Category Archives: Political

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.

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.

GP partnerships – sinking into obscurity or sailing into the future?

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

vmrmyolqzwo-andreas-ronningenThis post was co-authored with Ruth Riley. Ruth is a medical sociologist and qualitative health researcher with an interest in the mental health and wellbeing of NHS healthcare professionals. She is Principal Investigator of a NIHR SPCR funded study: Exploring the barriers and facilitators to help-seeking amongst GPs: Improving Access to Support.

In the past, the huge majority of GPs were partners, with partnership seen as the obvious career pathway. Partnerships consist of groups of general practitioners who own and run their practices, meaning they are in some regards their own bosses. However, the numbers of salaried GPs (employed by the partners) and locum doctors have been soaring in recent years. Many younger doctors and GP students are now deterred from seeking partnerships, seeing them as unattractive or even risky.

As a researcher looking into the mental wellbeing of GPs, I have found myself inclined to agree. I have spent the past 12 months of my working life interviewing distressed and anxious GPs who are working in a context of increasing workloads and financial pressures, and analysing those interviews. So many of those GPs have spoken to me and the project’s PI Ruth Riley about the difficulties of partnerships that it’s been hard to see what the advantages might be.

When more and more partners resign, it can become a sickening game of tag to find out who is the last doc standing.

It won’t be news to any readers of this blog that there is a recruitment crisis in general practice. GPs are retiring, resigning and relocating in droves, meaning those remaining are hideously, heart-breakingly overworked. And they don’t have the option to leave at the end of their shift and sign the work over to the next doctor; a GP partner’s shift starts and ends with her or him.

Being small business owners, GP partners are financially responsible for their practices, meaning that when more and more partners resign, it can become a sickening game of tag to find out who is the last doc standing – and who is therefore personally responsible for the masses of debt a forsaken GP practice will have built up.

GP partners are also expected to act as managers, running the books, organising human resources for staff members and disciplining wayward employees. Medical school doesn’t currently offer much in the way of management training (although there is a move towards introducing this), meaning these roles can be extremely stressful for GPs and are sometimes very badly handled, resulting in stress for the whole practice.

Add to this a total absence of formal occupational health protection during periods of ill health, no guaranteed maternity leave and having to juggle the potentially fragile and fraying egos of your colleagues every week in a partnership meeting, and it becomes resoundingly clear why partnership feels like a poisoned chalice to so many.

To counter this gloomy picture, I have heard some arguments in favour of the partnership model. Some of the doctors I interviewed spoke glowingly of the team work, trust and mutual support within their partnerships. One participant in particular worked at a surgery which is a shining example of good practice, with all members chipping in to fund a therapist to come in twice a month and provide supervision. If more partnerships were able to run this way, how much better could things be?

A recent debate (2016) in the BMJ argued that maintaining semi-autonomous employment will save GPs from a similar stand off to the one in which the junior doctors continue to find themselves. However, I wonder if this is true? The department of health and the NHS seem entirely capable of imposing changes and demands on GPs within the current model, so I find this doubtful.

The partnership model works well for some; merged super-practices with all salaried GPs may be best for others.

There is no one model which will suit all doctors; and there is no one way of working which will suit every team of doctors. Some partnerships are small and supportive, some are large and lonely. And the reverse can also be true. The dynamics of each group will depend on so many factors: the personalities of the doctors involved, their experience, the socio-economic status of the area and much more besides. The partnership model works well for some; merged super-practices with all salaried GPs may be best for others. This is a complex debate and there is no easy answer.

However, there is one thing which would help towards solving these problems, and that’s a genuine increase in funding to general practice from the government. More money could mean more doctors, more capable managers, more training and more occupational health support, all of which could make the partnership model more sustainable, or allow thinking space for a viable alternative. The GP Forward View promises this cash, but will it arrive in time? Critics have said the promised money isn’t in addition to existing funds, but is just rebranded existing funds. Without that extra money, the future of GP partnerships seems in danger of sinking.

References

Majeed, A. & Buckman, L. (2016). Should all GPs become NHS employees? BMJ. 355:i5064

 

 

 

Book Review: The State of Medicine by Margaret McCartney

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

Latest posts by Adam Staten (see all)

thestateofmedicine300The State of Medicine is an eloquent, passionate, comprehensive, and, in many ways, dispiriting overview of the repeated damage inflicted on the NHS at the whim of successive governments. The frustration of the author, a GP from Glasgow, pours from every page, every paragraph and every sentence, as she contrasts the efforts of doctors to practice evidence based, safe, humane and cost-effective medicine, in a system that is routinely upended and overhauled according to manifesto sound bite, political opinion and, occasionally, outright self-interest.

Whilst the general themes of this book will surprise few who work in the NHS, the actual facts and figures, such as the vast sums wasted on management consultancy firms, may make the eyes of even the most hardened cynic water.

Each chapter begins with an interview with someone who is able to give a different perspective on our collective woes. Amongst these are some real gems that offer unexpected insights into different niches of the NHS world. The words of an A&E consultant who was working at Mid Staffs during the scandal may send a there-but-for-the-grace-of God shiver down your spine, and the thoughts of a Nobel prize winning economist will have you bewildered that there are still so many advocates of insurance based health care systems.

Dr McCartney offers a clear account of the follies of the last few decades and a personal view of where and how the NHS should proceed from here with ideas such as buffering the NHS from policy makers, funding it properly, treating health professionals with respect, and actually basing policy on evidence.

The message of this book is important. We must hope that it reaches a general readership, or, hoping even more bravely, that it reaches an audience amongst the political classes.

Just how successful are STPs likely to be?

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

Latest posts by Jonathan Leach (see all)


PlansThe NHS in England is going through a process called Sustainability and Transformation Plans (STPs). As the NHS England website describes “each system will produce a multi-year Sustainability and Transformation Plan showing how local services will evolve and become sustainable over the next five years – ultimately delivering the Five Year Forward View vision of better health, better patient care and improved NHS efficiency”.1

All 44 STP areas have now published their plans and it appears that there are a number of common themes. Firstly that there is a recognition that there are efficiencies and cost reductions to be gained by reducing back off costs, by improving procurement (mainly from single and at scale purchasing) and by co-locating health and social care staff and thus being able to reduce the buildings estate and improve integration. Secondly by reducing (or at least not having any more) acute and hospital beds often by centralising services in a given area. Thirdly that a considerable amount of work currently undertaken in a hospital sector can be encompassed within primary care and that primary care (including general practice) will have the capacity to undertake additional work transferred from secondary care by improved prevention, better integration and the greater use of (predominantly) nursing and allied staff supported by better social care and that fourthly that themes 1 to 3 will lead to better care and at lower costs. Do current STP plans stand up to scrutiny and have they used the lessons of history in building their plans?

It may surprise some to realise that a British health service successfully did a very similar task over 20 years ago. Following the fall of the Berlin Wall there remained a British population attached to HM Forces in North West Europe and spread from Berlin through Northern Germany and into the Low Countries. It was served by British GP and community practices (often with integrated community hospital type beds) with British hospital services located at four locations across the wide geographical area. There was widespread recognition that whilst primary care (including general practice) services were good, access to secondary care was difficult due to the large distances patients had to travel and that the overall system was inefficient and expensive even if other standards were high. Following considerable work, the eventual model implemented a system whereby it increased the focus on community services; on prevention; on only referring patients to hospital when the experience, expertise and technology that a hospital setting could provide and it integrated staff under one management structure. Within this all health staff (including community based consultants) used the same GP based computer system2 and within the structure there was the ability to ‘flex” staff in a geographical region according to patient demand.

A key element of the changes was the closure of the British Military Hospitals and a change to accessing local German hospital services for episodes of care under contract. Within this was an aim to save over £4M or 10% of the then budget (based at 1994 prices).3 As part of the process there was a ‘bottom up’ mathematically derived approach on the numbers and types of community staff required to meet both accessibility needs and quality standards and especially in the changed system whereby many services which had previously been supplied in a hospital setting moved into the community.With the changes predicted to hospital services, there was a significant increase in community resources and staff which included general practitioners, midwives, health visitors and others.

There are clear parallels from the above experience in British Forces Germany (BFG) to the challenges that currently confront STPs; what can be learnt from this experience? Firstly that there needs to be a single and coherent vision based upon a needs assessment of the population; in BFG there was a large evidence based exercise in involving patients by means of questionnaires, public meetings and focus groups and it was clear that most patients wanted improved access and that travelling the large distances for British secondary care was unacceptable. Secondly there needs to be “cross system” professional engagement and broad agreement on the direction of travel; within this is an ability to address the many difficult issues and questions that any major system change will raise. Thirdly that there needs to be a full understanding that as hospital systems change, that there is detailed plan (including mathematical modelling) of how, where and when community services would be able to cope with the increase in patient volumes and potential complexity. The BFG experience is that practice workload increased by approximately 10%, so this area is not to be underestimated and as described above was expected and met with a large increase in staffing of all groups. Fourthly that whilst integration is helpful (predominantly to the quality of care), improvements in productivity are likely to be marginal. Other studies have reached similar conclusions.5

The challenges confronting STP leaders are significant.  In many cases engagement with the public, the professions and politicians has only just started – this is to be regretted as consistent evidence on system change is that early engagement, considering and overcoming barriers is required. Secondly there needs to be urgent analysis of the implication of proposed changes to hospital services on the community services including general practice This is much wider than increasing the number of nursing and allied staff but must include where and how medical care is provided including prescribing, taking a broad holistic approach to patients many of whom have polymorbidity, managing risk and where responsibility for decisions lies. An analysis of published STP proposals reveals that this area of detail is lacking in all. Finally there needs to be an overview on whether current STP plans can be delivered in planned timescales given the significant number of barriers they are likely to encounter and very importantly whether in reality they are likely to deliver the required improvements in productivity and cost reduction without significantly affecting patient safety and experience.

References

1. https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/stp/ accessed 18 Dec 16
2. Everington P and Leach AJ. Integrated Primary Led Care – A view of the future? In Richards J (Ed). Conference Proceedings – Current Perspectives In Healthcare Computing. 1996.
3. Hansard http://hansard.millbanksystems.com/written_answers/1996/jun/04/market-testing accessed 18 Dec 16
4. Leach AJ, Whitmore MK, Schofield J, Morris G. Health Service Market Testing – the Experience of the Community Services Review Team in British Forces Germany. J R Army Med Corps. 1996. 142. 67-70.
5. McWilliams JM. Cost Containment and the Tale of Care Coordination.  N Eng J Med 2016: 375: 2218-2220

Obituary for St James Church Surgery: the death of a practice

St James Church Surgery 1987-2016:
the demise of small General Practices

A personal celebration and lament

David Zigmond

picture1

Small general practices used to be very common and mostly popular. Yet due to healthcare policies they are now increasingly rare and almost extinct. What are we losing? This is a portrait, in words and photos, of a recently closed practice.

St James Church in Bermondsey, London served as an NHS General Practice for nearly thirty years. Its closure, in August 2016, was forced by rapidly tightening regulations about working premises and practices.

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Until its demise, this small practice retained an uncompromising ethos centred around the kind of personal continuity of care that can come only from personal contacts, relationships and understandings. Early on in my stewardship – as the Principal GP – I thought that this kind of human matrix was best assured by a small, traditionally modelled family-doctor practice with a low turnover of clinical and reception staff: such a compact, stable nucleus can be far more personally manoeuvrable and responsive, than can be managed in larger practices. Yet, paradoxically, this ethos has become countercultural and, eventually, untenable.

A small but significant example: the staff decided not to have the now prevalent automated telephone greeting and ushering devices. Instead, the telephone was always answered by a friendly receptionist: voices became known, recognised and matched to the face of the patient later arriving, and be personally greeted, at Reception. Fragments of data and stories could then make larger, human wholes; personal understandings grew organically; quiet bonds of affection offered comfort, containment and support. Therapeutic influence often started with the receptionist.

Such subtle human interactions are impossible with automated devices and algorithms – yet now, almost everywhere – the cybernetic is inexorably driving out the humans.

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In these last twenty years the culture of the NHS has – despite ubiquitous and reassuring soundbites – moved away from such responsive humanity and into rigid systems managed by corporatism and industrialisation. Despite this difficult and increasing organisational estrangement, the surgery at St James consistently managed to harbour exceptionally good patient and staff experience, loyalty and safety. So this small practice survived as a bright, but doomed, island-beacon of traditional humanistic healthcare perched perilously above a rising ocean-tide of institutional depersonalisation. Eventually the tide rose faster than we could erect defences: in particular we could not cope with, or afford, the vast and ratcheting demands of compliance legislation.

Despite popular support and the very evident real-life excellence of this surgery it was deemed, by non-negotiable procedures of the Care Quality Commission (CQC), to be too anomalous for their vouch-safety. The decision to summarily close the practice in 2016 was dramatic in its emphasis and decisiveness: you can read about this in Death by Documentation1 and The Doctor is Out2.Meanwhile, do peruse these pictures of our much-loved practice: the container for so much, and so many kinds of, humanity and its vicissitudes; a conduit for so many life-events, poignant encounters and their guided supports.

As you take an imaginary wander around this once very alive, now deceased, workspace you can see easily how little the physical ambience of this clinical service resembled its more contemporary purpose-built peers. This was both fortuitous and deliberate: august spaces were filled with bright, warm colours, soft comfortable furnishings, hangings of expressionist and impressionist art, humanly crafted objects from natural materials. More typical ‘clinical’ objects, surfaces, instruments, notices and accoutrements were mostly relegated to the background, though always with convenient accessibility.

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All humanly constructed environments also convey meta-messages about values, roles or expectations. The ambience at St James said: Healthcare is a humanity guided by science; that humanity is an art and an ethos. The now prevalent, and certainly more approved, practices of modernity seem to say: Healthcare is a science administered by our regulated experts. Wait quietly.

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What effect did this have? Well, our staff and I drew much pleasure, comfort and enlivenment from our libidinal surroundings, just as the sensually aware homeowner does. Very significantly, patients would often express this too: “It’s so lovely coming in this room, it always cheers me”, or “I feel better and calmer already, just sitting here, doc…” were typical of hundreds of appreciations I heard over the years. Such exchanges fuelled our wish to come into work each morning.

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NHS management bodies took a very different view. Eventually the CQC would – with Olympian judgement and resolve – pre-empt any further contention over personal preference v institutional prescription: the Practice was closed by legal (Magistrates) Order. In their evidence the CQC cited previous official assessments – over several years – recurrently showing miscellaneous failures of compliance to the increasing regulations across a wide range: disabled access and facilities, documented checks of fire exits and my own (non) criminal record…

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But what of the real-life evidence? Of enormous patient and staff popularity and loyalty, excellent care and the remarkable lack of complaints, litigation, untoward events or deaths, staff sickness or accidents. These counted not at all. Nor did the power of patient choice: there were many, evidently compliant, neighbourhood practices eager to recruit but emphatically declined. Nor was heed paid to the fact that many of the regulations were far more suited to large airport-like practices with their much greater staff and patient turnover and anonymity: these made little sense for our small practice. This plea was deemed inadmissible.

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A longer view shows that the portents for such inevitable ‘constructive decommissioning’ had been gathering for many years. A decade ago we were forewarned by a lesser-powered inspectorate: you can read about it in Planning, Reform and the Need for Live Human Sacrifices3. In more recent years NHS financial plans, too, were designed for the unlikely survival of small practices.

So, St James Church Surgery – with its rich local history of human engagements, affections and memories – was finally closed by legal mandate. The fact of its long and exceptional popularity was deemed an irrelevant inconvenience. But the questions raised by this elimination are with us always: What do other people want and need? How do we (think we) know? Who decides, and how?

And more ordinarily: when you go to see a doctor what kind of space, greeting and dialogue do you wish for?

The photos of the home of this affectionately-held centre are only of the space itself: to avoid any issues of confidentiality I have not pictured the people that vitalised the place. As in the best medical consultations, we often have to imagine those crucial, though absent, others.

I hope this small gallery, in memoriam, will not only preserve cherished memories: for the future it can help generate larger questions about the complexity of what we wish for, how we jeopardise these things, and how, instead, we may secure them.

Understanding the erasure of this old, traditional bastion of family-doctoring can help fuel what should be an endless debate. How do we discern between change and progress?

—–0—–

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References

  1. Death by Documentation. The penalty for corporate non-compliance. David Zigmond (2016)
  2. ‘The Doctor is Out’, The Observer, 18.9.16
  3. Planning, Reform and the Need for Live, Human Sacrifices. Homogeny and hegemony as symbols of progress. David Zigmond (2006)

1 and 3 are available via David’s Home Page: http://marco-learningsystems.com/pages/david-zigmond/david-zigmond.htm

Note
If you want to read more about how these kinds of questions were answered for many years at St James (and many of the better small practices), the anthology If You Want Good Personal Healthcare See a Vet: Industrialised humanity. Why and how should we care for one another? David Zigmond (2015), New Gnosis (available from Amazon), explores these themes.

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

A short break for tribalism, war and dodgy goddesses.

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

img_4067-copyBahrainis are migratory, especially during the annual Ashoora holiday. Ex-pats and locals alike flee the country, squeezing through Bahrain’s easygoing airport like a cork from champagne. Cyprus is beguilingly close, so there we landed for a couple of days R and R. The Greek goddess Aphrodite beat us to it, allegedly emerging from the sea at Aphrodite’s rock, between Limassol and Paphos. Aphrodite’s subsequent progress is recorded, comic book style, in astounding mosaics on view in Paphos. I guess mosaics were the digital medium of the day – every floor tells a story. But assuming local legends to be correct, Aphrodite was not well advised about hotels. Emerging from the sea she had to travel 30 miles to the Baths of Aphrodite for her shower. This looked romantic but not too hygienic. (Also not very private, hence I suppose the dodgy mosaics.) I confess that the shower in our hotel was preferable.

I’m not sure exactly when Aphrodite wafted by, but Cyprus certainly does history in depth. The remains of a nine thousand year old Neolithic stone built settlement have been excavated at Choirokoitia, thoughtfully situated en route to the airport. The settlement is an extensive village of circular stone huts built on a hill. It is in an excellent defensive position, surrounded by a stout stone wall. So presumably this was to enable the inhabitants to sleep soundly, defended from stray cats, mountain lions, and the odd time-expired velociraptor? Except that the entrance is clearly designed to defend it from other people. So here we have it. The human race – successfully threatening one other for thousands of years.

Cyprus seemed to sum up the human condition. Such beauty, happy sunshine, more myths than you can shake a Doric column at, war, bloodshed and brute tribalism. Cyprus is still partitioned into Greek and Turkish parts by the Green Line – a weeping scar across the face of Europe. As we drove up to Nicosia a huge Turkish flag dominated the view, painted on a mountainside to the north. You can see it from space. Rather insensitive to the Greek neighbours? Not for the relatives of the 87 unarmed Turkish civilians massacred in the nearby village who then made it and maintain it as a memorial. In all some 2,000 civilians died and tens of thousands were displaced. And this is not the seventh century, this was Europe in 1974.

img_4099Arriving at Nicosia we cross through the mighty old Venetian walls, many times the height of Choirokoitia. Yet in the middle of this European capital city streets suddenly stop, blocked by seemingly cobbled together barriers of oil drums, cement and barbed wire. Handsome old buildings crumble gently into the no man’s land beyond. These two half-cities carry on like a man with a severed corpus callosum who can no longer recognize his own hand, yet seems to think it’s business as usual.

I was fascinated by Steven Pinker’s thesis in The Better Angels of Our Nature. Written in 2012 he cites evidence that overall humans are becoming less violent. I confess I can’t get it myself. It seems a bit too reminiscent of Fukuyama declaring “the end of history” after the fall of the Berlin Wall. Humankind engages in unending outbreaks of violence. Whether we wish to put this down to our inner chimp, original sin or a fallen nature seems to be pretty much a matter of language. I am thankful to live in a western lacuna of peace and comfort, but I would be a fool not to recognize its fragility, its contingency. And this decade seems to illustrate painfully what Francis Schaeffer termed the age of “personal peace and prosperity”; I’m ok, comfortably smug, whilst half the world is in uproar or poverty.img_4356

Humans appear to be incurably tribal when stressed. Faith hope and love are shown the door at the first sneeze of a financial meltdown or regional instability. Like junk food and junk bonds we know tribalism is wrong but just can’t stop. The Venetian walls of Nicosia are a fine old sight – they have been defused but molder on, their moats turned into gardens and car parks, mere reminders of a primitive past. But the oil-drum-and-concrete wall through the heart of Nicosia is a bizarre and sorry sight, a reminder of our primitive present. And we live in a world seemingly attracted to more walls. Tribalism seems buried deep in all our hearts. Our walls develop but our human nature does not.

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.