Monthly Archives: October 2016

Medicine in an Age of Empires

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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Photo by clarita at Morguefile.com

I recently attended a talk at the hospital post-graduate centre where the speaker introduced herself as the hospital’s new ‘heart failure consultant’ rather than the new cardiologist. This set me thinking, as many things do, about the strange nature of secondary care medicine. Single organ specialisation is now a thing of the past, apparently our hospital based colleagues are best employed dealing with single problems of single organs. Many of the same thoughts occurred to me when I listened to a lipid specialist describe the difficult and technical differentiation of familial hypercholesterolaemia from poly-genic hypercholesterolaemia in patients with a cholesterol of 8. They all ended up on statins by the way, and they did very well.

This degree of sub-specialisation has, of course, big knock on implications for the way we deliver care in general practice. If, as a hospital consultant, you establish yourself as the lead for a niche service then you really have to tout yourself as the best person to be dealing with that particular problem, perhaps even the only person who should be dealing with that problem. If you want to spend your time looking after malfunctioning left little toes then you need to tell everybody else to leave the left little toes to you because they simply won’t do a decent job of it. Here, guidelines are key. Guidelines are both the supply route and the fortification of all the little medical empires that spring up all around us.

For me this is the best explanation for all the guidelines that at some early and arbitrary point advise that the GP ‘consider referral’. At this point many of us will obediently refer to the specialist only to find that the specialist almost immediately loses interest in the patient and passes them on to his team of specialist nurses who then efficiently steamroller the patient along a single issue algorithm. The single organ’s single problem is often dealt with wonderfully well but how often is the patient left at the end of it feeling slightly bewildered and taking a handful of tablets every day that they don’t really understand?

Perhaps this is all well and good. While the new service functions it allows us to unload all our left little toe problems to the hospital but, about thirty seconds after its launch, the new left little toe service will almost certainly be swamped by GPs following the guidelines. Suddenly our patients are waiting an age to receive treatment that we really could deliver ourselves. But there is a new problem now because, if something goes wrong, we’re left defending a decision not to refer to our specialist when the guidelines told us that we should have done.

At this point the guidelines are no longer an aid to us but they serve only as a length of medico-legal rope with which GPs can be hanged. Disempowered by the guidelines that tell us to refer, we are left either not providing standard treatments for our patients or facing the risk that, if something goes wrong, we could end up in hot water.

In circumstances like this it is good to ask Cui Bono? And not just because saying stuff in Latin makes you seem frightfully bright. This fragmentation of care often seems to be to the detriment of the patient and it can certainly make it harder for us to take management decisions. Sometimes the greatest benefit is to the consultants in maintaining their role as guardians of their own niches.

If we are to achieve the shift of patient care back into the community then guidelines should be written with a view to helping the generalist and not the specialist, and written by people who understand what it is to be a generalist. I could go further and suggest that we should stop funding consultant led services whose practice can be boiled down to a single A4 sized flow chart and spend more of our precious money on generalists both in and out of the hospital.

“The best of times, the worst of times” for general practice

Roger Jones

Roger Jones

Roger Jones is Emeritus Professor of General Practice at King's College, London and is the Editor of the British Journal of General Practice.
Roger Jones

SIMON STEVENS AT THE NAPC

quotefancy-359812-3840x2160As well as signalling the end for QOF, the keynote speech at the National Association of Primary Care by Simon Stevens, chief executive of NHS, was a ringing endorsement of his strong support for general practice. Newly and handsomely bearded, Stevens confirmed that this new investment in general practice of £2.4 billion will be made by 2020, and encouraged the audience to “rattle the cage” to make sure that the promises made for additional funding for primary care are honoured in the CCGs’ investment plans and in the Sustainability and Transformation Plans, which are currently being written.

It seems to me that Stevens has “got” general practice for some time – he repeated the now-apocryphal quote from a BMJ editorial: “If general practice fails, the NHS fails” – and, according to him, the Department of Health has got it too. They have moved from denial, through acknowledgement, to the “action stage”. He went on to give a very upbeat assessment of the range of interventions that are currently being made to turn the service around – in a nice analogy he suggested that general practice is not an oil tanker, but a flotilla.

First of all recruitment – and he reported early signs of positive effects of programmes of work being undertaken in the medical schools to encourage students and medical graduates to see general practice as an attractive career choice. There will be an additional 1500 medical students in UK medical schools before long, and the challenge of keeping general practice teaching and departments of primary care on their radar is not inconsiderable.

Stevens also thought that there were some early signs of improvement in the numbers of returners to general practice, and recognised that for them, as well as for other GPs, such as those working in out of hours services, medical indemnity costs were proving significant barriers. He announced, in the speech, that £5 million or “whatever it takes” will be made available so that GPs are not “on the hook” when wishing to work at night and weekends.

He is very keen on expanding the non-clinical, non-traditional workforce in primary care. He reported that 485 clinical pharmacists are now working in the NHS, with 500 more planned each year for the next three years. There is funding for 3000 more mental health therapists, and 22 areas are already benefiting from this additional resource. He strongly endorsed the importance of practice nurses, practice managers and receptionists, and the importance of providing resources for external training and support for them.

He described the “Time to Care” programme, including 10 changes that can make a real difference to practices, such as dealing with the delays and costs associated with continued re-referring of patients between primary and secondary care. He also reported that over 800 vulnerable practices have been involved in the BMA/RCGP practice resilience program, and also recognised the importance of improving the built environment for general practice. He said that 560 practice improvement schemes have been completed, as part of the GP Infrastructure Scheme, with 316 in train, and 300 more announced on the day of his speech.

The Primary Care Home was a strong theme of the entire conference, and was touched on by Stevens, the report that this concept is being developed in 77 locations, where it may be possible to square the circle between this type of base general practice and the need to work at scale.

And it’s true – Stevens did say that this is the end of the road for QOF, which he said was “now nearing the end of its useful life”, and had descended into a box ticking exercise. New voluntary contracts are being developed as alternatives to current pay for performance arrangements.

Stevens was remarkably candid during an extended question and answer period. He was asked when the government would wake up to the need to charge patients to see their GP, and he replied that this was not what the country wants, and he had no intention of introducing charges. He was pressed by a GP registrar on how general practice was going to become a more attractive career option and by me on how he might turn the tide of early retirement, which is contributing to the workforce crisis. The answer to both is, of course, to be positive about the important role that general practice is going to play in the NHS of the future, the new opportunities for developing new ways of working, and achieving a better balance between work, family life and leisure. He also acknowledged that in important disease areas such as cancer and cardiovascular disease the NHS does not perform well in comparison with many OECD health systems, and recognised that much more will need to be done about early cancer diagnosis and cardiovascular prevention and disease management. Let’s hope that the oil tanker/flotilla analogy works, and it is possible to see some early “quick wins” in time to turn the tide.

How research is helping with GP wellbeing and informing performance at Feel It Festival

Johanna Spiers

Johanna Spiers

Johanna Spiers is a qualitative health researcher working at the University of Bristol. She uses a range of methods to investigate different health psychology topics. Her current work explores the experiences of GPs who are in need of support.
Johanna Spiers

file0001634469948GPs work back-breaking hours, often in isolation. They make hundreds of decisions every day, sometimes without time to eat, drink or breathe. The fear of making a mistake or receiving a complaint is ever present.  GPs feel constantly under threat, overly scrutinised, under pressure, disillusioned, demoralised by the battering they receive at the hands of the press. Many GPs love their jobs, yet find themselves crumbling in the face of ever increasing workloads, a constantly changing system which seems almost designed to trip them up, and the pressure of running a small business with ever decreasing funds.

I am a qualitative health psychologist based at the University of Bristol. Our team (from Bristol, UCL, Keele and the Practitioner Health Programme) are conducting a qualitative study exploring the experiences of GPs living with depression, anxiety, stress and/or burnout. We are hoping that our findings will help define the barriers and facilitators to help seeking for this group, as well as illuminating participants’ experiences of mental illness in a resonant manner.

Our analysis is ongoing, and of course we hope to publish our findings in several high impact journals. However, we wanted to communicate our research findings to a wider audience and engage the public with this topic area using a more dynamic and creative approach.

In collaboration with The Elizabeth Blackwell Institute at the University of Bristol, the study team have commissioned Viv Gordon, an innovative and talented dance artist with lived experience of mental illness to communicate the findings of our study. Viv has used anonymised transcripts as a source material to create a performance piece called Pre Scribed (a life written for me), which will be performed at the opening night of the Feel It Festival (http://www.bristol.ac.uk/blackwell/public-engagement/feel-it/).  Having seen a preview of the script, Ruth Riley, the Principal Investigator of the study, said that “Viv has crafted a sensitive and imaginative tragi-comic performance piece based on a doctor’s life script while examining and engaging with some of the paradoxes of being a doctor-patient.  This is an unforgettable, emotive and hard-hitting piece, not to be missed.”

Viv says of the experience:

The research transcripts offer such rich stories, such important stories, that it feels a great privilege and also a great responsibility to translate them into a performance that captures the complexity of the GP experience. The challenge for me is to offer something that illuminates the research without telling the audience what to think or how to feel but instead raises questions, curiosity and dialogue. My own experience of having what I call a “high functioning breakdown” a few years ago is helping me connect with the internal tug of war that goes on for people who are genuinely doing their very best under unmanageable circumstances. It’s important to me that I’m coming at the subject with that personal understanding and I hope that can add weight and authenticity to the performance work.

As an academic, it can be discouraging to feel that no matter how important and insightful the findings of a research project may be, they are likely to have a pretty limited audience. Most researchers will talk about wanting to do work that makes the mystical and revered ‘Real Life Difference’, but the reality can often be more about inciting the same half dozen people one sees at every conference to a lukewarm discussion before heading off to the buffet. It is therefore really refreshing to see our findings turned into something with genuine emotional power, and the potential to reach a diverse audience.

I would love to feel that our work had the potential to influence governmental policies on support for GPs, and who knows, maybe it does. What I am sure of, though, is that Viv’s piece will engage members of the public, who may then approach their GPs with more empathy, and read their Red Tops with more skepticism. And of that, I feel truly proud.

The Do-It-Yourself ‘Package of Care’

liam-piggottLiam Piggott qualified from St. George’s Hospital, and completed his GP training in Brighton. He works as an out of hours and urgent care GP, and is pursuing surgical training.

As an out of hours GP, nothing can be more soothing to hear than the words “package of care”.

Think of the setting, the very familiar crisis of a long-widowed frail patient, living up until now independently, who tips over edge following a UTI, fall or similar event. Often in their late 80s, with no family nearby, who by product of their generation would not readily ask for, or accept, help. Typically, the patient doesn’t require a hospital admission, and is quick to tell you they do not want to be admitted if possible. If you are lucky, a call to a community assessment team, be it a nurse-led crisis team or rapid response service, leads to “thank you Dr Piggott, we will call around and assess the patient today and arrange a package of care”. I can say from repeated experiences locally to where I work, these services are excellent. They typically include an urgent home assessment and provision of carers and/or night sitters, and following on from this input from social workers, occupational therapists, physiotherapists and district nurses if required. Seeing the patient as I do, usually as a one-off encounter, it’s difficult to follow the journey the patient takes after this is, in regaining independence and wellbeing as far as possible.

This lead me to reflect on the very personal experiences over the last two to three years of older relatives that nearby to me, and yes, I did ask their permission prior to writing this article. The relative in question, after a good old bout of urosepsis, found in himself very much in the above situation. Incidentally, he had a nephrectomy in 1947 – I wonder if he was one of the first patients on the NHS to have had this operation? Moving on, the above mechanism for his home care worked smoothly and quickly, and a flurry of activity lead to our new favourite term; a “package of care”.

But what interested me were not just the clinical aspects of what my relatives immediately required, but what helped them, over a very long period of time, to reach a quality of life and level of independence they had previously enjoyed. They had effectively arranged a “do it yourself” package of care. There are so many things in our day to day lives that we take for vantage. Things so simple and second nature, we don’t even think about them, or perhaps until we are unable to do them. The immediate ones are obvious; cooking, cleaning, using the toilet. But how about clearing a garden, going to the dentist, or withdrawing money from a bank?

Slowly but surely, and with a little help along the way, they began to construct and arrange ways of returning to their independence. A neighbour recommended a trusted gardener, who even took my them to a hospital appointment (not bad, for £10 an hour). The Parish magazine directed them towards a chiropodist who would visit them at home. A friend suggested a local lady who did hairdressing in customer’s homes. In time, they had these, and a window cleaner, a coffee morning group, an odd job man and a visiting community optician for good measure. Once the acute illness had resolved, these almost invisible community services and networks restored their confidence and enjoyment of life. They certainly now have a more active social life than me.

Oh, and what of the author, this heroic young doctor ? Well; he takes the bins out every Thursday night.

Heroes: general practice and Karpman’s triangle

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

Living in a different culture is exciting and fascinating. But living in Bahrain we do miss “culture” in its other sense. There is a magnificent National Theatre, usually empty, putting on just a few touring shows a year. The nearest opera house is 500 miles away. But for a small nation it sure has lots of cinemas.

So this evening we went to see Sully, a film by Clint Eastwood. It stars Tom Hanks as the eponymous pilot, Chesley ‘Sully’ Sullenberger, who heroically landed a passenger jet with 155 people on board on the Hudson River in New York following the loss of both engines after bird strike. I wondered how you could make a whole film about this one incident, assuming there would be lots of flashback time to Sully’s youth as a military pilot and his long flying career. But the main theme of the film is how, having pulled off a near miraculous landing on water saving each of the 155 people on board, the incident investigators then treated Sully and his younger co-pilot, Jeff Skiles. It is based on Sullenberger’s own account from his book, Highest Duty.

Within a minute of the investigators’ initial interview with Sully and Skiles starting it was obvious that the assumption was “you must have messed up – our job is to show how”. In moments Sully went from hero to suspect, who risked his passengers’ lives by choosing a reckless water landing rather than other options which “must” have been available. And anyway no twin engine jet had ever lost both engines through bird strike, so the pilots must have been mistaken.

The film follows Sully’s self-doubt, his being overwhelmed by media frenzy whilst trying to process a traumatic event, his imagined “flashbacks” to less happy endings. His wife and family alone at the end of a phone whilst he has to attend the inevitable investigation. Mostly though the film depicts the incredible imbalance of power between one man, doggedly seeking to hold a corner he knows from long experience to be right, against the investigative power of a large well-resourced organization with its absolute confidence that Sully must be wrong. And its annoyance that he makes it hard for them to prove this foregone conclusion.

Perhaps it is time for a confession. One of the many reasons why I left the UK after 35 years as an NHS doctor, was the sense that every year I worked, I and my family gained less from staying. But every year I worked I risked more and more from the career-ending multiple jeopardy and shame to which we are now exposed. The lines crossed several years ago, it just took me a while to work it out. I only once received one of the GMC’s notorious “we haven’t got you this time but we’ll keep an eye on you” letters. And this was for a complaint that a five year old child would have dismissed after the briefest perusal of the facts. Of course, had I been a locum the GMC would have, de facto, already smeared my name to all my places of work – don’t tell me that such letters are a “neutral act”. A close friend took early retirement as he feared the GMC brown envelope every day, for no reason other than the ever increasing background risk. And I also got out before I had the pleasure of a CQC visit.

Attribution: Steven B. Karpman, M.D.

Attribution: Steven B. Karpman, M.D.

When I was a trainee I was taught about Karpman’s victim/rescuer/persecutor triangle. The heroic rescuer saves the victim. But this attracts the attention of the persecutor, or often the victim becomes a persecutor. Now the rescuer is the victim. And so the drama unfolds. Rescuing can be dangerous to your health. Have we as a profession become imprisoned by Karpman’s triangle?

But back to the film. If you haven’t yet seen it then look away now. Sully has to demonstrate the failure of simulation to model reality. If a pilot had turned back to the airport at the very moment of bird strike then they might just have made it within the three minutes remaining. But it required 17 simulation attempts to pull it off. However it took 35 seconds to assess the situation and make that decision. And if Sully had followed all prescribed procedures, rather than relying on his experience and judgement, it would have taken longer. But his rapid decision and his consummate skill in landing a passenger jet on water (plus a big dollop of luck) let to everyone on board surviving.

Well, being a film, the investigators grudgingly accept he was a hero. They don’t apologise for their persistent accusations to a man trying to come to terms with a traumatic event – but hey, that would be a fantasy. Similarly you and I have to just live with the knowledge that we did a good job. A better job than we are ever contracted for, because we see ourselves as professionals. It’s enough, but for how long?

Anyway, we’ve just arranged to fly to Muscat to see an opera. But I don’t reckon I’ll be seeing Sully as an inflight movie any time soon. Still, at least I’m safe.

STPs – plans being made about us, without us?

Jonathan Leach

Jonathan Leach

Jonathan Leach is a GP in Bromsgrove and Chair of the Midlands Faculty of RCGP. Jonathan initially pursued a military career for 25 years as a doctor before returning to the NHS. He is especially interested in supporting general practice at a time when it is under significant pressure.
Jonathan Leach

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NHS England is in the process of implementing the Sustainability and Transformation Plans (STP), which draws together Clinical Commissioning Groups, local authorities and providers to show “how local services will evolve and become sustainable over the next five years”. In each geographical area there is a STP board who are considering the nine “must do’s” which range from meeting access targets for A&E and ambulance waiting times, ensuring that referral to treatment targets are met, plus other treatment targets such as waiting time for patients with suspected cancer and mental health access targets. Included within the list is a “must do” to address the sustainability and quality of general practice but probably the biggest challenge is to move the whole NHS into financial balance on a backdrop that most provider trusts are in significant financial deficit.

Emerging information from STP boards is that plans are heavily swayed by the need to meet financial balance and to meet specific targets such as A & E access times. There is also concern that many STP leaders have conflicts of interest as chief executives of large provider trusts or local government organisations.

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“Plans are being made about us, but without us”

A recent joint LMC/RCGP workshop in the West Midlands looked at what engagement there had been with general practice. It was disappointing to find that many STP boards had limited or no input from general practice but probably the biggest concern that emerging plans did not take a whole system approach and in particular consider whether general practice and the wider community services has the current capacity to manage a larger patient volume as hospital services change. A separate question was about whether some of the patients would be better predominantly treated in a secondary or primary care setting. One delegate succinctly described matters as “plans are being made about us, but without us”.

The view from the West Midlands workshop was very clear that unless there is a clear plan to increase capacity in the community services as hospitals change, then patient harm will occur. These plans need to be greater than  “working at scale and integrate” as whilst economies of scale will help, they will not address sufficiently the overall capacity of general practice and the community services to manage more patients who are currently seen in a secondary care setting. There was also a significant concern that increasing the workload within general practice was likely to make current concerns about the retention and recruitment of primary care staff worse.

What is therefore key as STP boards make their plans is that they need to consider a whole system approach and incorporate the voice of general practice at a strategic level. This voice needs to understand and articulate the views of general practice and the wider community services with the requirement that system changes are only made once it is clear that these services can appropriately manage the greater number of patients in a community setting.