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

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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

Drug Switch

Drug Switch

I had a dream last night. In it I was trying to persuade a mother that we should change her son’s prescription so that we could issue tablets (which we had established he was able to swallow) rather than the liquid suspension. The issue was that the main reason for wanting to make this switch was for cost. The drug was the same and no harm would come to the child, yet the mother was concerned that a cheaper drug might not be as good for him.

The dream is remarkable in that it is very close to the reality of what I often find myself doing. General Practice has, for many years, taken on responsibility for being cost effective as well as clinically effective. Prescribing has been a key area where we have seen this. As a patient you may notice the brand of drug you are prescribed may change from time to time. An old example would be when we consciously made an effort to change people from prescriptions for Ventolin to prescriptions for salbutamol. For those who don’t know, salbutamol is an inhaler used by people with asthma and other respiratory conditions and Ventolin is a brand of salbutamol. In other words, Ventolin IS salbutamol, and if you look on the packaging of Ventolin inhalers, it will say so. Prescribing salbutamol was cheaper for the NHS than prescribing Ventolin. As far as I am concerned they are the same drug. As far as I am concerned we should stop prescribing the more expensive brand and always go with the cheaper, but equally effective one. This does not stop patient’s complaining that salbutamol doesn’t work as well as Ventolin. There are numerous other examples. Before I continue there is a point worth drawing out here. People frequently make the mistake of thinking that ‘you get what you pay for’ applies to medicines. It does not. Costs of drugs do not vary according to quality, but according to what the manufacturer believes they can charge. A more expensive drug does not necessarily mean a better drug, and vice versa. Please do not make this mistake yourself, and please spread the word about this!

As we all know, the NHS is struggling financially at the moment. We are therefore continually looking for ways to be more efficient so that we can provide the best healthcare possible within the resources we have available. Cost efficient prescribing is one way to do this, and is appealing because changing drugs from one brand to another, or encouraging patients to buy their own paracetamol should not result in any adverse clinical scenarios, yet should save money. This feels like a no-brainer. It nevertheless feels like hard work.

In my experience most patients accept changes to their medication without question. I should point that that we do not change prescriptions without a corresponding letter of explanation. There will always be a few individuals, however, who are unhappy, and a disproportionate amount of time tends to be spent on these few. It seems to me that we have not done a very good job of changing the culture of our society to be more responsible. Instead we seem to have a society which is quick to offload responsibility to others with a backdrop of litigation and blame when things do not go according to people’s wishes. This leaves me with the awkward conversations tying to persuade people that is it ok to change their prescription, rather than one where everyone recognises the need to prescribe appropriately and cost effectively and to do their part. We need to move from a sense of entitlement to one of joint acceptance of the responsibilities. Clinical Commissioning Groups up and down the country are encouraging GPs to encourage patients to take some responsibility and buy what they can from the pharmacy. There is push back from other doctors about how this is being done, and while I recognise that the language and ‘mandate’ need to be correct I do think it is unfortunate that CCGs are being criticised and referred to the Advertising Standards Authority rather than helped to get this right http://www.pulsetoday.co.uk/clinical/prescribing/ccg-reported-to-advertising-watchdog-for-misleading-patients-on-otc-prescribing/20034946.article.

While this level of collective responsibility remains lacking we will continue to get push back from GPs about their willingness or otherwise to have these conversations. Doctors and other health care professionals will say that their responsibility is to the person in front of them, and that cost should not be a consideration. I disagree with this, and would quote General Medical Council duties to them which make it clear that we need to make appropriate use of the resources we have available to us . I was once at a public meeting where we asked if we could provide assurance that doctors would not be making decisions thinking about cost and resources. The response, provided by one of my fellow GPs on our Governing Body, was that of course doctors should be considering financial resources. It would be completely irresponsible to do otherwise.

I have long thought that we should just let all our patients know that they should expect their medications to change from time to time. We should reassure that any change is not expected to result in any detriment to their condition, but make it clear that we all need to collectively accept some responsibility for managing the NHS budget, and for appropriately spending money from the public purse. Every GP is aware, I am sure, that every time they sign a prescription, they are essentially signing a cheque and committing resource. I want to be clear in saying that I don’t think we should stop prescribing appropriately, but that we should continue to prescribe cost effectively, and that our patients and public have a role to play in facilitating this.

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



Follow Jonathan on Twitter @DrJonGriffiths

 

Featured image from https://pixabay.com/

Cheshire?

Cheshire?

Cheshire  no longer exists. A few years ago the multitude of Town, City and Borough Councils across Cheshire were all brought together into two unitary authorities, Cheshire West and Chester  and Cheshire East. From that moment Cheshire as an individual entity disappeared, although clearly the word still describes a geographical area for many people, and when I am asked where I live and work, I will always say ‘Cheshire’ rather than ‘Cheshire West and Chester’. (I actually live in Cheshire East and work in Cheshire West and Chester…from now on I will use the acronyms of CWAC for Cheshire West and Chester and CEC for Cheshire East Council).

 

The local authority boundaries have caused a problem for NHS commissioning because our Clinical Commissioning Group (CCG) areas are not coterminous with them. Our local hospital, Mid Cheshire Hospitals NHS Trust is based in Crewe (in Cheshire East), but patients from many parts of the Vale Royal area of CWAC also use it as their local hospital (as an aside Vale Royal was a previous Borough Council and no longer exists either, but was recognizable enough by local people for us to provide the name of our CCG). In contrast our two neighbouring CCGs tend to have their patients flowing to either the Countess of Chester NHS Foundation Trust (in Chester, unsurprisingly), or East Cheshire NHS Trust (in Macclesfield), each of which is entirely within the footprint of either CEC or CWAC.

 

Why am I telling you all of this? Partly to express a little of complexity we have grown up with and dealt with over the years of our CCGs existence, and partly to help explain some plans the four Cheshire CCGs have moving forwards.

 

As you may have already realised, there is a reasonable amount of duplication occurring across the 4 CCGs. Our mental health provider, for example, provides mental health services across the entire Cheshire area and beyond (into Wirral). We have also recently had cause to look at some procedures of limited clinical priority which we have done again over a Cheshire wide footprint to reduce the potential for a post-code lottery. It would make sense f we could do some of this together, and only once, without having to go to gain approval and agreement from four separate Governing Bodies, each of which might make a slightly different decision, bringing about the very post code lottery we were trying to avoid in the first place.

 

There is also an issue of capacity. In these times of limited financial resource the CCGs are running light. Capacity to commission effectively is stretched, and just when we wish to be working on transformation of local health and social care, and moving towards the development of Accountable Care Systems, we are in danger of not having the workforce to press ahead.

 

We are hoping that we can solve some of these problems by creating a Joint Commissioning Committee across the four CCGs. (For clarity I am talking about NHS Vale Royal CCG, NHS South Cheshire CCG, NHS West Cheshire CCG and NHS Eastern Cheshire CCG). The idea behind the joint committee is that we can delegate authority for some decision making up to a joint committee, ensuring that things that only need doing once, are only done once, and then freeing up capacity in the CCGs to focus on the work that really does need to happen locally. The key part of the local work will be in the continuing development of Accountable Care. We currently have three strong, local integration systems based around the footprints of the three local hospitals (Connecting Care in Central Cheshire, the West Cheshire Way in West Cheshire and Caring Together in Eastern Cheshire). It is possible that these will form into three Accountable Care Systems. Over time these may take on the bulk of the functions currently undertaken by the CCGs, while a merged Cheshire Commissioning Organisation could provide a strategic commissioning function across the whole – but we are a way off that yet!

 

The Joint Committee is the first step, and regardless of possible future directions of travel seems to be an important one that I would endorse. We need to be doing all that we can to be lean and effective. We do not want to be spending time on things that are being duplicated, and we do want to be able to spend the time on the things that matter locally. I believe that the joint committee will help us to do this.

 

So, what have we done so far, and how are things progressing? The four Governing Bodies have met individually and together to discuss and have approved the direction of travel. This has included executives, lay members and clinicians all working on the Terms of reference for the Joint Committee that are now in draft form and about to be approved. The Accountable Officers and Chairs from the four CCGs have been working together to bring this to this point, with numerous formal and informal conversations and email exchanges.

 

The next step is for the Memberships of the four CCGs to consider these proposals. Clinical Commissioning Groups are membership organisations, and the GP practices are the members. They are the ones who will ultimately need to approve any changes, and need opportunity to consider, discuss and decide. We neglect our local GPs at our peril. The Health and Social Care act that created CCGs in 2013 put clinicians at the heart of the commissioning process and GPs in the driving seat. We need to reassure our GP colleagues that any changes will maintain this ethos of clinically led decision making and ongoing clinical engagement. I would hope to be able to provide some of this reassurance. Clinicians have already been involved in this work (not just the Clinical Chairs, but also the GPs on the Governing Body), and we have ensured that clinical representation on the joint committee is enshrined into the Terms of Reference. The important point will be in deciding the work plan – i.e. deciding what the Joint Committee is actually going to do. This is not yet agreed, and I would suggest that the Memberships need to be kept fully informed of this process, along with the Governing Bodies.

 

The bottom line, in my view, is that we need to develop space to breathe, act and develop our plans at a CCG level. Without this, we are going to struggle with our plans for integration and movement towards Accountable Care. The Joint Committee should provide some if this.

 

If you want to follow how it all goes, then watch this space!

 

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

 

Follow Jonathan 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

 

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