Not Very Well

If you ask former GP Registrars at our practice to name a tutorial I used to do, there is a fair chance they will say “The one with Peppa Pig!” This is not because I think the Peppa Pig tutorial was better than any other, but more because they got to sit and watch an episode of a children’s TV program!

 

I would encourage you to watch it yourself. The episodes is called ‘Not Very Well’. Here it is on YouTube – you will have to deal with the adverts but it’s worth it – and less than 5 mins long. While you watch it I want you to think about Dr Brown Bear – his approach, the service he offers and his treatment. Go on, do it now and then come back…

 

At first glance Dr Brown Bear offers an excellent service. He answers the phone himself, quickly assesses the situation (Peppa has a rash and doesn’t feel very well), he tells Daddy Pig to put Peppa to bed and says he will come straight round. This he does, and before you know it he is there with his doctor’s bag and calm confident approach. He examines Peppa (essentially by looking at her tongue), declares that she “just has a rash” and that it is “not serious”. Everyone is greatly reassured. Peppa asks if she needs medicine. Dr Brown Bear declares that the rash will clear up by itself, but that if she likes he could give her “just a little medicine”. He has the medicine to hand in his bag and gives her some himself. As he leaves he says that he will come back later to check on her. Cutting to the end of the episode we see him do exactly this, arriving as the last of her spots disappear to declare that all is well.

 

Remarkable service. Surely the kind of service we would all like to have? Only this week I was chatting to someone I had met for the first time who commented how in the past the GP would visit for all kinds of things, “like chicken pox”, but that that didn’t happen any more – they clearly felt that home visits to children with chicken pox was a better service than the current one.

 

Let’s look at a few of the things Dr Brown Bear does, however, and see if we really think this is good practice:

 

  1. Answers the phone on the first ring. How many times have you played ‘fastest finger first’ trying to get through to your GP? I have been there myself, primed at 7.59am to call the surgery exactly at 8am in the hope of getting through for an appointment. Dr Brown Bear has his surgery sorted. But I’m curious as to why he has no reception staff? Is it really a good use of resources for him to be answering the phone himself?
  2. Visits immediately. Again, great stuff for the patient, but is this appropriate use of resource? There is a reason we don’t visit children with chicken-pox, and that is because they don’t need visiting. They can come to the surgery (or actually stay away form the surgery altogether and wait to get better!) I know that Daddy Pig has a car – I’ve seen him drive it in many other episodes, so I’m struggling to see why the home visit.
  3. The confident declaration that all is fine. This is what patients like to here – a confident doctor who knows what’s going on and who can tell you with certainty that things will settle. I have some issues, however,  with the cursory examination, and I think medico-legally he is leaving himself wide open if anything does go wrong. I would love to be as confident with my diagnoses and prognoses as he is, but life it not quite like that. I don’t see any safety-netting, nor leaving any room for the possibility that he has got the diagnosis wrong.
  4. Prescribing, issuing and administering medication. Let’s overlook the lack of an FP10 prescription pad, the ability to carry all required drugs round with you and the lack of checking off the dose and batch number, but let’s NOT overlook the fact that Dr Brown Bear has just said that the rash will clear up by itself! What is he playing at here? Why prescribe necessary medication? You will probably have realised by now that I have issues with this consultation, and this is surely the most unforgivable action.
  5. Repeat visit later.  I guess you could argue that this is the safety netting I was talking about earlier, but 2 home visits in 1 day for a child who could have come to surgery and who on the first visit was declared to have “just a rash” that would “settle by itself”? Clearly Dr Brown Bear doesn’t work for the NHS – he is either on a fee per visit or just has too much time on his hands.

 

All of the above suggests to me that the writers of this Peppa Pig episode have a very different model of General practice in their head than I do. They appear to have a very old-fashioned Dr Finlay model where the doctor knows best, the patient can expect immediate service and where nothing is too much trouble.

 

Having said all that, this cartoon is surely just a children’s cartoon isn’t it? Where is the harm in such an episode? We are not expected to think that life is really like this are we? Well, no, but I do have some concerns. I am concerned about the expectations that this raises. I am concerned that it encourages people to even think “wouldn’t it be nice if my GP provided that service” or for them to somehow look back and think that the way we practiced medicine in the past was better than how we do now. I think this episodes does encourage those thoughts – and don’t forget who will be watching Peppa Pig – it’s not just the children but their parents and carers.

 

And it’s not just Peppa Pig. Go out and look for children’s books about visiting the doctor. You could essentially write one now as they all have similar elements:

  1. Child wakes up feeling poorly – typically rash, sore throat, cough or earache
  2. Parent (usually mum) rings doctor and gets immediate appointment
  3. GP examines child
  4. GP declares diagnosis and provides prescription
  5. Child is better by the end of the day after taking prescribed medication

There are so many things wrong with this portrayal of events, but particularly the bit where a prescription is required every time. Where are the books that encourage a bit of self care? Where they point out that a sore throat usually takes 3-7 days to get better, but will do so on it’s own? That coughs can take 3 weeks to resolve and medication is not usually needed?

 

Children’s books and TV programs might appear trivial, but they are teaching our children, their parents and their carers about what to expect in the world, and they are getting this wrong. We need a new narrative describing the role of the GP and what people should expect from us. We need to move away from the idea that, as I overheard a parent saying to her child as she brought them down to my room “the doctor will make you better” – that may be the case, but more often than not, particularly with acute childhood illness, the child will get better by themselves.

 

The NHS has changed from what it was, and General Practice has changed too. We all need to understand this and change our expectations. I think General Practice has got better, not worse, and although there are significant challenges currently with overworked, under resources doctors and surgeries, I think the care given is as good as it ever has been. If you want to take a glimpse at people’s views of what General Practice is to them then you could do much worse than searching Twitter for the hashtag #GP150w (the brainchild of Jamie Hynes – excellent stuff) where you will find a vast array of people who have described General Practice in only 150 words. It really is worth a look, and I doubt if anywhere will you find anyone visiting unnecessarily or deliberately prescribing unneeded medication!

 

My final comment is to reinforce the need for us to reconsider our expectations and be aware that children’s story writing may be raising expectations above what can realistically be delivered. I recently blogged about the GP Patient Survey, perhaps those practices who received lower scores are victims of not coming up to the standards set by Dr Brown Bear?

 

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

 

Follow Jonathan on Twitter @DrJonGriffiths

 

Part of Who I am

This blog was first published on the NHS Vale Royal CCG website in September 2015.



A scene familiar to doctors and nurses. An urgent call in the middle of the night followed by a rapid fumbling with clothes and shoes as you shake the too little sleep out of your head. The run through the quiet and empty corridors of the hospital before bursting onto the ward, your destination immediately made obvious by the busyness and urgency around one patient. As you approach you see resuscitation already underway, someone doing chest compressions and someone else ventilating.
Many of you reading this will relate to the scene. Two things make this memory different for me. Firstly, the patient is not an elderly person potentially coming to the end of a life well-lived,but is only 17 months old. Secondly, the patient is my son.
Over 11 years ago, this scene brought to an end 7 months of living in Birmingham Children’s Hospital with our son as he was treated for a rare haematological (blood) disease (Haemophagocytic Lymphohistiocytosis). He had undergone chemotherapy and a bone marrow transplant, but eventually died with a respiratory infection.
I’m not going to give you a blow by blow account of the 7 months in hospital, nor the final minutes as he died, but my life was changed forever. It had already been changed 17 months previously when our twins had been born. It was changed again when we found the non-blanching rash and took him to the Out of Hours service, and then the hospital. The relief when he didn’t appear to have meningitis/septicaemia, yet the anxiety about the low platelet count. Growing concern as he become more poorly rather than better, then the devastation as the diagnosis was eventually made, followed by months of treatment. A traumatic, roller-coaster during which time we essentially lived in the hospital, one of us sleeping by his bed every night, the other either in Edwards House (I cannot thank Edward’s Trust enough for providing this accommodation and the support that came with it. I wonderful organisation without whom I genuinely don’t know how we as a family would have coped) or at home. Our daughter, his twin sister, did the same, learning to crawl, talk and walk on the ward during those months. Ask anyone with young children about how much happens in the 7 months between 10-17 months of age, yet for us that time watching our daughter develop passed in a bit of a blur.
Even though we knew he was really poorly, even though we knew he was on Intensive Care, nothing prepares you for seeing someone performing chest compressions on your infant son. It felt as though my world fell apart at that moment. I have to do annual resuscitation training. Often the trainer will bring a paediatric manikin, or at least will talk about how to perform resuscitation on a baby or child. I sit through these sessions, I learn from them, I do the practical, but I guess you now know what I will be thinking about.
You don’t expect your children to die before you do. Nothing prepares you for that.
I have never written about this before, and rarely talk about it. It’s not that it is a secret, but it is not the kind of thing you tend to routinely tell people when you meet them, and if you don’t tell them then, when do you tell them? There will be people reading this, I expect, who have known me for some time, yet who do not know about this. I guess the question, therefore, is why I am telling this story at all? I think maybe it is precisely for that reason. Precisely to make the point that we don’t know everything about the people around us. We don’t know what people have lived through and experienced, and we shouldn’t make assumptions.
I am sharing this blog for that reason, but also because the time seems right somehow. It is part of who I am. If you want to know me, then you need to know this. This experience has changed me more fundamentally than anything else.
Not long ago I blogged about the power and importance of personal stories, so here is this one. Thank you for reading it.

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

Best and Worst?

Best and Worst?

General Practice is currently struggling. You don’t have to look very hard or very far to realise this. We are struggling to recruit doctors, struggling with increasing patient demand, struggling with paperwork and struggling to find more hours in the day to manage all of this. What we need is support and understanding, which is why I am struggling a little with some recent local newspaper reports following publication of the annual General Practice Patient Survey. This survey asks a small sample of patients to rate their experience of the practice. Questions range from those asking about ease of access to their confidence and trust in the GP they saw. The survey results are great for headlines, but in reality things are somewhat more complicated and there is a danger that people can jump to the wrong conclusions about practices and individual GPs without knowing the full story. 

One of the first things that the results encourages you to do is to compare your practice with others. I’m not sure how helpful this is. While I understand that people want information about the kind of service they can expect to receive in any one particular surgery compared to others in the town, you need to remember that it can be like comparing apples with oranges. The geographical location of each practice along with quirky historical preferences by patients means that every practice has a unique demographic make-up. The ability of the practice to meet the needs and expectations of the population it serves therefore varies considerably. This means, in simple terms, that Practice A might be able to provide two 2 hour surgeries per day, and still find not all slots filled (although as I write this I can’t think of (m)any that manage this!), while Practice B a few miles away has to put on two 3-4 hour surgeries and still have to see extras to meet the demand. This does not necessarily mean that Practice B is any worse, or providing poorer care than Practice A. 

This brings me to my second point. The indicators looked at and the questions asked of patients do not cover all aspects of care. A large part of the survey seems to be structured around access, around the ability to get to see a GP or nurse. The survey does not look at clinical outcomes, at how well the surgery actually treated their patients. This phenomena is not unique to General Practice, of course, with many of our NHS targets and standards relating to how long we wait for things, rather than about whether the interventions make us better or not. That’s partly because access targets are easy to measure. We need to remember, however, that we should be moving towards measuring what we want to measure rather than just what we can measure. We must start measuring the things that truly reflect quality of care provided and outcomes. Access is an important area of quality to measure, but it is not the only area. We must look at all things together. Care Quality Commission reports, for example, have not flagged any concerns for the particular practice mentioned as being ‘worst’ in the local article, where a rating of ‘good’ has been applied. Let us not forget this. 

I would also suggest that the way in which this survey is undertaken is flawed. A random sample of your practice population is invited to respond. In the case of the practice highlighted by our local newspaper, only 105 out of 220 questionnaires were returned. Only 48%. This is a tiny proportion of the practice population, and they have not even targeted those who have recently had an appointment. There is a risk that you only bother to complete and return the survey if you have an issue to highlight. If you are happy with your care, you may not find the time to complete it as you do not see it as important. So, a very small sample size (some would say too small to be meaningful), from a cohort who may have an intrinsic bias with regards to how likely they are to respond.

The survey equally does not provide any local context or attempt to look at underlying reasons. I’m sure that those who put the survey in place would say that this is not the job of the survey, and that it is simply to highlight areas to the practice that they may wish to focus on. If that were solely the case then this might provide helpful intelligence for the practice to use to improve. The fact that the results are published on the internet, however, immediately turns these questions into targets which will be reported against by the media and interpreted as such by patients. The risk is that it fuels accusatory and blame-seeking behaviour rather than seeking to understand, support and encourage improvement. 

This latter bit is exactly how the results will be used in practice, however. Highlighting areas to look at and work to improve. Practices take these results seriously because they know patients will form a view of them when reading them. Practices also recognise that the survey can highlight areas that need attention, although more often than not these areas were already known and understood, and actions being taken. 

It would be remiss of me at this point not to thank all local practices for the hard work they have done. Many will be justifiably proud of their excellent survey results alongside the CQC findings across the patch. All are working hard, all are finding things challenging at the moment, all are continuing to provide care for the people they serve. 

My plea would be for everyone to take some time to fully understand and appreciate the pressures being experienced by General Practice at the moment. A good place to start with that would be to read this report in GP Online and the King’s Fund report it refers to. 

All parts of the NHS are struggling to cope. Could I suggest we stop pointing fingers and start supporting in order to improve things?

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

Follow Jonathan on Twitter @DrJonGriffiths

No Stone Unturned

No Stone Unturned

Our local area has been fortunate enough to be included in the national intervention programme called the Capped Expenditure Process (CEP). My last blog (Coalition?) was about the positive effect that the CEP has had on our local relationships in that we are working much more collaboratively. This blog tries to explain why we are needing to do this.
 

Essentially it is about balancing our budget.

My understanding is that the CEP is in place for those areas where they have particularly struggled to manage within their financial allowance and/or to agree contract value between commissioners and acute providers. The line that NHS England and NHS Improvement have taken on why these 14 areas need to work on this is because “The NHS has to live within the budget that parliament allocates and it is grossly unfair if a small number of areas in effect take more than their fair share at the expense of other people’s hospital services, GP care and mental health clinics elsewhere in the country”. So that’s told us then. We are spending more than the money we have been provided with, and as the NHS has a fixed overall budget, we must be spending money that was originally allocated to someone else. I bit like me taking some of your pay check because I’m going overdrawn, while you are saving.

 

The NHS has a fixed budget, and we are allocated a fixed share of that determined by a nationally developed formula. If you want you can have a look at the CCG allocations here: https://www.england.nhs.uk/wp-content/uploads/2016/01/ccg-allocations.pdf I recommend that you do. It’s interesting reading. They start with the 16-17 allocations, then as you scroll down the figures move to 17-18 and beyond. What you need to understand is that the while each CCG has it’s allocation, most receive either more or less than that for historical reasons. Everyone has their ‘distance from target’ and each year should move closer to what has been decided is their appropriate allocation. My CCG (NHS Vale Royal) works very closely with our neighbouring CCG (NHS South Cheshire) and we are both receiving less than our target allocation. In other words, we currently get less money than the allocation suggests we should. You can see this in the spreadsheets via the link above. For our local system we are approx £13m below target allocation. There are clearly other CCGs that are over allocation and receiving more money than their target. I will refer you to the NHSE statement in my third paragraph above and let you ponder that for a moment.

I want to be clear though. Even if we were to be in receipt of our full target allocation, we would still be spending more than we have available. Getting our target allocation does not provide us with a solution. We have asked about allocations, and the response is clear – once we can demonstrate that our system is as efficient as any other, and we are not outliers for activity or spend on any benchmarking data, then we can have a conversation about allocations. Until then, we should work on those things. I understand that and it is clear we cannot influence this.

The message is clear and simple. We have a fixed financial resource, and we need to live within that. This is not a message that people find easy to hear. When I have talked with people about how we choose to spend the monies we have, often there is a reluctance to engage in this conversation. People prefer to talk about how we need more money, not about how to most appropriately spend what we have. At a recent meeting people wanted to talk about how much the government spent on Trident rather than face the realities of accepting we have less money for local healthcare than we think we need. It is not that I disagree with the sentiments, and I would like there to be more money, but this is beyond my control. I have to work with what I have. (There is a blog here is worth reading that makes an interesting comment about the concerns that healthcare professionals have raised about our Health Secretary and why they may be misplaced. He argues that criticising Mr Hunt for there not being enough money in the NHS is missing the point – it is how that money is being spent that he could be criticised for. https://libertarianweb.wordpress.com/2017/06/15/jeremy-hunt-is-a-terrible-health-secretary-so-why-does-he-keep-hanging-on/).  

The result of all of this is that we have to make difficult decisions. We cannot afford to continue spending in the same way we have in the past. Things have to change.

The bottom line is that we need to focus on providing the best possible healthcare and outcomes using the resources made available to us.

Some things are not contentious. We can be more efficient, and do things that are unlikely to effect clinical services, but there will be harder decisions to be made where reduction in service, or changes in how and where they are delivered will need to be made. The ask of us from NHS England and NHS Improvement has been to ‘leave no stone unturned’. We have done this. We just need to be careful that there are not important things resting on the stones before we disturb them…We have developed high level plans which we now need to work up into reality. We need to share these initial plans with patients and staff and carefully consider the impact they may have. There are opportunities here to do things better, but there are clear risks that we need to fully understand. 

I want clinicians involved in this, although recognise that many find this uncomfortable. Without clinical input and guidance, however, we risk inappropriate plans that could put people at risk of harm. 

This must not happen. 

I also want the people of the area to know about this, and understand what is happening. These blogs are a small part of highlighting that the Central Cheshire area is having to make difficult decisions. 

Comments are welcomed.


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



Follow Jonathan on Twitter @DrJonGriffiths



Photo from https://www.pexels.com