imjustagp.com

Re-Forms

One of the joys of my working life is the constant stream of forms I have to fill in , I am not being sarcastic .

The variety and sincerity of some of the absolute nonsense I am asked to fill out really does give me pleasure and hope for the future . Pleasure in a way that makes me inwardly smile how petty and risk averse people have become and hope for the future because when I finish this career I can start another one designing those forms for other professionals to fill out for no particular good reason.

Having promised at the end of the last article to keep things a little lighter I will, with this reflective and practical piece to help get rid of or deal with some extra work that none of us need, a reform so to speak.

Now I’m not talking about things like life insurance reports or holiday cancellation forms, both of which I can see a function to.However the layout and structure of those make it as difficult as possible to put relevant information in anywhere and also to leave as much ambiguity and wriggle room for the insurance companies as possible. “When did the client recover enough to undertake a significant part of his work ?” how many variables does that have in it ? ,but that is not for this piece.

The focus of this is all of those bizarre and to be frank ball aching requests for “ is the patient fit to do this, that and the other “. Now don’t get me wrong, should I have been sat around collecting pressure sores, counting my vast fortunes and generally plotting the down fall of the NHS then someone asking my opinion on whether they are fit to pick their nose or not would be a change but, they don’t call me Jeremy and my surname doesn’t rhyme with anything remotely as comical so funnily enough I do have better things to do.

I was asked this week, seriously enough whether a patient was OK to have reflexology as they were pregnant. My answers were colourful and varied and I am sure you can fill in a few yourself, has the patient walked on a pebble beach recently?, then I’m sure they will be fine , what the hell is reflexology? and why in gods name are you asking me? . If you are thinking of doing something to a pregnant woman you might consider dangerous enough to cause harm then don’t do it. If you are doing something you don’t think is dangerous then you are an adult make a decision, you don’t need me to tell you. But there is the crux, people, patients and society has been encouraged and disempowered in to a situation where risk management has been mistaken for risk devolvement. Before the abuse starts for knocking complementary therapies, personally I don’t care what works for the patient as long as it does them no harm, doesn’t fleece them for cash and they feel better after it.

And that is what all these forms are about individuals, companies and organisations not trying really to manage risk but to devolve it to third parties to say they have managed it . You will have multiple examples, is this person fit to
sky dive, walk up a hill in outer Mongolia, have reflexology, go to school, do PE , do a voluntary pubic hair removal, grow a moustache, act in a TV commercial, fart .

The list could be endless so in the spirit of positive general practice that abounds at the moment I thought I would share a form I have designed. This is to give out to any person who presents a form to be filled that you deem unnecessary and to be frank stupid. Yes I know all the arguments re charging patients a fortune to discourage etc but this is more fun and you can still charge !

_________________________________________________________________

Thank you for asking the very very very busy doctor to fill out this really important form , for them to do this they need certain bits of information that are vital so they can assess the risk before they start the process . Either you but preferably the person who has asked you to get the original form done should fill it out . Failure to do so will result in the form not being done by the Doctor or saying they will get round to it but not saying which year .

Full name
Address
Date of birth

NHS number (you must find this without the receptionists help)

Full details of activity you wish to undertake giving :-
Complete cardiovascular outlay profile , altitudes, partial pressures of oxygen, weather conditions at the time, a comprehensive run down of flora and fauna in the area that may pose a problem, the time of day the activity is undertaken, how many times you are doing the activity, is it something you would let your children/parents do, does the daily mail think it’s a good idea,have your friends done it previously, will it affect availability of weekend appointments (irrelevant but gets brought in to everything) and anything else you feel may be relevant, please don’t ask what may be relevant that is you or the person who asked you to fill out the original forms decision .

Qualifications of person instructing you to get this form filled including GCSEs and primary school certificates

Full legal risk assessment of the activity

Full breakdown of the activity by a barrister including case law of all successful action against clients for this activity

History of documented evidence that anyone ever came to harm from doing the activity you are to undertake

An opinion piece (in no less than 3000 words) as to why you feel the need to ask me to fill this form and what you are hoping it will achieve (appendices and bibliography required)

A case study showing how a GPs opinion no matter how mighty would make any difference at all to the outcome .

Written undertaking that you, your colleagues or employees do not now and will never read the daily mail

Once all of the above is done (feel free to add as many points as you wish) then let the surgery have the completed information and we may then make a judgement whether we can fill out the original form, of course we will be charging by the minute and given the amount of information we need to read it will be a considerable fee .

Or there is an alternative that yourself or the person who has asked you to fill out the original form could actually accept that life has risks and just self assess those and take them like a grown up.

Thank you for your time and please don’t let us know the decision
______________________________________________________________

Fell free to nick the above and change as you wish. Now I’m not sure whether this will work or not but it will be fun trying and like all these things a variation of the ridiculous can sometimes help. Instead of form filling we could perhaps spend our time seeing patients, a reform we would all welcome but what would I know I’m just a GP.

feel free to contact/comment via twitter @imjustagp

 

 

 

 

 

 

 

 

ADMISSION AVOIDANCE

      Is it me ? When I was a house person , house dog, house plant , whatever the politically non correct name my senior chose to give me that week we took admissions directly . That’s right to those younger than me we held a bleep, answered promptly if we could ( else got shouted at by switchboard and our free calls to relatives in Australia stopped ) and spoke to the admitting GP directly . Now as a junior and inexperienced in the vastly superior ways of working in the community I would sometimes be frustrated with the quality of referral to hospital , one DR in particular known as DR RED PEN because of his choice of coloured biro was a regular culprit. But I was young and impressionable , these were the days of my 96 hour per week contract and I regularly worked 120 . You can almost hear people reading this saying “yeah, yeah, course you did” I hate to say it, but it is true .

Those hours and contract were wrong but it did give you a huge amount of exposure and forge some good habits and make you appreciate how difficult it is to do . See I have worked in a high pressure medical admitting environment for several years and know it is tough , know that the quality of referrals are important and that for quick flowing good medical care in hospital the speed and accuracy of decision-making round an admission is vital .How many accepting clinicians have worked in General Practice and understand the reverse pressures?

And that being said how many of you as GPs would just admit someone to make life easier, or that you thought you could manage in any other way , I would suggest very few of you . The reasons for that are multiple .

One is above because you know how crap it is to receive a poor admission having done the job . Though I must apologise to DR RED PEN because , as it turned out most times in the end it was appropriate and my experience at the time didn’t allow me to understand the pressures they were working under or the clinical acumen they had (humble pie eaten)

Two, and perhaps the most important one is we like our patients (well most of them,joke ) and the last thing we want to do is put them through the stressful and often ridiculously gruelling process of admission to hospital , which are , as we know, some of the most dangerous places on earth .

Three, have you tried dealing with the ambulance service recently , never mind looking at response times. the financial and clinical pressures they are under is immense and to be honest we are looking at a community rickshaw for exactly this purpose to try to speed up the process . No, don’t be ridiculous they can’t go on the bus ,we are a rural community, there are no buses.

Four and the reason I am writing this piece, is an apology to the hospital admissions person , I use that phrase because it varies from speciality and area .

I do my best to be a good GP , be patient advocate , manage our scarce resources and treat and investigate patients in a clinically appropriate manner as per my personal , ethical and professional responsibilities. Now here come the shocking headliner that will blow most STPs .or whatever else they are called away .

IT IS NOT MY JOB TO AVOID HOSPITAL ADMISSIONS !!

Do you get that, my role is many but part of that is not to keep patients out of hospital , my role is to manage patients in a way I feel is clinically appropriate with 25+ years of experience . Now some may disagree and I am happy to be educated but can only do what I can do with the regular 12-14 hours a day I work.

Recently I had a rather frustrating afternoon , several urgent visits, multiple secondary care problems to sort out , sick notes that hadn’t been done, meds that hadn’t been given on discharge, frontal lobotomy not stitched up , you know the usual stuff . In the midst of all this a patient who I had seen previously and liaised with a consultant about re their management , they were getting worse, had seen a partner that morning, who had tried to admit them but left a message on the wrong answer phone as it wasn’t clear which he should use, and asked me to chase up in the afternoon . Fair enough , we have a good team way of working but I didn’t get round to it till 4 ish . I chased and I chased to try to do the right thing, phone calls to secretaries, bleeped multiple registrars who didn’t answer, long waits . Eventually got the right secretary who said the consultant was at another hospital , rang said hospital put through to multiple wrong clinics and secretaries, eventually spoke to said consultant ( who is excellent) , they decide to admit to the hospital they were in as medical admission .
Fair enough , I’ll be nice and admit patient as I’m sure consultant busy, this is even though I now have 2 emergency visits backed up , one of which is 8 miles from practice (yes this is rural GP) and whose daughter is struggling to rouse and doesn’t want admission and given this article i’m very glad about that . I ring medical admissions and get them on my second attempt , hey it’s a record. Answered by very nice sounding person who didn’t introduce them self , and when asked “ who are you “ gave me a name but no job title ( hands up which GP hasn’t given a full life history only to hear the words” I’m only the ward clerk i’ll get staff for you “ . We elicited this was the admissions co-ordinator and I went through the admission , patient details, clinical details and “no I haven’t seen the patient today, but my partner has “, “ yes the consultant wants them in today” and the questions continue . Now I can only suspect that I am not the only GP who feels like this and to be honest the admissions procedure seems to ask a full medical history now, the official answer for this is to make sure the patient is admitted to the “appropriate “ place . Well here’s the crunch , I’m an experienced clinician , the consultant has asked for it and look at all the reasons above, if they need to come in then please don’t delay things anymore and just accept them . We used to use a phrase which was to “see and sort“ because for whatever reason the GP can no longer manage this patients conditions in the community and they need more intensive care/investigations . If I feel the patient is acutely unwell I will send to the Emergency department and I can probably work out which ones those are else please just accept the admission and don’t make us fight for it .
The tensions right through the system are palpable and here is the bit I’m not proud of .
After the coordinator ( who was calm beyond belief) had asked and put me on hold for the second time , we are now in to over 1 hour to admit a patient , they came back on and said the consultant on admissions was querying things . At this point I lost my rag a bit and mumbled under my breath and I must add not directed at anyone “ oh for flips sake” or words to that effect, totally unacceptable for which I apologised profusely immediately . I stated it wasn’t directed at anyone and especially not the coordinator but it was sheer frustration for me, the patient , the system and the patient who was unrousable 8 miles away who was being delayed from being seen . The coordinator quite rightly said that it was unacceptable but accepted it was not directed at them , I apologised again and explained re the pressures we are all working under . Eventually we agreed the two consultant would speak to each other and I apologised once more to which she gently stated it showed a lack of professionalism .

I didn’t respond , I put the phone down gently, shut the door on my consulting room and let the tears well , I was disappointed in myself for letting it get to me, disappointed that the patient had such a delay but mostly, hurt ( which I will get over) for being told it showed a lack of professionalism . Everything I and my colleagues do in general practice is about putting patients first, not systems, tick boxes or protocols .Professionalism is not about swearing or not , although I completely accept I was in the wrong , it is about caring , acting always in the best interest of the patient , going the extra mile, never giving up , respect for experience and so much more .

I gathered my thoughts, and my kit and went off on the emergency visit knowing the day was getting ever longer , 8 miles from the practice I walked in to a fantastically caring household who looked after their elderly relative , sat there the patient now wide awake and looking well , “ Hello Dr. what brings you here” the patient said .
I smiled and then I laughed, that is why I do this job and that is what admission avoidance is all about but what would I know ? after all I’m just a GP.

Thank you for reading , the next one will be a bit lighter in mood I promise .
any feedback welcome via twitter:- @imjustagp

I’M JUST A GP .

This is a piece of therapeutic writing and god knows as GPs in the NHS we all need a bit of therapy now and then . There will be no ” visions ” , ” journeys ” , ” taking this forwards ” or other such mind numbing phrases that irritate all of us and make us play bingo at presentations and meetings .Try it if you’re bored at the latest announcement on ” how to reconfigure and save the NHS ” count how many times you hear those phrases and the first one to 69 or whichever else number you choose wins. Brightens up the meeting no end .

The real reason for this is two fold , no origami pun intended .
The first is personal , I’m approximately 25 years in to my career in medicine and general practice and at a bit of a cross roads so it is working out to me what is really important for the next however many years I do this , lucky as I was to come in to this profession with a pretty pure motive ,patients .

And secondly because I love general practice and I want to protect it , not enshrine it, not embalm it, not stop evolution but do exactly the opposite by stopping those people who believe that the sub specialisation of every branch of this job I do is the only way forward , to be frank that’s testicles .

At this point let me apologise to anyone who is reading this for my English skills , grade c 16+ English , for the record that wouldn’t even get you to medical school these days but that’s a whole other discussion .

I am extremely privileged , I do a job I fundamentally love, in an area of the country that is stunning , I have patients who are fantastic, vibrant, interesting and have become my friends ( rural GPs still have this ) . I work in a partnership that has been going as a single business for 120 years, all my partners past and present are excellent , caring ,compassionate ,competent doctors who have worked as a team , we include as partners nurse practitioner and practice manager .My kids go to local non fee paying schools and have grown up in idyllic circumstances and all this from a working/middle class comprehensive boy who was told to look at polytechnics as I may not be able to do medicine ( should have mentioned bloody minded Yorkshireman )
So with all that why the hell am I writing this ,and that as they say , is the point .

The other day there was a bit of a eureka moment , don’t worry you can remove the picture of me in the bath from your head because I was watching athletics .

GENERAL PRACTICE IS THE DECATHLON .

The crown of all events, the multi skilled, multi talented , balanced individuals who know their own areas of strengths and weakness. They practice harder on those areas they struggle with , they look externally for help and coaching from experts in the areas they need to, but the focus is always the same . To achieve your personal best in every area ,to try and achieve the best possible overall score ie patient care . I know the heptathlon is performed by women in modern athletics but this isn’t about gender , a GP is a GP .
‘m feeling quite gladiatorial writing this but must tone it down as I am sat on a balcony in Greece and much as the olive wreath is near to hand the Spartacus look went years ago !
And the decathlon analogy moves on in to all areas and is one of the main reasons I am questioning what I do next .

Let me allude . GP is one career that gives you great autonomy, opportunity to just do things , not faff , not put it through a committee, just do it and you take the consequences . I love that , I don’t always get it right , I hope I have got better at listening and reflecting as I get older but what a great mover for change. The problem is the powers that be have started to try and stop that . One question you should always ask is when someone says you can’t do something just say ” or what ? ” . The replies are often very enlightening. Rebellious streak in me always gets the better and if you are acting in the patients best interest as an independent practitioner then it is not your right, IT IS your duty. I have lost count where the micro managing numpties have stated, it has to be on this form , written this way , to this person , with these details, on a Friday am between 8 and 8:30 if your names Brian and etc etc etc .

I am a decathlete, I will do my best in my events , advise me, but you do not do my event and if you are not helping me then please go away .

And the encroachment of secondary care modus operandi in to primary care is stifling and I believe harming overall patient care . Just for devilment here the next time your local acute trust looks at a significant event if you write and complain ,specifically ask them to look at the area of psychological damage to the patient . “well they didn’t have full blown cancer so the delay in the CT scan result caused no harm”. tell that to the quivering wreck in front of you who has planned their funeral, sold the silver and is all but dead and buried in their head. And that is one of the fundamental differences , we understand that , in general practice we care about those things, we try and empathise and understand .

I am a decathlete, I will do my best in my events , advise me, but you do not do my event and if you are not helping me then please go away .

Recently we have been informed re incontinence assessments that they must go to the appropriate team . Let me explain when you finally get round to broaching the subject with said patients/relatives. You want to strike while the iron is hot and need some help now, its not medically urgent so you can’t justify an urgent referral but if you wait for the six week routine one then the patients think, why did I bother I should have just put up with it . Well we used to use common sense, someone within the team would have a brief chat , give some interim pads/advice and await formal assessment . Well apparently that’s not allowable as they may not give exactly the same advice as the inco team , as my kids would say ” no shit Sherlock ” . The whole point is they aren’t the inco team but they are there and available .We are giving as the military say 80% ie 80% of something is better than a 100% of nowt .

I am a decathlete, I will do my best in my events , advise me, but you do not do my event and if you are not helping me then please go away .

And all these people are well meaning , pleasant and believe they have their place in the system but if you listen to the patients most of them are happy with generalism . The encroachment of work from secondary care is beginning to make our jobs untenable and if we stick with the decathlon analogy I am being asked to take extra events on , do the events I do twice with less training time , less coaches , less rest and all the time being told its good for the overall score , well do you know what , its NOT !

For the first time recently in this job I have properly started saying NO and that is soul destroying for me , but it has to be ,as I firmly believe as a profession if we don’t then the patients will suffer and as individuals we will crumple .We cannot provide safely more and more for less and less .So the message from me to the profession would be ” DEFINE YOUR CORE “

I can hear all the politicians going ” that old chestnut, next ” but bear with me
If every practice defined their core contract work and then wrote to their NHS England coordinator with it laid out and stated that outside of that any other work would incur a fee or would be returned then it would set some things in motion . It would establish a contract dispute, in my county possibly 70 of them , can you imagine the chaos, disastrous in some ways but i see no other way of effectively negotiating with them because they are being pressured so highly from above . And hopefully out of that chaos comes some common sense where we are allowed to get back to doing what we do so well .

I am a decathlete, I will do my best in my events , advise me, but you do not do my event and if you are not helping me then please go away .

Should be our mantra for everything we do , contracts, community care , coal face consultations , negotiations , federations , lmc , ccg etc

So on a personal front I will fight with every last breath to protect my patients care from those who are trying to dismantle and fragment a system that has evolved in to I believe the best family medicine in the world . As a system we need to say “NO”, loud and clear , for those elders leaving the job I don’t blame you .But please help, offer counsel and for those just entering who want to be salaried, non principal , welcome .How can we help you stay ? and did you know how wonderful this job once was, and if we stick two fingers up hard enough will be again .
To those between the two like me ,look after yourselves on the 12-14 hour daily grind, your families and friends are your saviours, exercise when you can , shout, get angry , that’s fine because it is bloody frustrating at the moment but maintain the purity , if you can , of the patient focus and the slightly rebellious streak that gives us hope .

And remember in all our dealings today whether community , secondary care, ccg, cqc, external agencies, NHSE ,capita, etcetcetc then ask of them do they pass the decathlete test , if not then …….

I am a decathlete, I will do my best in my events , advise me, but , you do not do my event and if you are not helping me then please go away .

 

twitter          @imjustagp

Dear all,

Thank you for taking the time to read my Blog .

I am a full time rural GP in the north of England who in spite of everything loves his job.

This is a forum to air what I hope are common sense views about General Practice in the UK . The views are my own and do not represent any other organisation I am a member of.

The aim is to raise issues I feel strongly about, share good practice and frustrations and hopefully a little splattering of humour chucked in for good measure .

If it raises a smile , a question, a discussion or some hope , then it has served its purpose.