Counting

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

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Winter Planning

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