Everything you know about going to the doctor is wrong

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/

 

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Risk

Risk

The sound of running feet followed by a twang, a thump and then a crying child. These were the noises that grabbed my attention while I stoked the fires of our portable pizza oven at our Cornish campsite. Not the noises you want to hear while trying to relax on the last night of your holiday. First check – is it my child? No. Not good news though as it is my nephew, 7 years old, and he is not a happy chap. Dad (my brother-in-law) is quickly there, and we determine that he’s hurt his arm. Then I hear the inevitable, “Don’t worry, Uncle Jon is here, he can have a look at it.”

 

I think these scenarios present an interesting challenge for the GP. They are, on the one hand really difficult to manage, and on the other, really easy. They are difficult because it is really hard to give a confident diagnosis in this acute phase. As a GP you NEVER see someone with an injury which is only a few seconds old. We all know that children will cry when they fall over, whether there is a serious injury or not, and it is impossible to know in those first few minutes whether this is likely to be anything more serious than a bruise. In some respects the person most able to determine whether there is a problem or not is the parent, who does know how likely their child is to be crying like this with a minor injury. I suspect, however, that there is an expectation that you should know. That you should be able to instantly say whether something is broken or not, just by looking at it. It happens in the movies all the time after all. So, you feel immense pressure to be able to get this right, even though you know you probably can’t really tell.

 

In contrast, the scenario is easy to manage because what to do next is really simple – you watch and wait. If he calms down and starts moving his arm, you’re probably ok. If he doesn’t, then he needs an X-Ray.

 

He didn’t settle down.

 

He had spent a week participating in reasonably high risk activities. Body-boarding in reasonably rough seas, hard-core coasteering, climbing over rocks on the beach and cycling at high speed around the campsite. He broke his arm tripping over a guy rope. Isn’t that a lesson for life? We worry about the obvious, risky things, but fail to notice the simple ones. How often have you heard the same story about how people get injured? Occasionally it is from the high impact road traffic accident, but more frequently it is a simple trip or slip. I have been physically present 4 times when someone has had a fracture. Only on one of those occasions would I have predicted a fracture based on the level of injury.

 

So what is the lesson here? A couple of things I think. The first is that we need to be aware that it isn’t always the obvious, high risk items that will bring us crashing down, but often it is the less obvious issue that slips under the radar. As a CCG Clinical Chair I have spent more time dealing with things relating to issues like removal of sutures or irrigation for ear wax than you would imagine, yet I bet you would never have predicted this would be a major problem. When we run our risk assessments we rightly focus on the things that we can see looking ahead, but you don’t know what you don’t know (I’m sure you all remember Donald Rumsfeld’s famous quote on this[1]). I’m not suggesting we need to put everything onto our risk registers, but that we need to keep alert, keep our eyes open, and watch for any warning signs of problems we were not expecting. Game of Thrones fans might relate to this recent quote from the ever-sneaky Petyr Baelish, “Don’t fight in the North or the South. Fight every battle everywhere, always, in your mind. Everyone is your enemy, everyone is your friend. Every possible series of events is happening all at once. Live that way and nothing will surprise you. Everything that happens will be something that you’ve seen before.”

 

The second point I wish to make is related – we are poor judges of risk. We see risks in things that are relatively safe, and ignore risks where they are present. Participating in ‘high risk’ activities is often much safer than you imagine, because you take precautions and are alert to the danger. Meanwhile we are blind to the risks of everyday activities like driving or crossing the road. We also have a distorted view of the likelihood of disastrous events occurring. The media has heightened our sense of risk for terrorist events[2], plane crashes, murder, child abductions and other high profile scenarios, all of which remain, thankfully, relatively infrequent compared with car crashes[3] (for example). Not many people spend their lives worrying about having a car crash, however, but I suspect a good number are worrying about terrorism and considering avoiding places like London and Barcelona at the moment.

 

Our failure to properly understand and respond to risks also factors into our approach to medicine. Conversations between clinicians and patients too infrequently explore the risk-benefit ratios in question for treatment options, and we often perceive greater risks in our actions (whether this be starting or stopping therapy) as opposed to our inactions. There is also an increasing culture of ‘better safe than sorry’ and of wanting to investigate to eliminate all risk, without consideration that increasing investigation can increase medicalisation, ‘over-diagnosis’[4] and carry its own risks.

 

These are complex issues and far too overlooked.

 

So what do we need to do?

  1. Consider, inquire about and understand the risks that you face.
  2. Be aware that there are many unexpected things that could suddenly arise and cause you a problem.
  3. Try to keep your view of risks proportional to reality.
  4. Explore the risks of treatment options with your doctor, including the risk of not doing anything!

 

My nephew needed 3 hours in surgery and 4 wires to fix his fracture. He’s doing ok now though!

[1] https://en.wikipedia.org/wiki/There_are_known_knowns

[2] http://www.telegraph.co.uk/news/0/many-people-killed-terrorist-attacks-uk/

[3] https://www.gov.uk/government/publications/annual-road-fatalities

[4] http://www.preventingoverdiagnosis.net/?page_id=1176

 

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

The Fell Race

The Fell Race

The hardest running race I think I have ever done was the Langdale Horseshoe Fell Race. At 21.1km long and with 1450m of total ascent it was a killer (that’s 12.5 miles and 4600 feet in old money). The route starts and finishes at The Old Dungeon Ghyll Hotel  and takes in Thunacar Knott, Bowfell, Crinkle Crags and Pike O’Blisco. The worst part of it was that they have set times at which they close the checkpoints. This means that you have to get there before the checkpoint closes, or you are disqualified. The first checkpoint with a closing time is Esk Hause Shelter and I remember struggling to approach this with time running out. I was pushing hard, back of the field, with my brother encouraging me, although it looked as though he was floating effortlessly across the fells beside me. I was convinced I would not make it, but I did, with probably only a minute or two to spare. There was a moment of relief, then the crushing realisation that I was able to carry on! Only 40 mins to get to the top of Bowfell… The problem with just meeting the target was that meeting the next target was harder, and so it went on. I got round, I was nearly last, but I finished making it past each checkpoint just before they closed. After the event I remember an ‘encouraging’ friend saying “Why were you so rubbish?” I forget my response…

There are a couple of tenuous analogies I want to draw out here. The first relates to NHS finances. If you fail to get across the line at the end of the financial year, and post a deficit, then you don’t get sent down the mountain for an early shower. Instead you carry on the next year, but with the previous year’s deficit taken off at the start. This means that if you are already struggling with the money, then next year is harder. You have to keep running, but the checkpoints become harder and harder to reach as you go on. Getting out of this downward spiral is tricky. We (my CCG) have just found ourselves in this difficulty. Posting a deficit last year means we start with less this year. This is one of the reasons we find ourselves in the Capped Expenditure Process (CEP). I have recently mentioned this in a couple of blogs (No Stone Unturned and Coalition). We are at the point now of taking our provisional plans to our next Governing Body – you can read the papers here. We are looking for the Governing Body to approve our approach and take things forwards. There is much work still to do, and nothing will be enacted before the public have been engaged in developing proposals and quality impact assessments have been undertaken.  Final plans will in some cases be brought back to Governing Body for final sign-off. When speaking to colleagues about the need to achieve financial stability, people use a couple of words which always draw attention, namely ‘rationing’ and ‘cuts’. I can see why, although I think if we get this right there is less cause for alarm, and more of an opportunity to get things right for our area.

This is about living within our means. It’s about ensuring that we only spend the money allocated to us to spend (this was the main point of discussion in my last blog, No Stone Unturned). We have a ‘gap’ of about £30m locally. Our plans look to bridge this gap in a number of ways, and I want to use the blog as an opportunity to explore the possible scenarios we may develop to do this.

One of the areas we are looking at is referrals from Primary Care. There are currently many patients who get referred on to hospital by their GP who actually could be managed better in a different way. Reviewing our approaches to referrals should not affect quality, so long as we have alternatives in place, and are able to disseminate best GP practice. There are various ways we could look to do this. We already use a company called Medefer to help provide advice and guidance to GPs to avoid unnecessary referral. We are also considering peer review and ongoing education to ensure patients receive the care they need in the most appropriate place (which is not necessarily with a consultant!)

Thinking back to my fell race, it would have been nice to have arrived at Esk Hause Shelter will plenty of time to spare. I could have pressed on happy in the knowledge that even if I needed a brief rest, or to slow down, that I could do so without worrying about hitting the next checkpoint in time. The NHS has a variety of targets, and it is always nice to exceed them with a comfortable margin. One of the targets that our local hospital is currently exceeding is the Referral to Treatment (waiting time) target (RTT). This target essentially states that 92% of people referred by their GP will wait no longer than 18 weeks from referral to treatment (if required). The hospital currently meets this standard for 97% of patients. By changing referral practice, we can bring ourselves in line with other areas so that the national standard is met.  Urgent cases, particularly patients presenting with symptoms that would turn out to be cancer, would not be affected by this change in referral practice.

If you need to save money but want to continue to meet your constitutional targets, then this is an obvious place to look – we think we can still meet the standard for 92% of patients (which is what we are required to do) by slipping our performance down from 97%. This, may mean longer waiting times for some patients (please note that for urgent cases, particularly patients presenting with symptoms that could turn out to be cancer, there are other targets and we are NOT talking about them.).

The obvious problem is that if you aim to just achieve the target then there is a greater chance that you will miss it. This is a risk that we will be running and we are, in fact, likely to fail this target at times during the year, although we are planning to be delivering again before the year is out.

This is an example of something we are doing to help with costs while balancing patient need. We need to spend some time thinking through the implications and running the quality impact assessment on this and other ideas, but it gives you an idea of where we are at.

I am keen to hear views on this and on other elements of the CEP. I suggest you keep an eye on this blog and future blogs as well as other communications from the CCGs.

Featured image is of me on the slopes of Bowfell, but not taken during the Fell Race mentioned!

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

 Follow him on Twitter @DrJonGriffiths

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

 

Hospital-Centric

Hospital-Centric

Our local health care system is hospital-centric. 

I suspect most of the NHS is. 

There is a huge amount of work being undertaken in the community, but what I mean is that the current funding streams encourage increased investment in secondary (hospital) care and not in community based care. Our local system has some of the highest rates of admission to hospital from A&E for less than 24 hours in the country. When we have looked at this we are told that one of the reasons is that there are not community based alternatives to admission. It has been suggested that we should invest in these community services in order to reduce the admission (and potentially attendance) rate. The problem is that the money we need to do this is tied up in the hospital contract, which is based on Payment By Results (PBR – essentially a Pay As You Go contract where the hospital gets paid for the activity undertaken). When we suggest that we should reduce the hospital contract (in order to invest in the community services), we are told that we cannot do that because the hospital need the money to keep dealing with all the people they are seeing and admitting because of the lack of community alternatives. You see the problem – a cyclical argument. 

This is a problem because we (the CCG) have a fixed financial envelope which we are under considerable pressure to live within. Most parts of the system are on fixed, block contracts, and one part of the system (the hospital) is on PBR. This appears to drive certain behaviours. Let’s use an analogy to make the point. With regard to your personal income and expenditure, how do you budget? You most likely look at your income, and then work out what you can afford to spend on your house, car, groceries, holidays etc. You know how much money you have and this dictates what you can afford. You also choose how to prioritise this, so if you want to spend your money on holidays, you might have to have a cheaper car, and vice-versa. This is how General Practice works – you know how much money is coming in, and you work out how to spend it – how many GPs can you afford, how many nurses, receptionists and so on. If income goes down, or remains flat while demand increases and expenses rise, then you have hard decisions to make – less take home pay for the partners, or less services for the patients? I would ask you to pause here and note that GP partners are genuinely subject to fluctuations in their pay year to year. In recent years I believe that some GPs have been in deficit (we hear about hospitals in deficit, but not General Practice), and this can mean GPs receiving less money, or working harder for no or minimal increase in funding, 

There is another way you could budget. You could decide what kind of lifestyle you want – which car, house, brand of cereal and type of holiday. Then work out how much it would cost, and then set out to earn that. I suspect not many of us do that. I would, however, suggest that this is how hospitals can behave. They can work out how much they feel they need to run the hospital, then ensure they deliver the level of activity required to bring in the income. There are many ways you can potentially do this ranging from entirely appropriate efficiencies to other things I would question: lower thresholds for operative procedures, waiting list initiatives pulling more people through the system, admitting people from A&E for assessment before discharging home, increased consultant to consultant referrals. 

I would suggest that the tariff based PBR system can drive these behaviours, and is not conducive to system-wide collaborative efforts to reduce costs. It is a particular problem when you remember the fixed financial envelope the commissioners have.

What we need are system-wide ‘control totals’ that bring all parties together to decide how best to spend the limited resources we have. Rather than having individual organisations aiming to increase their slice of the pie, we need to put patients first and appropriately budget as a system. 

Some places are doing this. Accountable Care Organisations are all about this and STPs should be doing this. It requires hard work and for some people a real change in thinking. It is, however, essential that we do this. The financial situation we find ourselves in locally is going to be worse for 2017-2018, and if we can’t work together to solve the issues we face, then we are in trouble. 

We need to move away from systems where the NHS world seems to revolve around hospitals. We need to emphasis the importance of out of hospital care so that all understand that the majority of healthcare in the NHS takes place in settings other than A&E or a hospital bed. We seem to have a fixation in the UK that we should fight to maintain the viability of all hospital services, regardless of the impact this may have in other parts of the system – you will probably be aware of campaigns against closure of hospitals and hospital departments, but can you recall many campaigns against closure of General Practices? As a colleague of mine once said “MPs don’t lose their seats over General Practice closures.”

When we try to move the money from hospital care to community care, these are the barriers we come up against, but we need to do it. We need to be able to demonstrate that closing a ward in order to keep people closer to home and provide care in a different way is a good news story. This absolutely requires investment in General Practice and other community based services and disinvestment in hospitals.

The NHS England “Next Steps on the NHS Five Year Forward View” does talk about increased investment in Primary Care and Mental Health as well as a focus on “Integrating Care Locally”. This direction of travel sits comfortably with me and I sincerely hope will support us to commission in this way. Above all I hope that we can all move towards systems that enjoy increased collaboration and that can move away from the hospital-centric systems that currently exist and enter the new world of seamless care that people need.

 
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 Job In The World?

Best Job In The World?

As a GP I make a lot of phone calls. Two recent ones stick in my mind. The first was to someone I had, in fact, already spoken to earlier in the day. They had experienced a case of acute back pain, and while I had confidently dealt with this over the phone, I had sensed that they might have been dissatisfied with the lack of face to face assessment. I decided to call back later that day. They were surprised, and very grateful. They were feeling better, and commented “Thank you for calling back, that is very kind, I really appreciate it” or words to that effect.

 

I clearly remember making the second call. I had the hospital letters on my computer screen in front of me as I dialed. “Hi, it’s Dr Jonathan here from the surgery. I’ve received the correspondence from the hospital and wanted to check in with you. How are you getting on?” This patient had been diagnosed with cancer following my referral a couple of weeks earlier. We talked through what had happened so far, and what plans were in place for further tests and then treatment. The call ended with me once again being thanked, this time not only for me taking the trouble to call, but also for the speedy referral leading to the diagnosis.

 

Thank you. I hear it a lot. In fact, most people thank me at the end of the consultation. When a medical student recently spent a 6 week period sat with me, we frequently had patients taking the opportunity to tell him what they thought of me – they were all positive and grateful. And before you start thinking that I am just trying to ‘big myself up’, I really don’t think I am anything special – I think most if not all GPs would get the same response. The phone calls I describe above are just part of our normal, everyday work, and if you are a GP then you will undoubtedly recognize the scenarios.

 

Being a GP is a wonderful thing. Is it the best job in the world? I think so. It has its problems, and I am not naïve about them, but it is still a job where I believe I can make a positive difference to people’s lives, and that’s what makes it so good.

 

You don’t, however, currently hear GPs talking positively about their chosen career very often. Last week on two separate occasions I heard people essentially saying that while we as GPs are currently wanting to lobby for there to be more GPs, why would anyone choose this as a career option when “all they hear from us is how awful it is?”

 

Good question.

 

How do we square this circle? We genuinely need there to be more GPs, but how do we balance expressing the challenges currently being faced with all the positive elements of the job that are still there, and why many of us became GPs in the first place.

 

I became a GP because of the ability to help people ‘from cradle to grave’ , because of the ability to view people holistically, to come alongside people and their families, to work in a broad and diverse setting where you never know what’s coming through the door next, where despite that you can make a difference and where people say ‘thank you’ and really mean it. There were practical considerations as well – obligation to work Out of Hours was disappearing, meaning no nights, evening or weekend working unless I chose to.

 

All of this remains.

 

I was at a meeting last week where GP Mike Smith talked about how GPs have ‘lost the joy of the work’. Things have changed over time, the demands have risen, the capacity has not, the work has in many areas shifted onto the GPs, while the resource has not. Despite this, I would argue that General Practice remains a wonderful thing. We just need to re-find that joy. We want and need to be recognised for the work that we do. I recently gave my TEDx talk on ‘Choosing to be a Jack of All Trades’. I will post the video once available, but I talk about the great value I think generalists have, despite the popular opinion that specialists are better (watch my talk to see what I think about that!).

 

It’s time to start celebrating General Practice again. We need to remind ourselves of the many people we see day in and day out who say ‘thank you’, who value us as people who have helped them and improved their lives for the better. We need to remember the smiles and quips from patients coming to see us, the “How are you, Doc?” the “You’re looking well, Doc” and the “you’ve lost weight, Doc” (yes – patient will say these things). They say these things because they know you. They see you as a part of their community, as a part of their lives that consultant specialists don’t get to be part of usually. This is precious stuff. This is life affirming and the reason many of us are doing the job. We must not let anything drive this out of us.

 

I think we can have this regardless of our contract or employment status. You can have this whether you are a partner or a salaried GP. It fits nicely with any agenda promoting Accountable Care or Primary Care Home. It is what General Practice is all about, it is our past and it is our future.

 

We need to find the joy of the job. We need to remember that we are of value. Let’s celebrate and promote all that is good about General Practice. Let’s remember that being a GP is the best job in the world.

 

 

Dr Jonathan enjoyed working 8 or 9 sessions per week as a full time GP for many years. He is currently proud to be a 1/2 time GP at Swanlow Practice in Winsford, Cheshire, and works the rest of the week as Chair of NHS Vale Royal Clinical Commissioning Group.

 

Follow Jonathan on Twitter @DrJonGriffiths