Community

Have you ever ordered something, perhaps in a restaurant, and then realised when it arrived that it wasn’t what you thought it was? I was in Paris recently and ordered a pizza. I chose to add the optional ‘egg’. When it arrived I had not expected that the egg would only have briefly glanced at the pizza oven and essentially still be raw! What do you do in these situations? Sometimes you can send things back, but sometimes you have to accept that your understanding or interpretation was not quite right and re-frame your thinking. I got on with eating my pizza and raw egg.

I wonder if there is some confusion and re-framing that needs to be done around what we are talking about when we describe General Practice Networks, Primary Care Home, Care Communities and similar. To my mind these terms are not all freely interchangeable, and I wanted to describe what I think a couple of these mean, and the difference between them.

Locally we have encouraged the development of what we are calling ‘Care Communities’. We have also encouraged the development of a GP Federation. The question I guess I have is whether either of these constitutes a General Practice Network, and does it matter? I think it does.

GP Federations and GP Networks

GP Federations and GP Networks are about General Practice (the clue is in the title). They are about how GP practices can work together in potentially different and more efficient ways. This might include hub working to provide services for patients across a larger footprint than individual practices can manage themselves. In Winsford, where I work we already have two such examples. We offer extended access appointments whereby practices provide appointments open to patients of neighbouring practices –this means that patients in the town have access to appointments every evening even if their registered surgery is closing at 6.30pm. We also currently have a scheme operating a paediatric clinic weekday evenings. Children can be booked into these slots each evening, regardless of which practice they are registered at. Working in a collaborative way like this ensures improved access for patients in an effective way for the GPs and their practices. To my mind, GP Federations are likely to cover large numbers of practices and large geographical areas, and GP Networks likely to be smaller units within the Federation. In other words, a Federation might cover several towns and outlying rural areas. While a GP Network might be restricted to a single town and surrounding area, fitting in with the 30-50,000 population coverage we hear so much about.

A GP network might also look at sharing some back office functions, thus working more efficiently and reducing costs. There are a number of examples of this around the country.

GP Networks and Federations can also negotiate with local commissioning groups to bid for and then provide services for local patients. It is much harder for individual practices to do this than it is for a larger federation on their behalf.

As you can see from the above examples, I think a GP network or a GP Federation is very focused on General Practice, on the services they provide and on how they operate and work. I would like to suggest that this is distinct from what a Care Community might be.

Care Communities

Once again, I think the clue is in the name. Care Communities are about the local community. They obviously need to include the local GPs, and therefore likely the local GP Network, but they are wider than General Practice. To my mind, for a Care Community to be effective it needs to be as broad as possible and think as widely as possible. The NHS has not traditionally been very good at this. We tend to think ‘health’ and struggle to raise our eyes up and beyond that. GPs can also fall into the trap if thinking just about General Practice, and not even about the entire community health system (I say this as a GP myself). We need to include the wider Primary Care team – district nurses, Occupational Therapists, Community Physio, Midwives, Dentists, Opticians, Pharmacists and others I am sure to have missed out (apologies). Care Communities also need to think ‘whole community’. By that I mean social care, education, housing, town planning, local employers, third sector, local sports clubs, leisure facilities, industry and more. I believe that by tapping into the resources within the community as a whole could unlock solutions to many of the public health problems we are struggling to solve.

As previously mentioned, I work in Winsford in Cheshire. We have a Primary Care Home model in place supported by the National Association of Primary Care (NAPC). Team Winsford meetings include more than GPs. We are thinking whole community and need to continue to do so. As I have already suggested, if we try to solve the healthcare problems in our communities by looking to just the GPs and health professionals to do something, we are likely to fail. In this time of budgetary constraint we need to include the community and fully utilise the resources we will find there. As I write this I am aware that tomorrow I have a meeting with Town Council representatives to talk about how we could think about smoking cessation in the town. When it comes to smoking we could take a medical model in how we approach it, but we immediately come up against whose responsibility it is (Public Health or NHS?) and who will pay of the prescription and support services. This, unfortunately, will probably get us nowhere. If, however, we take a community approach, we are likely to come up with very different suggestions and solutions that are not based around who can or should prescribe medicines to help, and based more around the other ways we can support smokers to stop.

Want more examples?

The Somerset town of Frome is a good place to start. By working as community they have managed to reduce hospital admissions. Check it out here: https://www.theguardian.com/commentisfree/2018/feb/21/town-cure-illness-community-frome-somerset-isolation

Somewhere else? Look further North to Fleetwood in Lancashire. They are using the Primary Care home model championed by the NAPC to work as a community to improve health. You can see what they are doing in this short video. https://www.youtube.com/watch?v=ontqsXah0x0

I started this blog asking whether you had ever ordered something and found it was not what you thought. I think that many GPs have entered into GP Networks and Care Communities, thinking that it is about GPs, and are only now realising they could be about something very different and much bigger than anticipated. This could be scary for us. A medical model of health is deeply engrained within us, and it is hard to step out of this and embrace something different. We need help and support with this. I hope that when this realisation occurs that we will not be sending our order back to the kitchen, but instead going with it and changing how we think and view community. Thinking of it as a resource and not a problem to solve.

Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Clinical Chair of NHS Vale Royal Clinical Commissioning Group.

 

Agree with this blog? Disagree with this blog? Contact Jonathan by commenting or on Twitter @DrJonGriffiths

Counting

In my last blog I talked about the need to remember Primary Care when it comes to Winter Planning (https://drjongriffiths.wordpress.com/2018/08/01/winter-planning).  Since this was published I have seen Social Media posts about how we measure workload in Primary Care, including this blog from Samir Dawlatly https://blogs.bmj.com/bmj/2018/08/17/samir-dawlatly-we-need-better-ways-to-measure-gp-workload/. This is important for a number of reasons.

 

First and foremost, as described in Samir’s blog, are the issues of safety relating to ever increasing, unsustainable workload. Ask any GP and they will likely tell you the same thing in this regard – individual GPs are struggling, going off sick, retiring early, emigrating, leaving. Practices are struggling to recruit, struggling to balance the books, and in some cases going under. We really need to understand the numbers involved here to draw some lines and tackle the problem.

 

The second reason is what I want to talk about though. If we cannot quantify how much work is undertaken in Primary Care, how can we begin to quantify the value of Primary Care? Like it or not the NHS has an internal market. It is transactional. Money ‘follows the patient’ and hospitals are paid according to numbers of patients being seen. Additionally there are targets in place relating to hospital activity – 4 hour A&E target, 18 week Referral to Treatment target etc. All of this means that hospital activity is measured (there is a whole industry devoted to this), and if you are measuring it, you can show to everyone how well you are doing, and how hard you are working, how important you are and (crucially) how important it is to invest in your services. The risk with Primary Care is that we don’t count things in the same way. And if you don’t count it, you don’t seem to count.

 

How will we see increased investment into Primary Care if we cannot demonstrate its value? We are already fighting an uphill battle with popular opinion seeming to think that Specialists are more important than Generalists (see my TEDx Talk for what I think of this https://youtu.be/-BfcvI49GCw). If hospitals are already more important than Primary Care, and they are able to demonstrate how hard they are working, and with the majority of the country’s media reporting in a way that suggests that NHS equals Hospitals, is it any wonder that Hospital care continues to be resourced in a different and, I would argue, more favourable way than General Practice?

 

We have to do something about this. We have to start to count.

 

Of course, individual practices already do count, or have the ability to do so with a click of a mouse. Primary Care has excellent IT. My IT system can tell me how many people have been seen in the past year, how many phone calls, home visits and face to face appointments. I have just looked – it took me a few seconds to see that in 2017 our surgery of just over 10,000 registered patients saw 8,406 patients in a total of 47,819 booked appointments (I will digress to point out that we had 3,474 wasted appointments where people did not turn up – this is more that the entire number of appointments I personally had on offer to see me for the whole year as a part time GP. I’ll just leave that statistic hanging there…).  The information is all there. We just don’t share it. GPs, in fact, may be reluctant to share it due to fear that it will be ‘used against them’. They may fear that we will immediately start comparing numbers between practices and ‘encouraging’ those who have seen fewer patients to work harder. This is not what we should be about though. We should be about demonstrating our value.

 

I fundamentally believe that General Practice is of incredible value to the NHS. Unfortunately, currently, that value appears to be immeasurable. Unless we can do something to show what we are doing, and how this is helping the system as a whole, we will struggle to attract much needed resources into Community and Primary Care. Everyone is trying to bring about the fabled ‘Left-Shift’ – moving resource from expensive secondary care to  more cost-effective Primary Care, but so far this does not seem to be happening. It feels like enough is enough. Time to act. I would suggest we need to be brave, take what seems to be a risk, and put the money where we know it is needed, and where we know it will do good. The challenge back to me will surely be “Jonathan, how do you know it will do good? Can you tell exactly how it will help and what you will achieve?”, and I fear that I won’t be able to tell them. At least, not in terms of the numbers and figures they are looking for.

 

The problem is that General Practice just doesn’t work that way. Some have described the GP-patient interaction as occurring within a ‘black-box’ where you cannot see what is going on. We need to get over this and just do something.

 

If providing some numbers and counting some patient-contacts will help – let’s start there.

 

Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and is Chair of NHS Vale Royal Clinical Commissioning Group.

 

Got a question? Find Jonathan on Twitter @DrJonGriffiths

Winter Planning

Last week the UK was gripped in the middle of a heatwave with ‘hottest day ever’ records potentially being broken. Nevertheless, tomorrow I will be attending a meeting to discuss Winter Planning. This is entirely appropriate of course, and too many times in previous years Winter has seemed to arrive unexpectedly with a flurry of activity to shore up A&E and try to hit the 4hr A&E target. I think everyone recognises the need to deal with Winter as business as usual, with constant planning around how we manage flow through the system. I have the pleasure of being the vice-chair of our A&E Delivery Board, so such discussions and plans are now very familiar to me. I always approach these meetings and conversations, however, with a slightly heavy heart.

 

The reason for this is not because I don’t recognise the importance of the A&E target (it is a measure of quality and good indicator of how ‘hot’ your system is running amongst other things), but because of the inevitable focus it brings to just one part of the wider system. No matter how much we might talk about how the 4-hour target is not just about A&E, we usually end up talking about hospitals. More than that, we usually end up putting the bulk of any additional money into the hospital.

 

Let me be clear. This blog is not about criticising the hospital. I think they are doing a great job under difficult circumstances, and if I were them I would also want to invest more money into A&E staff, A&E buildings, hospital beds and ward staff. If you are dealing with patients queueing in your waiting rooms, filling your cubicles, filling your corridors, stuck on your wards, what would you do? Locally we know that our Emergency Department is not big enough. We need capital to sort this (and are struggling to find it at the moment). We also need more staff, particularly for key anti-social shifts (and that’s not cheap).

 

I think we continue to miss a trick though. We continue to sideline Primary Care and Community Services. Social Care has been brought into the fold through the Better Care Fund and the focus on Delayed Transfers of Care, and that is a very good thing, but Primary and Community are not round the table (at least not enough to make an impact yet).

 

This is a mistake. Primary Care has so much to offer, and if we neglect it we do so at our peril.

 

If you subscribe to the HSJ, you will have read this article about Luton and Dunstable and how they use a wider system approach to achieve their 4-hour target (https://www.hsj.co.uk/emergency-care/tackling-the-four-hour-ae-target-with-a-whole-system-approach/7022898.article). The hospital runs a GP clinic and streams patients there when able. This is a good approach, but I would advocate additional resourcing of GPs in their practices to help tackle the whole problem.

 

Let us remember that around 90% of all NHS contacts take place in Primary Care (for less than 10% of the budget). As a GP I see people with all manner of problems with all manner of degrees of urgency. Although I am not really an ‘emergency service’ I do deal with many things that otherwise would find themselves presented at the Emergency Department.  If you decrease my capacity in General Practice, then people will inevitably drift  into A&E. There are also plenty of people pitching up at A&E with Primary Care problems. Locally we have struggled to ‘stream’ these people to a GP. Our local ambulance service reminds us at every A&E Delivery Board that we have no local AVS scheme (Acute Visiting Service) and that paramedics are then faced with little option other than conveying to hospital.

 

If you ask A&E, they would like GPs to do more to keep people away from them (a recent HealthWatch survey in our A&E suggested that a number of people were there because they felt they couldn’t get an appointment with their GP, and you will probably have seen news headline this week about lack of extended access to GPs https://www.bbc.co.uk/news/uk-england-44938759). If you ask the paramedics, they would like to be able to ring the GP and get them to visit the patient asap to avoid taking them to hospital. If you ask the GPs, well, you will get a range of responses!

 

The problem is that GPs are not just sat there waiting for more work, twiddling their thumbs with their feet up. They are not on the golf course during their hours-long lunch breaks. (Check out my blog of January for more myth-busting about GPs – https://drjongriffiths.wordpress.com/2018/01/30/10-insider-tips-i-bet-you-dont-know-about-your-gp/). GPs are busy and can barely lift up their heads enough from their work to consider how they might contribute to the urgent care issues around them. They have no more capacity to take on extra visiting of patients who have rung 999 (or 111), and they are delivering the best access they can. GPs are not trying to do a bad job, and they are not trying to put up barriers to their patients. They are still doing an excellent job and providing quality care for huge numbers of patients every day (significantly more than the local A&E will be, albeit dealing with patients who are usually less unwell!)

 

All of this needs to be taken seriously. General Practice needs resourcing properly if it is to work effectively, and we know that an effective General Practice is a wonderful thing. Fail to do this, and we will fail the NHS.

 

I wonder how much talk there will be at my Winter Planning meeting about GPs and Community Services? My fear is that any talk that there is will be around how GPs can help with the 4-hour target, which is missing the point slightly. GPs need resourcing in order to keep the whole of the NHS going. They need resourcing to keep GPs doing what they do best – working as expert generalists in the community, providing continuity of care close to home in a remarkably efficient way.

 

Let’s acknowledge the importance of Primary Care, and put our money where it needs to be spent.

 

Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire and Clinical Chair of NHS Vale Royal Clinical Commissioning Group.

 

Want to ask Jonathan a question? Find him on Twitter @DrJonGriffiths

Cheshire? – Part II

Last year I wrote a blog about the plans in Cheshire to create a single Joint Commissioning Committee (JCC) working across the four Clinical Commissioning Groups in Cheshire (West Cheshire CCG, Vale Royal CCG, South Cheshire CCG and Eastern Cheshire CCG). You can read the blog here and I would recommend that you do.

 

https://drjongriffiths.wordpress.com/2017/08/04/cheshire/

 

I’m pleased to say that we have established this committee. It is up and running with representation from all of the four CCGs from a clinical, executive and lay-member perspective. We also have our local authority and public health colleagues in attendance as well as a nursing representative.

 

We are now turning our attention to the possibility of merging the four CCGs into one.

 

The question I am being asked is “Why?”

 

This is a good question. When CCGs were created they were made as Membership organisations, with the local GP practices as the Members. They were (mostly) small and representative of their local area, able to understand the local needs and commission appropriately for them. GPs have good representation on the Governing Body, and easy routes into this to ensure their voice is heard. Surely creating a much larger organisation will risk losing this?

 

I understand the concerns, but we need to understand why we are suggesting a move to Cheshire-wide Clinical Commissioning.

 

It is all about the development of Integrated Care.

 

The one consistent thing we have been working on since the advent of CCGs is integrated care, closer to home, seamlessly managing patients,  avoiding them bouncing between services, keeping people out of hospital, developing primary, community and mental health to reduce the need for secondary care intervention. The Holy Grail for CCGs seems to have been trying to achieve this. We have done much to work towards this, but have much we still need to do.

 

A local Integrated Care Program will hopefully bring about some of this. In its development we will be creating something new that will perform some of the functions of a provider, and some of a commissioner Some of the functions currently undertaken by a CCG will be done in an ICP. This means that we may need less people in the CCG (and more in the ICP) and that the CCG will need to operate very differently to it does now, to allow space for the ICP to develop and perform well.

 

That’s why we need to consider merging the Cheshire CCGs. To allow us to develop Integrated Care, which is what we believe we need to do to improve things for our patients. This is fundamentally about improving patient care.

 

Developing ICPs and devolving budgets to them also means that local GPs can continue to work in local care communities, having a voice and a say in how we develop local care.

 

There is another reason that is specific to the people of Vale Royal and South Cheshire. We have long been working together to develop integrated care around the Central Cheshire area, primarily because most of our patients will use the same local hospital. Recently we have moved to develop two integrated care programs across Cheshire – Cheshire West ICP and Cheshire East ICP. This has split the Central Cheshire work, with Vale Royal aligning with West Cheshire and South Cheshire aligning with Eastern Cheshire. If we are to ensure that local patients get the same ‘offer’ when they present to the same hospital, but from different ICPs, then we need one commissioner to define the outcomes required and commission accordingly. In simple terms a patient from Winsford presenting at Leighton Hospital should get the same care as a patient from Middlewich. (If you are not local, then look at google maps to see what I mean.) One Cheshire Commissioner will help us to do this. There are other examples already happening that we could do with addressing – patients in Winsford or Northwich (within Cheshire West and Chester Local Authority) received different weight management services to patients in Frodsham or Tarporley (also in Cheshire West and Chester).

 

As well as creating space for ICPs we do want to address the inefficiencies of 4 CCGs across the area – we can commission more effectively and get things right for our population if we do it once.

 

All of the above explains our ‘Why?’

 

The ‘How?’ question is next. Our plan is to continue developing the ICP and to gain approval from our GP Memberships to pursue work to bring the CCGs together, creating joint committees, appointing a single Accountable Officer and bringing the executive teams together. If we are to then look to merge by April 2020, then we need to put in an application with NHS England by July 2019. If we can put an executive team in during the current financial year, they can help us to pull all this together.

 

The ‘How?’ will also inform the ‘What?’ – in other words, what will the final merged CCG and the ICPs look like. We need our Memberships and others to help us with this. GPs are rightly concerned about how they will continue to have a say and a voice – we need to build this into the process and we want to hear from our GPs with regard to any ‘checks’ that need to be in place as we proceed. We need to work on how GPs will be represented, and how they can be sure their voice counts.

 

Some have asked if this is a ‘done deal’ – absolutely not – if the GPs don’t want a merger, there will not be a merger. Some have asked if we are being told to do this by NHS England – absolutely not – this is our plan and vision.

 

My final point is a ‘What if…?’ – as in what will happen if we don’t merge. I think this creates problems for us in Central Cheshire as it drives planning into two geographies that are co-terminous with the Local Authorities. This pulls apart our natural local health economy. A single commissioner can set the desired outcomes across both Local Authority areas, and ensure everything is joined up.

 

We cannot do this without the engagement and involvement of our local GPs who need to feel they are listened to.

 

It has been about a year since my previous blog about ‘Cheshire’ – maybe next year I’ll be doing another one to let you know how we are progressing.

 

Dr Jonathan is a GP in Swanlow Surgery in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.

 

Got a question? Find Jonathan on Twitter @DrJonGriffiths

Why won’t my doctor just do what I want?

Following on from my recent blogs “10 Insider tips I bet you don’t know about your GP” and “Everything you know about going to the doctor is wrong”, I thought it was time to give you some pointers about how to ensure you get what you want out of your GP appointment. We have probably all felt frustration in struggling to make an appointment, taking time out of a busy day and waiting to be seen only to then feel that what we were after has not been provided. How can you change this? Here are my tips:

 

Make sure what you want is what you need.

To quote The Rolling Stones “You can’t always get want you want…”. This is the most fundamental tip you need to understand. You need to consciously think about what you want from your doctor and whether this is actually what you need. The two things are not necessarily the same. Sometimes this is about taking a step back in your thinking. You may have gone to the GP wanting a referral to a specialist, but what you actually need is your problem addressing – this is going to bring you into conflict with your GP if she (or he) feels they can sort your problem without a referral. Maybe you have gone to the GP looking for antibiotics for your cough? As I have said in my earlier blogs, what you really need is someone to properly assess you and make an expert decision about whether you need treatment, further investigation or just a bit more time for things to settle. If you go to the doctor with the intent of seeking their opinion and view on your condition – this is easy to get your GP to do.

 

Be crystal clear about what you want.

If you do not explain, clearly, to your doctor what you are after, don’t be surprised if you walk out without your needs being met. As I have said before, your Doctor is not telepathic! I strongly suggest, however, that you remember the first point here, and try to keep an open mind about what you want, and be prepared to listen to what your GP has to say. Let’s try to have grown-up adult conversations with our doctors about what is concerning us, what is important to us, and what we are hoping for. This is a much better place to start than with a demand or with unrealistic expectations.

Probably the most important thing you can do to get your doctor to do what you want is to ensure they understand where you are coming from, what your concerns are, what you have already learned about the problem and what is important to you. Fundamentally your doctor wants what is best for you, but a large part of that is for your doctor to understand what you feel the best thing for you is. Patient Centered Care is what this is all about. Your doctor doesn’t want to do things to you that you don’t want.

The flip side to this is that your doctor does not want to do things to you that they think will not help you, or may harm you. If you find yourself in a situation where you are asking for an intervention and your doctor is reluctant, this needs exploring. I would urge against digging your heels in, insisting on action, and complaining when you don’t get it. The far better initial response is to fully understand why the doctor is concerned, and to let them know where you are coming from. This might not resolve things, but at least improves understanding on both sides (and let’s face it, if we are talking about ‘sides’ then things have already gone wrong – your doctor would always like to be on your side…). Try to aim for co-production of plans.

 

Understand what your GP is able, and not able, to do.

As with anything in life, if you are asking the wrong person, you are not going to get what you want. This is an area of difficulty with GPs as their remit is so broad it can be hard to know where their responsibility ends. In simple terms GPs provide primary care services for patients who are or believe themselves to be ill or suffering from chronic disease. This includes health advice, referral to other services and, if requested, immediately necessary treatment due to an accident or emergency within the practice area. (This is a paraphrase from para 8.1.2 from the GMS contract and thanks to a social media contact for signposting me to this). It is sometimes easier to describe which services they are NOT paid to provide for you, as this can cause misunderstanding. They are not obliged to provide a home visit just because you don’t have a car. They are not obliged to provide a fit note during the first week of an illness, as you can ‘self-certify’. You can use the form found here: https://www.gov.uk/government/publications/statutory-sick-pay-employees-statement-of-sickness-sc2. They are not obliged to write you a letter for anyone explaining how your medical condition affects your housing/horse-riding/ability to attend lectures/ability to sit your exams/ability to wear a seat-belt etc.* They are not obliged to complete medical insurance forms*.

 

*There are a number of private services that GP will usually provide, and these letters and reports fall into that category. Your GP will charge you for these services. For some of them, your GP will need to make a decision about whether they can complete the form or not. If, for example, you are asking your GP to sign a form to say that you are fit to run in the Paris Marathon, then they may not feel they have the expertise to make such an assessment – there are alternative providers that you can find on-line who can do this for you.

 

The thrust of this tip is to make sure you understand that your doctor is unable to provide everything that you might like them to. Try not to go in with a demand, but a query, and try to have found out in advance if they are really the right and/or only person that can do this for you.

 

Remember that your GP provides a different service to your consultant.

This means that your GP is not usually the person to ask to get things done at the hospital. If you have been to a consultant and they have arranged tests that you want the results of – I would suggest you ring the hospital. Whoever arranges a test is the person who will receive the results. Please do not assume that your GP will have the results, and even if they do please don’t assume they are the best person to relay those results to you. Specialists tend to arrange specialist tests. Your GP may not know how to interpret the results, and may not know what the consultant plans to do next.

People commonly attend the GP wanting things sorted out with their hospital appointments. Why not ring the hospital directly? If you don’t have a direct dial number, just ring the main hospital number and ask to be put through to your consultant’s secretary, or if it is about your appointment, then ask for the appointments department. Cut out the middle-man (the GP) and go direct to the person who can help you.

 

In conclusion

We have just scratched the surface here in terms of the number of reasons that might be behind your frustration that your doctor is not doing what you want. The key message from me is for you to understand that your doctor does really want what is best for you, and for you to understand that they might not actually be the person to be asking. Sometimes it is about thinking more closely about what you feel you need, sometimes it is about finding the right person to help.

At the end of the day, being clear and seeking to understand is fundamental. I hope these tips will help you to do just that.

 

Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group

 

If you have any questions for Jonathan why don’t you find him on Twitter @DrJonGriffiths

Everything you know about going to the doctor is wrong

You’ve been going to the doctor all your life.  You know how this works, right?  Wrong.  In my last blog I gave you “10 insider tips I bet you don’t know about your GP” (https://drjongriffiths.wordpress.com/2018/01/30/10-insider-tips-i-bet-you-dont-know-about-your-gp/), and now I’m going to tell you how you need to change your approach to going to the GP, and why.  Do you think your GP’s primary aim is to ‘get you better’?  Do you wait for your doctor to ask all the right questions during the consultation?  Do you feel cheated if you don’t walk out without a prescription?  If so, you’d best read on…

Your doctor is probably looking to assess rather than looking to treat

This is really important to understand, and often where things can get off to the wrong foot in a consultation.  What is your approach to going to the GP?  If you have a bad cough or sore throat, what are you looking for from your GP?  If the answer is that you go in order to be ‘made well’, then I would suggest you change that approach.  Your doctor knows that the majority of acute illnesses get better themselves.  Coughs, colds, sore throats, earache, tummy ache, vomiting, diarrhoea, rashes etc all tend to be ‘self-limiting’.  When your doctor sees you she (or he) is not thinking “What do I need to prescribe to sort this out?”, they are instead thinking “Do I need to treat this?”

There is a fundamental difference in the two approaches.  One has the expectation of a treatment; the other has the expectation of a professional opinion.  If you go expecting the former, you are setting yourself up for disappointment, and potentially confrontation when your doctor has other ideas.

My tip: Go to your GP for their expert opinion, not necessarily for them to make you well.

  

Your doctor will learn more from the story you give than the examination they perform

People often go to the GP in order to be examined in order to work out what is going on.  It’s important to realise that the history is much more important than the examination (doctors use the word ‘history’ to mean the story that you give – i.e. your description of the symptoms you have).  This means that getting your story straight is really important.

When you first sit down in the GPs office, they are likely to start things off with an ‘opening gambit’ – an open question inviting you to say why you have come.  Each doctor will likely have come up with something that they are comfortable with such as “What can I do for you today?”, “How can I help you?” or “What seems to be the problem?”  Regardless of what they say, this is your opportunity to explain why you are there.  Be as detailed and specific as you can.  Don’t just say “I have a sore throat” and wait for more questions.  Instead try “I started with a runny nose 4 days ago, then when I woke up the next day I had a bad throat.  It has got worse rather than better and I’ve been taking paracetamol at maximum dose for the past 3 days.  I am not eating anything as it’s too sore, and I’m not drinking much either.” You see the difference?  A good doctor will follow up with another open question, such as “Is there anything else?” which will allow you to provide even more detail not just about your symptoms but also about your thoughts, ideas and concerns.  Adding “I had tonsillitis a couple of years ago and this feels just like that, I wondered if I had it again?” is helpful as it lets the doctor know where you are coming from.

Be clear about how long things have been going on for. You would be surprised how often people say things like “I’ve had this cough for ages”, or “It’s been like this for a long time”.  Don’t leave your doctor guessing – if they have to resort to asking “Has been days, weeks, months or years?” then you have probably been too vague!

Get as much out as you can in that first minute or so, fully explaining your symptoms as well as your own ideas or concerns about what’s going on.

In addition, be upfront about any “list” of problems you might have that you want dealing with.  If you read my previous blog you will remember that I said “Your doctor does not like lists”.  I think this is largely true, although a list declared at the outset that can be tackled together with your GP is not always a bad thing – just be aware of how much time you might have (usually no more than 10 mins to include time walking to the room and the computer entry).

My tip: Tell as much of your story as you possibly can in the first two minutes of your consultation.

 

 Your doctor really wants to know why you are there

It might be obvious to you, but may not be obvious to them.  Take the previous sore throat scenario.  If you don’t tell them upfront then your GP is left guessing.  It could be for any of the following reasons or a multitude of others:

1. You want antibiotics
2. You want to rule out tonsillitis
3. You are worried you might have glandular fever
4. You are worried you might have throat cancer
5. You want a sick note

I hope you can see that the doctor will manage a consultation looking to reassure about throat cancer very differently to one where you are not looking for anything other than a note for work.  It does help your doctor if they know what your motivations are.  Don’t be offended if your GP says “Why have you come?”  It’s really hard to frame the question without them suggesting you didn’t need to be there (which is not the intent behind the question!).  Above all – don’t treat this as a ‘test’ for your doctor to see if they are good enough to work things out for you – surely you want a partnership with them in order to get the best outcome – for you!

My tip: Be very clear why you have attended to see the doctor, and do that at the start of the consultation.

  

Your doctor may not be able to say what is wrong with you

And that does not mean that they are not a good doctor!  Your doctor will be hoping to make a definitive diagnosis, but more often than not they will instead be looking to make a list of ‘differential diagnoses’.  This is a list of conditions which all share similar symptoms.  On that list there will be conditions that your doctor will wish to actively rule out, and if they can’t, they may wish to investigate further.  Sometimes they can do this within your consultation.  Sometimes they will need to arrange further tests.  Sometimes they will want to see you again to see if things have settled.  Sometimes they will send you away with instructions about what to watch out for to prompt a return visit.  Which approach is appropriate depends upon your history and the examination findings.  Do not be surprised or disappointed if your doctor cannot tell you, for certain, what is wrong with you.  It is more likely that they can tell you what you don’t have.  This is a key part of what GPs do – try rule out important, serious, life-threatening conditions. Whatever is left may not need treating, or even diagnosing!

Very often your GP will use time as a tool to aid diagnosis.  This might mean that you don’t get a definite diagnosis on your first visit, but when you come back (not better), then this will trigger further tests.  This does not mean that you should have had the tests the first visit.  Don’t be fooled by the ‘better safe than sorry’ mentality – having too many tests is also bad for your health, resulting in, potentially, side effects from the tests and/or ‘over diagnosis’.

My tip: Don’t worry if your GP can’t tell you what is wrong first time!

 

 

Your Doctor is not just a gatekeeper for a prescription

It is not all about the drugs.  Remember the first tip.  What you really want is an opinion, maybe a diagnosis, and only treatment if you need it.  Sometimes when people go to their GP they feel that it was a waste of time if they don’t come away with a prescription.  NOT TRUE!  The assessment and evaluation and opinion that a medication is not needed at this point in time is of great value.

Here’s another thing.  Why would you want to take a drug that you didn’t actually need?  Do not be fooled by the better safe than sorry mentality.  There is risk associated with every course of action.  Taking prescription medication comes with a risk (that’s why you need a prescription, you need someone qualified to decide if you need it, someone qualified to decide if the potential benefits outweigh the potential risks.  The risks vary from drug to drug, but for commonly prescribed antibiotics they include side effects such as diarrhoea, allergic reactions, thrush, rashes and interactions with other medications.  There is also the risk of increasing antibiotic resistance that comes with increased antibiotic prescribing, and, of course, the financial cost to the NHS of the prescription.

My tip: Don’t be rushing to take prescription drugs.

 

 I hope you can now see that there is more to general practice medicine than meets the eye.  Understanding how your GP is approaching their consultation with you can help you adjust your approach with them.  Being on the same page as your GP can only help this process and get you the help you need when you need it.

Please share these tips and follow the blog for more content!

If you want to ask Dr Jonathan anything, then find him on Twitter @DrJonGriffiths

 Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.

 If you liked this, why don’t you also try:

 https://drjongriffiths.wordpress.com/2018/01/30/10-insider-tips-i-bet-you-dont-know-about-your-gp/

 https://drjongriffiths.wordpress.com/2017/09/28/the-school-told-me-to-come/

 https://gpandhuman.com/2018/02/01/think-of-your-gp-appointment-like-a-train-journey/

 

10 insider tips I bet you don’t know about your GP

We’ve all been to the doctor, right?  We know how it works; we know how to get an appointment and what to say when we go.  I’m always surprised at how little people do understand about how their doctor’s surgery really works, and how to get the best out of them.  Most people don’t realise that a GP runs a small business and that they get paid a set fee to provide all of your care.  Do you have any idea how long your appointment slot is, or how many patients your GP will see each day?  Hopefully you won’t need to visit your GP very often, but a bit of insider knowledge can help you when you do need to go!  How many of these insider tips and nuggets did you already know?

 

1. Your Doctor would like to give you more time
   • Most GPs provide just 10 minutes for an appointment. Although this might not seem very long you must remember that this has increased over the past 20 years from a typical 7.5 mins per appointment, and from even shorter appointments before then.  GPs can choose to offer longer appointment times, but there is a balance between length of appointment and how many appointments they make available.  This is obvious when you think about it – do you offer fewer, longer slots, or more, shorter ones?  What would you do?  Depending upon your reason for attending, 10 minutes might be more than enough time, or woefully inadequate.  Got a sore throat?  You might be in and out in 5 minutes.  Hearing voices and suicidal?  You might be in there for half an hour, or probably longer. Your doctor will rely on a variety of problems presenting to balance these demands on their time, and hopefully will run roughly to schedule.  Often they will run late.
   • You can help this by understanding how long your appointment slot is (just ask when you book), and working with your doctor to get things done in the time allowed. If you already know you are going to need more than 10 mins, ask reception if you can have a longer slot. They will probably be happy to oblige.

 

2. Your Doctor does not like lists

• Well, let me clarify this. Your Doctor would advocate you knowing what you are coming for, and if writing this down in advance will help you, then I would suggest you do so.  However, bearing in mind point one above, if you only have 10 minutes and if you pull out a list of 5 problems this is pretty stressful for your GP.  Were you expecting 2 minutes per problem?  Be realistic.  Prioritise what you want from your doctor.

 

3. If you arrive 10 minutes late, you have missed your appointment.

• What I mean is that if you are 10 minutes late (or more), then you are not just late, but your appointment slot has come and gone. The next patient is now due.  Remember that the impact of being late is not just on your doctor.  They may be prepared to finish their surgery late in order to see you, but what about all the other patients who have booked in and arrived on time?  If you arrive late, this is who you are causing hassle for, all the people around you in the waiting room.  I guess I’m just asking you to think – is this fair?

 

4. Your Doctor is not telepathic

• Pretty obvious, right? Yet it seems that people think their GP will know what they are worried about, which of their problems is a priority for them and what their hidden fears are.  A good doctor will no doubt explore all of this with you, but you can short-cut this.  Be up front about what is on your mind.  If you are worried because you think your rash or lump might be cancer, then say so.  If you want to exclude some rare condition because your mother had it – let the doctor know.  Try not to leave your main problem until the end.  You would be amazed how many people get through the whole consultation and then, at the end, say something like “While I’m here, can I mention this chest pain I’ve been getting?”

 

5. Your Doctor is a specialist

• They have just specialized in being a generalist! Don’t make the mistake of thinking that there is a hierarchy of doctors, with GPs at the bottom and hospital consultants at the top. Your GP will have spent a minimum of 5 years in training AFTER medical school. They are experienced doctors qualified to look after you. Sometimes people think that going to A&E means you get to see a ‘proper doctor’ – remember that the junior doctor in A&E is likely significantly less experienced than your GP. Many people think that being a GP is the hardest job a doctor can do. If you are concerned that you might need to see a specialist, then talk this through with your GP – they are in a really good place to decide with you if that is what is needed, or not.

 

6. Your Doctor is self-employed

• Did you know this? Why does it matter?  GP partners own the business of the practice and are ‘independent contractors’ to the NHS.  Many members of staff at the surgery, including some of the doctors, will be employed, but by the surgery not by “the NHS”,.  This has a number of implications:
• Firstly, your GP receives a set amount of money per patient per year to provide all of their care. It doesn’t matter whether you see your GP every week all year, or don’t attend for 5 years; your GP gets the same amount of money for looking after you.  You must not think that by seeing your GP you are ‘doing them a favour’ by bringing in money for your attendance!  The amount of money your GP earns varies from practice to practice (they are all individual small businesses) but the average is around £140 per patient per year.  This is really good value (less than 40p per patient per day), particularly when you consider this is the money the practice receives to provide all the services and pay all the staff including the doctors.
• Secondly, this means that your doctor’s surgery is contracted to provide certain things, and not others. It’s worth remembering this as this is why you will sometimes be asked to pay for things.  In simple terms your GP is contracted to provide medical care, but not to do things outside of this such as the multitude of letters they are asked to sign.  If ANYONE asks you to “get a note from your doctor”, you should really question this before heading off to the surgery.  Many of these requests are unnecessary and just seek to move a perceived risk from one person to the doctor, who may not be in a position to carry that risk.  Check out this website first for more info:

http://www.ganfyd.org/index.php?title=Get_a_note_from_your_doctor

• The payment GPs receive is not affected directly by referrals or prescribing – the costs for this are in a separate budget. If your GP decides to prescribe an expensive medicine for you they are not paying for it themselves.  People often think that GPs switch medicines to cheaper ones in order to personally benefit financially.  NOT TRUE!  They are doing this to help the NHS budget as a whole, which I would hope we would all be in support of.
• Because they are small businesses, they bear any increasing costs themselves. Rising indemnity fees (insurance against being sued) have to be paid by the doctor themselves.  A doctor working only 2 days per week can be paying £6,000 per year on indemnity insurance.  Why does this matter to you?  Because if they are paying £6,000 on that they are not spending that £6,000 on another receptionist, or nurse, or another doctor.  The higher the costs, the less likely the surgery is to be able to add in additional services.  So, bear this in mind when you are thinking of suing your GP!
• Despite what The Sun might tell you, your doctor does not earn £700k per year (unless your GP happens to be the sole one in the country that does … )

 

7. Your Doctor wants the best for you
   • If your GP decides not to refer you on, or not to prescribe anything, or not to investigate you it is not because they are trying to be difficult or just trying to save money (don’t forget, their take home pay is not affected by these things). It’s usually because they don’t feel you need any of the above.  They also understand, probably better than you, the risks associated with over referral, over treatment and over investigation.  This is not a game where you need to see how much you can get from the NHS.  This is about keeping you healthy, investigating when appropriate, and treating when we need to.  Bearing this in mind, your GP will not mind explaining it to you – just ask.  If you were hoping for an X-ray, mention this and have a grown up conversation with your doctor about the pros and cons of doing that.

 

8. Your Doctor is not taking part in a medical drama.
   • When you watch the TV, watch out for the doctors. I bet, 9 times out of 10, that they get the diagnosis right, first time.  I’m afraid this is not real life.  Many conditions are not at all obvious, and time is the only sensible way to start to differentiate between them.  GPs often get vilified in the press for not picking up serious illness (“I attended my GP 3 times before they referred me with my cancer…”).  In reality serious illness often initially presents the same as mild, self-limiting illness.  A cough, for example, can be caused by many things, from a simple viral infection to lung cancer.  The patient who presents to their GP with a cough that they have had for less than a week is unlikely to get a chest X-ray on the first visit, but if it has failed to settle after 3-4 weeks, then that’s a different story.  Be aware of this and remember that this is complex stuff.  In particular, ask about the things that you should watch for and under what circumstances you should return for review

 

9. Your Doctor might play golf, but probably not in their lunchbreak!

• The traditional view that people have of GPs is that they see a few patients in the morning; a couple of visits, then are free until evening surgery at 5pm. Plenty of time for 18 holes in the afternoon?  The traditional view is out of date.  Most GPs see 18-20 patients in morning surgery, followed by visits, and then a further 18-20 patients in the afternoon.  Many GPs see more than this.  In addition to these face to face consultations, there will be phone calls and paperwork.  Paperwork is an essential part of patient care, but takes time.  It consists of looking through the results of the investigations that have been ordered, reading letters from consultants, acting upon these letters (consultants will not infrequently give actions for the GP to undertake), signing prescriptions (signing prescriptions is one of the riskiest things that GPs do – be aware of this and don’t be upset if there is a query over your medication – this might just mean that the GP is taking the trouble to check that this is safe for you and won’t kill you) and arranging the investigations and referrals from the previous surgery.  The waiting room may be empty, but that doesn’t mean the GPs are all putting their feet up.  That’s a lot of patients seen, and a lot of decisions made. If you are waiting for the results of an investigation, this can be stressful, and you quite rightly will want the results as soon as possible.  Here are some things you should consider:
  • If the test was arranged by your hospital consultant – that’s who you should go back to for the result. Ring the consultant secretary (ring the hospital switchboard and ask to be put through) and ask when the consultant is going to convey the results to you.  If they try to palm you off by saying they will send the results to your GP, explain that you want the results from the specialist who arranged them who is in by far the best place to give appropriate advice.
  • If your GP did arrange the test, the smart thing is to make sure you know from the outset when and how you should expect to get the results. Are they going to phone you, or do you need to call?  Speaking to the receptionist if you are uncertain is the way to go – explain your problem, and ask how to proceed – they will probably be able to help you.

 

10. Your Doctor has entrusted their reception staff with an important job

• And that job is not just to make things as difficult as possible to make an appointment! The receptionist’s main job is to deal with enquiries, book appointments and generally ensure all is running smoothly.  They are not medically trained, but they will have a really good understanding of the services on offer. My advice would be to entrust them with a rough idea of the problem that you have.  This way they are able to direct you to the most appropriate course of action. Don’t forget that everyone who works in the surgery is covered by the same confidentiality clauses. You can trust that the receptionist is NOT going to be talking about you to others. Increasingly doctor’s surgeries include clinics run by nurses, physios, pharmacists and more.  If you ring and insist on an appointment with a doctor, without explaining that it’s because you have a bad back, you might have missed out on seeing the physio – probably a better option for you.
• If you are polite and friendly to reception, they will be polite and friendly to you. They are not trying to be obstructive, they are just doing their job – you might be anxious and stressed, but try to keep calm.  The receptionist can be key in getting the right help as quickly as possible – just remember, that help might not be the GP.

 

So, how many of these top 10 insider knowledge facts did you know?  As with all things, the more we know about how things work, the better able we are to work with the system and get what we need done.  I hope these facts and tips have been interesting and helpful to you.  If they have, why don’t you share them with a friend?!

 

If you want to watch something from Dr Jonathan about the value of the Generalist – check out his TEDx Talk online https://youtu.be/-BfcvI49GCw

 

Dr Jonathan Griffiths is a GP at Swanlow Surgery in Winsford.  He is also Chair of NHS Vale Royal Clinical Commissioning Group.

 

If you have a question for Dr Jonathan, why don’t you find him on Twitter @DrJonGriffiths