. Any doctor studying for membership exams will describe how the second learning cycle is so much more meaningful when digested with a wealth of clinical experience – the same is true of returning to secondary care having worked in primary care. We were stepping from a land of hypothesis into a land of diagnosis, from a world where uncertainty is used as a tool to a world where much is done to eliminate ambiguity.

The aspiration was to create a service for frail older patients. The pilot funding had been secured and we had a year in which to create a service of value. Would there be a role for GPs to work alongside gerontologists to create a Frailty Unit for these patients, focussing on key generalist principles – a holistic Comprehensive Geriatric Assessment, avoidance of over-medicalisation and aligning primary care, community services, social services and voluntary sector to facilitate this pathway?

We needed to learn another language – ‘management’ in order to communicate our understanding and to understand the ideas, concerns and expectations of managers.

The challenges that presented themselves were not clinical, in fact the familiarity of vague symptoms sets and unusual health beliefs in patients provided an anchor in a strange land. The challenges were operational, practical and political. We needed to learn another language – ‘management’ in order to communicate our understanding and to understand the ideas, concerns and expectations of managers.  In working with healthcare managers, we had to develop a new version of a shared management plan and understand each other’s agendas to improve concordance and collaboration. This was a GP consultation on a larger scale, held in an unfamiliar language, with different cultural backgrounds and with intrusive time constraint

In order to design a service for frail older patients you need to ask some fairly controversial and challenging questions of all providers, including familiar questions such as:

  • When is discharge safe?
  • When is it safe to stop a medication?
  • What if I miss something by not investigating?

However, some of the most useful questions include those not routinely asked such as:

  • When is admission safe?
  • When is it safe to start a medication?
  • What am I hoping to achieve in investigating?

Pressures, processes and clinician behaviour often means these questions do not have time to be asked, let alone answered.  And can you ask these questions unless you fully understand the alternatives?  GPs have all trained in secondary care however not all secondary care clinicians have had the opportunity to spend time in primary care – it is challenging to place trust in a system that you don’t fully understand, especially if your perception has been altered by examples of when that system has not worked well for your patients.

GPs will always be scholars – they are puzzle solvers, they delight in ambiguity and they will always seek to liberate themselves from conventions and assumptions.

So, our focus and first step was to start to develop mutual understanding with our secondary care colleagues, because those questions can only be asked and truly shared when they are perceived as a shared challenge. To start to gently challenge systems and behaviours was a fragile and privileged journey that required small tentative steps and open and constructive dialogue.

Over the course of a few blogs we would like to take you on this journey with us, to share our experiences, to explain the organic evolution of our service principles and structure, to reaffirm the notion that clinician-led service design and development can work, to celebrate in our successes and ask for your guidance with our challenges. GPs will always be scholars – they are puzzle solvers, they delight in ambiguity and they will always seek to liberate themselves from conventions and assumptions. These skills are not confined to clinical medicine.

A GP’s experience of the Grenfell Tower fire

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Ahmed Kazmi is a GP at Exmoor Surgery in West London. He is also a stand up comedian and his next shows will be used to fundraise for the dispossessed. For tickets go to: www.doctorahmed.net and to donate: www.justgiving.com/doctorahmed. He is on Twitter @drahmedkazmi

London 15th June 2017. I am a GP working in the West London area. My clinic is less than 800 metres from Grenfell Towers and several of our patients were resident there.

The day after the fire was a tragic day for many and a very atypical day in our surgery. We spent it trying to compile a list of our patients who had been dispossessed. We made comfort calls to those affected, (especially the vulnerable ones), offered walk-in appointments for those who found themselves without medication and tried to offer some comfort. It is difficult though, what do you say to someone who has just lost their home and every possession they own? “I am so sorry for what has happened to you, here is your insulin prescription”.

I went down to help at the rescue centres. Walking past the towers was eerie. It looked like something from an apocalypse film. There were men in white biohazard suits, police and exhausted firemen. The building was still smoking. I was fearful what state the rescue centres would be in. I took a big breath and entered.

If this type of unity is possible in times of tragedy I think it is realistic to aim for it all the time.

I struggle to describe what I saw without getting emotional. I didn’t see or feel any despair or terror. The overwhelming feeling was of love, unity and solidarity. Every corner of St Clements Church and Rugby Portobello Trust were taken over by agencies there to help. A make shift housing office, a lost relatives bureau, the Red Cross, a doctor and nurse station to name a few. There were emergency services workers circulating the floor. I have never seen so many priests in one place (which is saying something considering I went to a Church school!), even the Bishop was there.

The most beautiful observation for me was the conduct of the local residents. People arrived one after the other, with food, clothes and toiletries. People quickly sorted the items and displayed them and helped the affected pack what supplies they needed into bags. A group of young black Muslim boys, who were fasting themselves, walked around with jumbo pizzas offering everyone slices. A group of ladies arrived to offer face painting for the children.

As a doctor I felt slightly redundant. There were so many doctors and nurses who had volunteered the centres were very well staffed. I sat down on the floor and played with some children. I asked a young boy if he wanted to do a jigsaw (he replied he didn’t like jigsaws). I asked why he had no teeth. He said the dentist took them; we both laughed. I didn’t use my stethoscope those hours I was at the centre, but I still feel I was a doctor. I think sometimes empathy and witnessing someone’s grief are as important a part of our role as procedures or prescribing.

It was striking how all of the usual prejudices or divisions which so frequently surface, were all suspended. People from all walks of life were empathetic and loving to each other. For a period at least people stopped being black, white, Muslim etc and were just ‘human’. If this type of unity is possible in times of tragedy I think it is realistic to aim for it all the time.

My story of everyday scholarship in general practice

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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

You can read Revitalising general practice: unleashing our inner scholar by Joanne Reeve and Adam Firth at the BJGP here.

General Practice: The Game of Inches

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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.
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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

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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

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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

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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

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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.