Are we choosing well?

Are we choosing well?

I was recently part of a team of GPs who audited the hospital notes of patients who had been admitted to hospital. The particular group of patients we were looking at were those who had been admitted but then discharged in under 24 hours. The intent of the audit was to look at what was happening to these patients and whether they really needed to be admitted at all, or whether they could just have been sent home without the need for a hospital bed. 

I want to describe a not-untypical scenario I saw happening.

I rremember talking to one of my GP colleagues at the time, asking her how she would have managed a similar presentation in General Practice. The patient was in their 50s (although could have been any age) presenting with a cough and feeling breathless, they have had the cough for several days and they are worried they might have a chest infection, or even pneumonia. On examination they have normal blood pressure, normal pulse rate, normal chest examination (ie no signs on examination of a chest infection), normal pulse oximetry (a measure oxygen levels in your blood), normal temperature, normal breathing rate. I pause at this point and ask my colleague what she would have done. Confidently (because this is exactly the kind of thing GPs see all the time) she replied that she would have reassured the patient and sent them home. In A&E, the patient also had blood tests, a chest X-ray and blood-gases (a sample of blood taken from the artery to determine oxygen levels more accurately). At some point during this process they were admitted to hospital, before then being reassured and sent home.

If the patient had attended their GP, it would have taken a 10 minute consultation. They were in the hospital for several hours. If the patient had attended their GP, it would have cost the NHS around £35, instead it cost the NHS several hundred pounds.

Most people I speak to, including my patients, do not enjoy a trip to A&E. Most people I speak to think we should be using tight NHS resources as efficiently as possible. Despite this, there are many people every day turning up in A&E who don’t need to be there. Last week our local hospital was in the newspapers with this article about increasing numbers of people attending A&E.  I saw it first on FaceBook, and many of the comments suggest that people are attending A&E because they can’t get to see their GP. This is unfortunate, and I suspect largely untrue. I know a lot of GPs in my area and I am pretty confident that all of them would say they would see patients on the same day, where appropriate, if they had an urgent need that could not wait. You may well be asked to wait a couple of weeks for something routine and I don’t think that is unreasonable, but all GP surgeries have provision for emergency patients on the day. Many of the local surgeries in the Central Cheshire area have also been part of the The Prime Minister’s GP Access Fund. This has provided an additional 32,645 GP appointments across the area in the last year, just on weekdays. There have also been an additional 7,691 GP appointments at weekends. On top of that there have been nurse and physio appointments too. 

40,000 extra GP appointments in a year. That’s an average of 3,361 extra appointments per month. (If you read the newspaper article above it mentions that the hospital had an extra 1,600 A&E attendances over a 3 month period. I’m not sure how that is newsworthy, and this isn’t?) 

So, there are more GP appointments, including at weekends, as well as GPs making provision for urgent appointments. There are also Out Of Hours services available if your GP surgery is closed (call 111 to access these), yet still people are choosing to attend A&E for conditions their GP is more that qualified to manage. Do we understand why this is? I’m not sure we completely do. One thing I can be sure of, is that demand appears to be going up. Increased demand to GPs will result in an increase going to A&E. 

I have a few ideas about why demand is going up.

I think as a society we have become less tolerant of ill health. We are no longer prepared to wait it out. I see people attending with coughs, sore throats, sticky eyes and other self-limiting conditions on the day they start. We are unhappy living with the symptoms and want an immediate cure. 

I think as a society we have a greater sense of entitlement. Rather than gratitude for the NHS, and a view that we need to carefully use the precious service which is available for free, we all feel that the NHS is there for us, and that we are entitled to it. This drives increasing use. 

I think as a society we have ever increasing expectations. “You’re telling me that we can put a man on the moon, but you can’t cure my cough?” Well, quite possibly not, and if you’ve only had it for 3 days I’m probably not going to try to unless my examination of you suggests otherwise (or unless you have some other reason why I would need to, like COPD as an underlying condition). 

I think as doctors we can do so much more that we used to. Medicine has moved in. We are actively treating conditions today that a couple of decades ago we were not. Management of chronic, long term conditions has taken over a large chunk of the GPs time. Heart disease, kidney disease, COPD, heart failure, hypertension and more. All being treated and keeping us all living for longer and longer. This is good, but all adds to the ongoing demand. Our local hospital tells us that they are seeing patients with increasing complexity and acuity. In other words, they are sicker, and have multiple medical complaints.

I  think that as a society we are much more litigious. We also tend to think “better safe than sorry”, and seek out advice and reassurance much more than we used to. Schools, nurseries and employers increasingly send people to the GP to check up on things. Gyms stop people from joining until they have a medical certificate saying that it is safe to exercise (it almost always will be) and it has led to a culture requesting that you “Get a note from your doctor”. It also results in doctors behaving more defensively, requesting more tests, and bringing people back more often, none of which are necessarily a good thing. This might account for why in A&E, where you are likely to be seen by a doctor less experienced and confident than your GP, that you are more likely to have more tests (that you might not need), and find yourself unnecessarily in a hospital bed. (There is a side issue here about patients being classed and charged as admissions when they never get as far as a ward, or even a bed, and we need to sort that out too).

You may well be thinking that not all of these things should impact particularly on A&E, but suffice to say that if you increase the work going to GPs, some will spill out and have an impact on A&E. 

We all, collectively need to work out how to tackle this. GPs do sometimes need to look at their access issues and their telephone lines, but I hope you can see from this that GPs are working very hard, offering huge numbers of extra appointments over the last year, and doing what they can to meet the need. I get very frustrated and disappointed when I see them being accused of being the underlying problem behind the A&E crisis. A quick point here – the Prime Minister’s GP Access Fund locally runs out of money within the next 6-8 weeks. We have heard that additional monies are to be made available from the Government, but we have been hearing that for a while and have not seen anything in writing. We are concerned that there will be no money to continue this scheme. The CCG does not have any spare money to fund this. We could only find the money by taking it out of the local hospital. If the money is not forthcoming, those 3,361 extra appointments per month are all going to disappear.

I started my last paragraph says that we all need to tackle this together, and I really do mean all. This is as much a society problem as a GP or hospital one. We all need to do our bit. We need to choose well when we need care, and stop and think if we may initially need to help ourselves before seeking other services. We need a greater tolerance and understanding of risk, and to be less quick to pass all risk onto others. We need to acknowledge that self limiting conditions really are self limiting, and to be patient patients while we wait for them to resolve.

It’s time to rethink how we use and access NHS services. This can be done. Let’s do it together. 

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


Follow Jonathan on Twitter @DrJonGriffiths

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Tea and Cake

Tea and Cake

This week I will be baking cakes again for ‘Tea and Cake with Jon and Andy‘. I have been doing this for a couple of years now – putting aside an hour for any CCG staff member to come along and ask me anything. I bring cake, Andy brings his tea-pot.We do this every couple of months and it has been well received.

 

I get asked what this is about, and why I do it. There are a number of reasons.

 

To give permission to talk to me. Now, on one hand I think this is daft, because I’m telling you now that you can come and talk to me anytime, but I appreciate it’s not quite as straightforward as this. I’m not always available – I’m in surgery for 2 days every week and then have meetings filling my diary. Some days you can only really speak to me if you have scheduled the time into my calendar! The tea and cake sessions essentially do that for you. There is also something about members of staff having the confidence to go and say hello to the Chair. Again, I think I am approachable, but someone recently told their colleagues that they thought I was ‘scary’. Clearly I need to work on my approach-ability! The tea and cake sessions signal that it’s OK to come and say hello – in fact it is positively encouraged. I hope that through these sessions people will then see that I am not scary after all.This links to the next reason:

 

To make people realise I am human too. I am very happy to talk about non-work related topics in these sessions. I talk about my pastimes and hobbies, about the cakes I have made (or that my daughter has helped me make), and about anything that people want to hear about. These sessions are great as they give us a brief moment to lift our heads from the busy day and chat. I hope people can see that I am nothing special and also get a sense of who I am and what motivates me. Understanding me as I lead the organisation is important to me.

 

To give opportunity to ask awkward questions. And by this I don’t just mean questions that are difficult to answer, but also ones where there is no other forum to ask them. Meetings usually have tight agendas, and we try to stick to them – what if you want to ask something different, that perhaps only you want to know? We make it very clear that you can ask anything during a tea and cake session.

 

To say thank you. The cakes are always home made. Usually by me although sometimes my 13 year old daughter helps. People are always surprised and grateful for this. It is a little thing – but it is my way of saying thank you, and of saying that I value their work and contribution.

 

When I first started working as a junior doctor 22 years ago, my registrar used to encourage me into action after any break we had by saying,

“Come on Jonathan, it’s time to save lives and stamp out disease”

It is a line that has stayed with me throughout my career. I sometimes ask our CCG staff if they feel they are saving lives and stamping out disease, because I genuinely think that they are. It is a tough time to be an NHS manager. We don’t have enough money, and people frequently raise the issue of money being spent on managers rather than front line staff. I think this is understandable, but unfortunate, and I am not sure that people who say this really understand the value of the management taking place in CCGs.

 

I do know, because I see it, that CCG staff in Central Cheshire are hard working, dedicated and doing their best to improve the health of people locally. They talk to clinicians working at the CCG, they hear the patient stories at Governing Body and other meetings, they frequently live in the area and so are patients themselves, or have family members who are. They care passionately about the people of Central Cheshire and are working to ensure that quality healthcare is available for them. They are running projects to commission new and better pathways, they are monitoring the quality of local services, they are making sure the local hospital is paid for the work done, they are holding the trust to account for it’s performance targets.

 

They don’t get much, if any, recognition.

 

My tea and cake sessions are, in part, to recognise this. They are to say thank you, to point out that I value them, to answer any questions they have, and to hopefully inspire them to continue.

 

This blog is therefore to do the same. It is to publicly thank the CCG staff for their work, and to make sure they know they can come and eat cake with me in these sessions.

 

I could have written this blog about the front line staff working across Central Cheshire, and I hope that none of them feel I have overlooked them or missed them out – there is no slight intended. I know that they are all working hard as well, and that the people of this area are receiving the very best care. I could have written this blog about the staff I work with in practice at Swanlow. I see their hard work in clinics, admin and reception. I know they do an excellent job too.

 

This time though, this blog is about CCG staff – often forgotten and maligned, but doing essential work to ensure services are available for us all.

 

Thank you.

 

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

 

Follow Jonathan on Twitter @DrJonGriffiths

 

Photograph is of cakes made for the May 2016 Tea and Cake session.

Virtually Fractured Clinic

Virtually Fractured Clinic

One of the first blogs I wrote was about the relative of a friend of mine attending fracture clinic. I called the blog “Wait, wait, wait…“. In it I detail the experience of attending the clinic, the inconvenience and wasting of time encountered. Imagine my delight, therefore, when I heard that our local orthopaedic surgeons were keen to introduce a ‘Virtual Fracture Clinic’. Let me tell you about it.

Currently, if you attend A&E and they suspect you have a fracture, then you are treated and sent home with an appointment to attend fracture clinic for follow up. With the Virtual Fracture Clinic, rather than having to return for the follow up, you get a phone call from the orthopaedic doctors, who review your X-rays, ask how you are, provide advice and can often avoid the need for further attendance. Some people will need to be called back for assessment, but many not. Brilliant. This makes things so much better for patients, avoiding unnecessary attendances while maintaining the quality of the service. 

This clinic is a win-win. It’s better for patients, and it’s cheaper for the NHS. As a commissioner of a cash-strapped CCG this is music to my ears. As far as I’m concerned this clinic should be put into place immediately. 

There is a problem though. It might be a win-win, but it’s not a win-win-win. Good for patients, good for the overall NHS budget, but not good for the hospital bank balance. The clinic loses the hospital money as their are fewer out patient attendances. The hospital are the ones who can put this clinic in place, and they have so far not done so. 

This is what happens when you have a system built around individual organisations in their silos all looking out for their own organisational needs rather than the needs of the larger system. The hospital are being instructed to ensure they achieve financial sustainability, and this has become a greater driver than the need for system sustainability. This is what is playing out with our local Virtual Fracture Clinic. It is resulting in fracture lines appearing between the clinicians at the hospital and their management who appear to be blocking the development of the clinic. It is also resulting in fracture lines building between commissioners and hospital managers. 

This is a wholly unsatisfactory and unacceptable. For there to be drivers in the system that prevent the development of something that would improve the long term stability of the local health economy and, many would say even more importantly, be better for patients, then what is going on here? How can this be right? 

We need to take action. We need to push, hard, for clinics and schemes like this to be implemented. Canterbury, New Zealand chose to implement and fund any scheme that saved patient’s time. They recognised that this was a key way in which to improve and integrate their system. Locally, in Central Cheshire we seem to be a way off this.

The system needs to change. The system needs to recognise it is a system. Organisations need to recognise they are just one part of the system, and that we can achieve so much more together, but only by collectively doing the right things for patients, and the system itself. 

We have an opportunity here to do the right thing. Let’s not lose it. Let’s put aside our individual needs and put the patient first.

Fracture clinics are there to ensure healing. Let’s make this project the start of making our local health economy better.

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


Follow Jonathan on Twitter @DrJonGriffiths


Image courtesy of stockdevil at FreeDigitalPhotos.net

The Post Boat

The Post Boat

When I was 11 years old my family had the unexpected opportunity to have a holiday of a lifetime. Friends of ours were living in The Bahamas at the time, and we were invited to stay with them. We arranged a 10 day break during the Easter holidays. The trip would be our first and last overseas holiday as a family, and involved our first journeys by aeroplane. You can’t fly direct to Marsh Harbour where our friends lived, so we had flights from Heathrow to Nassau, and a connecting flight onwards. All very exciting.

The outward journey went well, we arrived safely and had a wonderful time. Part way through the 10 days our hosts checked with my parents about our return flight time. My mum explained that she had been rather taken with their descriptions in the past of how people sometimes used the Post Boat to hop from island to island rather than flying. We had therefore got a flight arranged back from Nassau to Heathrow, but thought we would just jump on the Post Boat for the short trip from Abaco Island back to Nassau. 

There was a stunned silence. “The post boat takes at least a week to make that journey,” we were informed. Ah. Our flight back to the UK was in less than a week. There was no way we could use the Post Boat, it was just going to take too long. To make matters worse, it soon became apparent that there were no available commercial flights either. We were stuck on the island, which me and my brother thought was great, but was somewhat stress-inducing for my parents!

It can be pretty stressful when plans fall apart. Sometimes it can be because planning has been poor, sometimes our planning was based on poor or inadequate information, and sometimes the planning might have been fine, but other circumstances beyond our control come into play.

We have known for a while that our local health economy was heading for financial difficulty. I recently blogged about that in a post I called Glass Half Empty. Our plan for some time has been to collaborate and work with local providers to integrate and transform our local system. We have known there wasn’t enough money. We have known we couldn’t carry on with the current levels of activity. We had a plan. It has become apparent that our plan is like the Post Boat – it is going to take time, and our flight is leaving now. The Post Boat still seems like the better way to do it. A better journey, a better or at least the same end point, cheaper and smoother. We’ve run out of time though.

In 1982 my parents had to charter a 6-seater plane to get us back to Nassau. The picture with this blog is of my family standing by the plane (I’m the older child). I dread to think how much that cost. It wasn’t what we wanted. It was stressful and expensive, but it was quick. There were longer-term implications I am sure in terms of our family finances. 

Our CCGs need to find the equivalent of chartering a light aircraft. We have to save money now, and our integration programme is going to take too long. We have developed a Financial Recovery Plan. It has all kinds of things in it, some of which sound really good for  both our CCG bank balance and for patients (I particularly like the idea of the Virtual Fracture Clinic), but many of the schemes are going to be about cutting or reducing services. We will have to look at how many cycles of IVF we can afford to fund. We will have to consider our prescribing, and are looking st promoting self care, and reducing prescriptions for Over The Counter medicines (in other words, please don’t ask for prescriptions for paracetamol or calpol from me, as refusal can often offend). We will have to consider referral thresholds for procedures like hip and knee replacement (so, for example, you might not be able to be referred unless your BMI is below a certain value and only if you are a non-smoker, and you might have to complete a 6 month lifestyle class first). We will have to consider all kinds of things that are unpalatable, unacceptable to some people, and certainly unpopular. 

The Kings Fund recently published a blog from Ruth Robertson about public perceptions of NHS finances. It’s worth a read and gives us an idea of how the public are likely to react to these initiatives. The key message for me is that we need to very quickly present these plans and schemes to the people of the Central Cheshire area. I believe that an informed and engaged public will understand and be tolerant of our actions. What we need to try and avoid at all costs is just cutting services without explaining why. I am disappointed that there is not a higher profile national conversation going on about this, as we are not the only area to be struggling with money. I have said before, and will say again now that I think the government and NHS England have a responsibility to be informing the public of the implications of austerity on the NHS. 

34 years ago, we missed the Post Boat. This year we are realising that the integration boat has already sailed. We still need to do the integration work but it is not going to solve our immediate financial problem. 

This blog is a warning. A warning to fellow commissioners who might still be on the Post Boat – are you sure it’s going to get you there in time? A warning to providers that the money is running out, and that drastic commissioning actions are about to be taken. And most of all, a warning to the public that NHS services as you know them are about to change. You may not like that. You may well blame me for them, and I can understand that, but the most important thing is that you understand why we are taking the actions we are. We want to do this with you, not to you, and the first step in that is letting you know what’s going on.

We’ve missed the boat, let’s make sure we all get on the same plane. 

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


Follow Jonathan on Twitter @DrJonGriffiths