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The NHS in London is currently in a bit of a pickle. It is aware that money will be tight in the future (with most of governmental spending these days seemingly necessary to save the Royal Bank of Scotland), so together with those friendly efficiency creaters from McKinsey it has started to look where it could make some savings. One of their ideas would be to ‘reduce the unit cost in the non-acute sector’ by ‘radical measures in staff utilisation (66%), appointment times (33% reduction in PC[primary care]) and prescribing costs (10%-15%)’ (link here: Strategic Planning Guidance 2009 10 appendix1 HfL affordability assumptions).
Now, I am sure that we all approve of reduction in prescribing costs and utilising staff better, but I do take umbrage with the suggestion to reduce my consultation times. Most days I have a 3 hour surgery in the morning and the evening. In each 3 hour block I’ll see about 18-20 patients, most of them about 10 minutes each. You could argue that 10 minutes isn’t much for the complexity of primary care medicine, and you would likely have a point, but after a long time coming, ten minutes has been the norm for consultations in general practice. Of course, neither doctor nor patient get the full ten minutes, as the clock doesn’t start when the patient sits down in front of the doctor, having taken his or her coat off. No, the clock starts when the doctor calls the patient from the waiting room. Depending on disability or injury, the way from the waiting room to the consulation room can be a long and slow one, so by the time the patient arrives, a third of the consultation might already be over. If patient and doctor are staisfied at the end of the consultation that everything is sorted, a plan is in place, concerns discussed, the doctor still has to meticulously document everything that happened within the consultation. Only then the next patient can be called in.
This shows you two things:
- how immensely important good timekeeping is within general practice (imagine a 5 minute overlap for the first 17 patients in a 3 hour surgery: that would mean an 85 minutes wait for the patient who had an appointment at the end of the surgery).
- how absolutely impossible it would be to reduce consultation times to 7 minutes. Experience shows that the only thing this results in is decreased satisfaction for both patient and doctor and an increased rate of referrals, as your GP has less time to sort things out on a primary care level.
As unnecessary referrals are a terribly expensive way to conduct medicine, the NHS in London is likely to pay more for their scheme to reduce consultation time. Nevertheless, that’s what happens if you invite consultants like McKinsey who have no interest beyond the obvious cost savings and are not interested in either the consequences or the ’soft’ (i.e. relational) side of medicine.
The NHS London insists this plan was widely consulted on.
Ah.
For the past 20 years people who ought to know better have been bashfully embracing one evidence free treatment after another, for fear that refusing to do so would make them seem reactionary old fuddy duddies. But hope is never dead. In this instance it springs from rather an unlikely source: the Royal College of Physicians.
This is the spirited introduction of an article by Nigel Hawkes in last week’s BMJ and he certainly doesn’t pull his punches:
And it is difficult not to feel a certain sympathy with the herbalists. With respect to modern medicine they occupy the same relation as alchemists do to chemists, astrologers to astronomers, or the Arts and Crafts movement to IKEA—historical anomalies that are almost (but not quite) touching in their rejection of modernity.
I have to admit that I am a bit ambivalent about the whole alternative medicine shindig. My motto is normally: ‘As long as it doesn’t harm you and you’re enjoying yourself and you’re not becoming poor in the process’, I don’t mind what people do with their money, and if they have fun sitting half an hour chatting with a chrystaltherapist, a reflexologist, a homeopath or a herbalist, that’s fine. As long they’re not being harmed financially, physiologically or emotionally.
I nevertheless get cranky when people come to me asking about therapies they have read about on the internet or sold by ‘friends’ and spent a large amount of money on and that have no evidence of it working (or worse, evidence of harming people). Unfortunately this happens a lot, and in the age of the internet even more than it used to.
Which brings us elegantly (or less so) to the nub of the problem: evidence. When I prescribe a drug to a patient, I have a clear idea about the latest evidence on its efficacy. Meta-analyses, reviews, double blind,placebo controlled studies do help to guide my prescribing finger.
Unfortunately there is no evidence out there whether it is helpful to put an opal or a quartz in your belly button when you have the runs, apart from auntie Agatha telling you the man who put that green stone in there was very nice and the everything was better after three days.
With other words: before you spend a lot of money on things that are likely not to work, check with your doctor. You always do your research before you by a new TV, so why not do the same for your health.
Hi all,
I would like to warmly recommend a feature from today’s Gaurdian. Deborah Orr, the former ‘Independent’ columnist, has produced an excellent account of the daily reality for mental health professionals and the clients they are caring for in the community. Well informed, sympathetic to the subject and well researched, this is an excellent piece of journalism and should be read by everyone with an interest in community mental health.
Pleas click here.
So the Department of Health released the second annual report of its Cancer Reform Strategy. Entitled ‘Achieving local implementation’, it highlights the stark variation in cancer detection and survival across England. Without fail, the GP bashing started immediately. The Sun quoted Katherine Murphy, director of the Patients’ Association:
“Patients will sometimes tell us that they had been going to see their GP for six to nine months with, say, a pain in their stomach and were told to go to the pharmacy and buy an over-the-counter medicine (and later are found to have cancer).”
In a time honoured strategy, General Practitioners are usually the first to face the wrath of the national media. Nevertheless, there are a few more variables to be accounted for before a successful early cancer diagnosis can be made and it’s not all down to the GP to make it happen. First of all, the patient must tell his or her GP about the new and worrying symptoms he or she might have. While this may sound obvious, there are a couple of reasons why this might not happen. A good example is the comparatively low percentage of men seeing their GP with early red flag symptoms and often presenting in the later stages of a medical problems (1).
Another reason often cited is patients who ’didn’t want to bother the doctor’. I normally tell these that I’d rather be seeing them a once more than necessary before we miss anything important. And by the way: we’re not ‘bothered’ by our patients. The reason that we’re sitting in the chair in the surgery, seeing forty patients a day is because we chose to do so. If I would be bothered seeing patients I would have chosen a different specialty (without naming one in particular, of course. But as you can imagine, there are a couple of specialties where you can reduce patient contact to a minimum) than General Practice. If you can’t stand the presence of your own patients, then you’re definitely in the wrong job.
So before making a diagnosis, the doctor has to know about the symptoms. When the General Practitioner then hears about the worrying complaint it is likely that he will request investigations (bloods, xrays, ultrasound, etc) or will refer directly to a specialist. If the complaints are classic red flag symptoms it is highly unlikely that any GP will be ignoring these and telling the patient to go to the pharmacy. That doesn’t necessary mean that GPs never get it wrong, but I’d wager the number is neglectable in these circumstances. But more frequently there are times when the symptoms just aren’t classic red flags. In fact they might be completely unspecific. In that case it is up to the individual practitioner to either investigate, refer or just wait for a week or two. This is the often quoted ‘Management of Uncertainty’ and is at the heart of General Practice, as most patients arrive with concerns that just don’t fit in any particular category. Medicine is fuzzy and patients rarely have text book presentations of one particular illness. Hence the management of uncertainty bit. And this is obviously the moment where things can go wrong in General Practice. Managing uncertainty is not easy, and GPs will get it wrong at times, no doubt about that. But I am sure this is due to the nature of General Practice, and exceedingly rare due to a single practitioner .
So let’s say the GP made the appropriate diagnosis and referred the patient. There are still plenty of things that can wrong: the referral might get lost. The appointment letter might get lst in the post. The clinic is cancelled. The Xray machine (MRI/CT-Scanner/USS) is broken. The xray report vanishes. The report from the specialist to the doctor can’t be typed because of staff ilness. And who will then pick up the phone and try to call the various partys? Exactly, it’s the patient’s GP who has a worried patient in his surgery who hasn’t heard anything from the local hospital and will likely sort it out by sweet-talking various members of staff.
So there we have it: before blaming GPs for the failures within the NHS, do consider the other factors that might hinder successful cancer detection and treatment.
Thank you.
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1 Ian Banks: No man’s land: men, illness, and the NHS. BMJ. 2001 November 3; 323(7320): 1058–1060
 pic by rob the lomond on flickr I just spent 3 lovely days in Gasgow, Britain’s most wonderful urban space (yes, I know that can be argued about, but as this is MY blog I can sprout my opinion vigorously). I always enjoy visiting this compact, ever improving city and marvel at the quality of life that can be had there (while of course not ignoring the pockets of terrible deprivation). The reason for my visit was the RCGP’s annual conference, the highlight in the ever-expanding throng of gatherings for general practitioners. There was plenty to marvel at: Steve Field’s comments on Fox News (‘Fascist TV-Station’), Mike O’Briens insistance that practice boundaries have to be abolished (loud boo-hiss in the room), Ben Riley’s (no, not the Jazz Drummer) excellent talk on the College’s e-learning strategy, Amanda Howe chairing a seminar on GP research, Stewart Mercer’s talk on managing multimorbidity in deprived areas: these were all engrossing, fascinating and possibly practice-changing.
There was the odd downer though. The promised talk on telemedicine didn’t make it into the final programme and the presentation by the South Eastern Scotland repesentatives of NHS education for Scotland (btw, try to find anything on that site) left me a bit underwhelmed. They were proudly showing off their new e-learning initiative, featuring little videoclips, clickable (interactive?) cases and forums. It all had a very nineties feel to it.
What I don’t get is why you would try to re-invent the wheel and spend another chunk of money if there is already plenty of (free) material out there? If every health authority in the country is starting to develop their own GP-curriculum based e-learning initiative, the numerous outside contractors will be laughing all the way to the bank.
On top of that it’s one thing to set up a web based initiative, but finding enough people to continuously develop content and keeping it up to date is not only expensive but also terribly time consuming and really should be managed by a dedicated team. E-GP, the e-learning initiative by the department of health has everything one could want from an online initiative, and it has the financial backup to keep it going.
So why not point your trainees there?
Anyway. These are only minor complaints. I nevertheless had a blast: learning and having fun at the same time must be perfect outcome for the organisers.
This week I attended an interesting event: “A UK vision for ‘Patient-Centric’ Care”, organised by The Economist and electronics giant Phillips. This featured eminent academics, doctors, civil servants (and employees of Phillips) to discuss their views of what’s wrong with the NHS, what could be done to improve it and who to blame on its current state. The obvious buzz word was ‘patient-centric care’, though non of the participants were actually able to tell the audience what that means. The resident cardiologist on the panel, a chap from the North East of England, thought it means providing patients with (obviously Phillips made) home monitoring systems, because ‘primary care is particularly bad at communicating with secondary care’. There should also be more use of ‘neighbourhood monitoring’ and utilising the ‘patients as the workforce’. GP’s were singled out once more when we were told that ‘primary care is not penetrating hypertension’.
Well, I am used to GP bashing. While I was not aware that we are particularily bad at communicating with our hospital colleages, my impression has always been that my colleagues in secondary are not particularly keen on our views anyway, but I might be horribly wrong. ‘Neighborhood monitoring’ happens everywhere and everyday in the UK. There are thousands of people who are looking out for a vulnerable person living next door, making sure that they take their medication, driving them to the doctor and checking whether they are well. There is nothing new about this. It’s part of the human condition.
After 6 hours of discussion, there was still no consensus of what ‘patient centric’ actually is (apart from home monitoring), but it really is so easy: involve the patient in the decision making of the management of his particular problem, give him/her the chance to raise all the concerns and worries he might have and make sure that you explain everything that involves his or her care.
There. That wasn’t so hard, was it?
In a recent Times article Professor Ian Gilmore, eminent hepatologist and president of the College of Physicians admitted that he drinks alcohol. He gives his liver at least two days of rest a week and always stays under the 21 units deemed the maxiumum for men.
I find that rather reassuring.
What I find a bit disturbing though is the claim in one of the online comments that milk thistle extract helps ‘rebuild your liver cells’. Your liver is quite able to rebuilt itself (if given a chance), and a Cochrane review showed that the stuff did not improve liver related mortality in any of the few high quality trials that were analysed.
Bottom line? If you like your liver, treat it like a liver physician would do.
Andy Burnham has a MA in English. Andy is also the Secretary of State for Health in HM Government. Before Andy became responsible for the health of the nation, Andy was
“Secretary of State for Culture, Media and Sport (January 2008 to June 2009); Chief Secretary to the Treasury (June 2007 to January 2008); Minister of State for Delivery and Reform at the Department of Health (2006 to June 2007); Parliamentary Under Secretary of State for Immigration, Citizenship and Nationality at the Home Office (2005-06) and Parliamentary Private Secretary to Ruth Kelly, Transport Secretary (2004) and David Blunkett, Home Secretary (2003-04)”.
With other words, Andy is as much an expert on general practice as I am an expert on etymology. He nevertheless presides over an impressive flock of civil servants, political advisors, private secretaries, etc (for further reference, please watch ‘Yes Minister’). One day Andy (btw, that’s what he calls himself on his homepage, so who am I to call him anything else) must have woken up and thought: how about increasing competition between general practitioner’s surgeries. Why let geographic boundaries decide which doctor the voter has to see? Let competition flourish and the best practice win.
Lovely idea, innit?
If only Andy and his minions would have thought this through. While I won’t even mention the problems practices in sleeper towns would have (if all the patients of working age suddenly register next to their workplace), the biggest problem is continuity of care for home visits. At present, GP’s visit their own patients at home if they are frail or illness renders them immobile. But what would happen if a patient living in North London, registered with a GP in South London next to his work place, fall ill? Does Andy really believe that the South London doctor will spend 3 hours on the tube to get to his patient? So the poor chap in North London has to have access to some sort of care up in North London. Currently he is not allowed to register with two practices, and even if, continuity of care would be a complete disaster, with one practice not informed about the other practice’s current referrals and investigations. At present the out of hour cooperatives are not responsible for patients during working hours, so should they expand their services? With what doctors? The ones that are already tied up in the government’s attempt to expand evening and weekend access?
There used to be a time when voting Labour was the natural state of affairs for healthcare workers.
This has changed.
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