Posted by I recently arranged to spend some time with the acute physicians at our local hospital. As a GP I am very aware of the pressures that we are currently experiencing but I am less sighted on what is happening in the hospital. I often find that the best way to really understand something is to experience it for yourself, so a quick email to colleagues at the hospital and we arranged this. I am grateful to Shirley and Tom for looking after me on the day.
I learned much and thought I would share some of my thoughts here.
During the course of the day I observed the 8am Medical Handover and the A&E ‘Board Round’. I spent time with consultant colleagues assessing patients in A&E and on the Ambulatory Care Unit. I visited the Medical Assessment Unit and had the opportunity to talk to nursing and allied health professionals from the frailty team, the respiratory team and the discharge planners.
The acute medical team use a handy electronic database which lists all the current acute medical patients in the hospital which can be filtered according to patient location. They colour code each patient – red are yet to be seen, amber have had a junior doctor review and green have seen a consultant. A really useful way to keep check on numbers of patients and who needs to be seen. The numbers were significant. I was told that in the past (before Covid-19) there would be around 40-50 medical admissions each day, with a bad, winter day being up to 60. Currently it is normal to get 60 medical admissions per day, and they have even been up to 100. The demand has increased hugely. I asked how many acute care consultants they had to manage this work – apparently according to the Royal College of Physicians for the numbers they are seeing they should have 10-11 consultants. They have 3. Locums are being used, and medical consultants from other specialities are being asked to help out.
There is a workforce crisis in the NHS that needs to be recognised. The Covid-19 pandemic has seen lots of extra money arrive in various parts of the system, but we really need more doctors (and I’m sure nurses and other allied health professionals too).
A quick note on what the acute physicians are trying to do – essentially assess the medical admissions, quickly investigate, treat and observe and either get people back home or transferred to the appropriate speciality for ongoing in-patient treatment. Depending on the nature of the presentation this might all take place in the Emergency Department or Ambulatory Care Unit (where people do not stay overnight), or the Medical Admissions Unit, where there are bays and beds just like a ‘normal’ ward. People may stay on the MAU for a few days before discharge or transfer.
For confidentiality reasons I will not talk about who we saw and what their presenting conditions were. We saw complicated medical presentations as well as people with difficult social situations, we talked about a patient who probably should never have been sent to the Emergency Department (ED), and another who had presented themselves but should probably not have been sent to the medical team. I saw excellent decision making that was at times pragmatic, well and truly involving the patient.
Multidisciplinary teamwork was very evident. Patients had already been seen by junior doctors, nurses, physicians associates and health care assistants. The frailty team was on hand and involved, the therapy team was available if needed.
There was some overlap and similarity with the work that I do as a GP, but much that was very different. There were people who had ended up in the ED who could easily have, instead, been seen by the GP either in surgery or at home, but most were very appropriately in hospital requiring the investigations and/or treatment that is available there and not in the community. There is currently an anti-GP media campaign that would suggest that increased hospital admissions are due to GPs not adequately assessing or managing patients. This was not what I saw, and talking to the consultants, it is not what they are seeing. While it may be that there are a few patients attending hospital because they felt they could not see their GP, the vast majority of these medical admissions are sick people who need hospital treatment or investigation.
Some key points to note in terms of differences between my GP work and this acute hospital medicine.
- Consultant colleagues are largely only seeing people after ‘work up’ from others. If you arrive in the ED with chest pain, you will have an ECG and blood tests arranged by the nursing staff before you ever get to see a doctor. The junior doctors will then undertake more investigations, so that by the time the consultant reviews the whole story is ready for them to assess. While my consultant colleagues may occasionally ‘clerk’ new patients before anyone else has seen them, they can still get that same day CT scan if they have concerns and as Tom put it to me ‘I would be lost without my CT scanner’. Obviously in General Practice this is not the case for any urgent presentations – we are using history and examination to determine next steps. It is important for hospital staff to remember this before criticising GPs for ‘inappropriate’ admissions as sometimes you only know there is ‘nothing wrong’ AFTER you have fully investigated. This full ‘work up’ is both a blessing and a curse. Although all the information is to hand, the junior staff may have undertaken tests that the consultant would not have ordered (over investigation) which can lead to chance findings of other, unrelated things (over diagnosis) that in turn poses a quandary around how to manage this and can lead to unnecessary treatments or longer stays in the hospital than really are necessary (over treatment). The concept of over diagnosis is not something I am going to explore here. You can read more about this if you wish: https://www.preventingoverdiagnosis.net/. While my consultant colleagues may occasionally ‘clerk’ new patients before anyone else has seen them, they can still get that same day CT scan if they have concerns and as Tom put it to me ‘I would be lost without my CT scanner’.
- Our IT systems are a world apart. Tom, who I spent the morning with, carried around his laptop, finding this easier than having to find a computer station near each patient. The laptop gave him access to the spreadsheet mentioned earlier as well as radiology images, blood results and previous hospital letters. They all appeared to me to be different systems. Each system required a fresh log in each time it was used. The hospital record with details of history, examination and investigations – was all a written record and not computerised. In my experience patients usually expect that their medical record is a single thing including GP record and hospital, or they at least expect that we can all view all the records. While some hospital staff are able to view the GP record (they have access to EMIS which is the system all local GPs use), not all do, and not all GP practices have allowed permission for them to view. GPs certainly do not have access to the hospital record (other than blood results and radiology reports, and of course we get sent discharge letters and correspondence from out patient clinics). My IT in General Practice is so much better that what consultant colleagues have to deal with. Everything for me is in one place (well, two really as I use a separate document management software (Docman) that at least does ‘talk to’ EMIS). I am, of course, generally only in one room, so can set myself up nicely with PC, two screens and everything I need right in front of me. There is an urgent need for better IT in hospitals including an electronic record. Ideally, we need something that integrates with EMIS and allows us all to see what’s happening wherever the patient has been seen. In other words, we need what patients believe we already have!
Some other key learning points for me:
- Hospitals are using Physician Associates (PAs) to great effect. In General Practice we have not all worked out how we would use PAs but there is an increasing number of them and many are keen to work in Primary Care. There is an opportunity here for GPs to consider this and use the Additional Roles Reimbursement Scheme to introduce these roles.
- I spoke to a member of the discharge planning team. It was very clear that patient flow through the hospital was being held up by a lack of social care. This is a major issue that all systems are dealing with. There are not enough nursing or residential home beds. There is not enough social care for people to go home with a package. We are struggling to get people out of hospital into ‘discharge to assess’ beds. There is a social care crisis.
- Covid-19 has left its scars on hospital staff. When talking about this one staff member was almost in tears recalling patients saying goodbye to loved ones via an iPad while taking their last breaths. The pandemic has been difficult for us all, but for some it has been deeply traumatic.
The most important learning point for me:
- We need to talk more. The Covid-19 pandemic has I think separated GP and consultant colleagues even more than we were separated before. We are working in silos, and don’t understand each other. It is all too easy when that happens for us to start blaming each other for things that are going on that are not the fault of anyone. This could result in consultants suggesting that GPs are not seeing people, or GPs suggesting that consultants are passing inappropriate work to them. Spending a day in the hospital helped me to understand their pressures, and I like to think that by talking to me they had a greater insight into the world of General Practice. Dr David Oliver’s recent comment in the BMJ also speaks to this (https://www.bmj.com/content/374/bmj.n2358). We need to understand each other better, and speak up for each other. We are colleagues, all trying to deal with significant increases in demand. It does not help us to fight each other. Everyone is working harder than ever and we all need to recognise and acknowledge this. This week I attended a workshop with colleagues from both Primary and Secondary Care in North Mersey. They had come together to establish some principles for how to work better together, looking to solve some of the difficult issues that we face at the interface between Primary and Secondary Care. The focus was on the patient, and that’s something we all need to do – focus on the patient and work together on solutions to the current issues that we are all facing.
Thank you to colleagues at Mid Cheshire Hospitals Foundation Trust for letting me observe your day. This is something I would recommend any GP colleague considers doing, and of course the invitation to reciprocate is always there.
Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire and GP Advisor to the Cheshire and Merseyside Health and Care Partnership
Follow Dr Jonathan @drjongriffiths
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Dr Jon Griffiths 
Thank you Jon for this insightful post.
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