NHS - Gone Fishing

I have had a very frustrating day as I have tried to speak to various GPs and other NHS-type people today. I don't think I can have done better than a 50% success rate. I am sick to death of out-of-office replies. Everyone else is mad busy trying to do the work of their missing colleagues.

Presumably in 2 weeks time they will swap over and we will be stuck with the usual summer of non-activity for another month yet. The patients will be seen but most other health related activities will drop off alarmingly.

This coincides with the usual early August alarm bells as all the junior doctors shuffle around from one hospital to the next. The Junior Doctor has been recording some of the pain. In fact, my experience has been that the first few days aren't too bad, as new staff usually get some kind of induction and so the more senior colleagues or staff grades may well be covering the bleeps. This can be good news for the GP as I have ended up getting a consultant opinion instantly. It is the second week when it all gets a bit tougher.

GP bloggers aren't immune either - I noted the anonymous comment on one of Dr Andrew Brown's postings. I will look forward to normal service being resumed after the NHS takes its holidays.

Alzheimer's - bad news

Well done to the Aberdeen team for progress with their new Alzheimer's drug. I feel obliged to offer congratulations as you can't get much more northern than Aberdeen. However, I feel far greater congratulations should be going to their publicists. They have managed to make a splash all over the telly and the front pages of the rags today.


I don't need to document here the cruelty of this disease and it is not Alzheimer's per se that is winding me up today. It has been reported here with spectacular disregard for any issues of medical evidence. Wheeling out some trial participants and parading them in the media hardly constitutes a fair assessment of any drug's future utility in daily medical practice. Do we even know if they got Rember or placebo?? (Rember is a typically catchy name - presumably the drug name is well nigh unpronouncable.) I have no doubt this is partially motivated by patient groups' disappointment at recent NICE decisions.

I just find that single issue organisations make me cantankerous. It might be something to do with being a GP. One minute I might well be seeing someone with Alzheimer's disease but ten minutes later it will be a mental health issue with no access to care or a cancer patient with worries about receiving the latest treatment. How can you favour one at the expense of the other? Opportunity cost the public health people call it. Perhaps that cost will be felt in the provision of care to other dementia patients. The BMJ recently publised an editorial on the use of antipsychotics for people with dementia. Non-drug measures are first line but are in short supply.

NICE may well be a centralist government's ugly henchman doing the dirty work of rationing but with the current NHS model then the bucks have to stop somewhere. A trial drug, possibly years away from licence and the Alzheimer's lobby have already got their first attack in. Well done.

What about some investment in non-pharmaceutical care? This story just continues to feed a public, media and medical obsession with magic pills.

Medical bloggers and the GMC?

Could medical bloggers soon be coming to the attention of the GMC? I realise this is something of a 'pop will eat itself' blog entry but some recent research in the US of A highlighted on 6minutes.com.au has raised the issue. Other medical bloggers out there may wish to have a gander. As a good medical educationalist I will reflect diligently and perhaps raise it as a probity issue in my appraisal!

A Good (Political) Death...

It seems entirely fitting that the government have published their end-of-life care strategy this week. Given the catastrophic outcome for Gordon Brown as Labour crashed to defeat in Glasgow East did the Dept of Health know something we didn't?

"How we care for the dying is an indicator of how we care for all sick and
vulnerable people. It is a measure of society as a whole."

Quite so. But there may be some knife-wielding Labour MPs that have missed this point. I feel the compassion of the medical profession may also be stretched to the limit here. The Lancet comments on the need to discuss death openly and how the plan advocates such measures as rapid response palliative care nursing teams. I feel we should be encouraging the Prime Minister to face up to his future (or lack of it) and put plans in place so we can accomodate his chosen place of death.

The good news for the government is that it is thought these measures could be cost-neutral. Hurrah! The new strategy may be a 10 year plan but I think I can advise this patient that the prognosis looks worse and it won't be that long before Mr Brown curls up his political toes and dies.

Taxi! Northern Doctor's Seven Deadly Sins - Greed

The Daily Telegraph have been giving it to GPs again today with their 'GPs forced to drive taxis' piece. Interestingly, it is one of the very few articles I have seen in recent years that highlight the disparity between certain posts in the profession.

My perspective, from the salaried side of the fence, is that there have been rumblings of problems for a wee while now and many practices have not been slow to squeeze their salaried staff. It has been clear that trainees coming off the scheme are struggling to line up work. I have even heard a rumour that one of the practices in the local town have been charging newly-qualified GPs to do sessions for them. The idea being they get a nice CV enhancing experience and possibly a reference to boot in an increasingly tough job market.

Some of the issues here overlap with my post a couple of days ago and I won't repeat the main arguments but I don't think greed is the predominant factor.

Many GPs recognise the issues and are keeping their partner numbers up. (The Jobbing Doctor for one and understandably upset at yet another attack). Some of this is accidental; an unintended consequence of changes in the 2004 contract. Some of it is simple market forces as small businesses try to protect their interests in difficult time. And some of it is related to the government inexplicably pursuing a vendetta against GPs for a contract they negotiated but seem to detest. But in a few isolated cases it is naked greed and we certainly have a couple of local practices milking the situation with scant regard for anyone's future except their own. I agree with niceladydoctor though - it is thoroughly insidious.

Prof Steve Field has got it right:

"We are calling on partners to look at creating more partnerships and more substantive salaried posts. We as a profession need to do that for doctors and for patients."

Darn tooting but what are the chances? They need to encourage practices to take on partners for the good of the profession and more importantly so that we don't destroy primary care as we know it. But all he can do is appeal to their good will and that may even mean they take a pay cut. If practices take on principals then their earnings will probably dip further. If they don't then they create divisions in the profession and push at the open door of privatisation the government have unlatched.

It looks ominously like a lose:lose situation.

Northern Doctor's Seven Deadly Sins - Lust

Although I am content to leave the majority of blobby knobs to the Genito-Urinary Medicine (GUM) mob, as GPs there are very few areas we don't occasionally touch (preferably with gloves on though).

Chlamydia remains a hot topic and the Health Protection Agency are advocating a annual screen for chlamydia in 16-24 years old who are generally a bit too lustful . Their press release is here and the full report here.

BMA News this week (Sat July 19, 2008) quotes HPA Centre for Infections director, Peter Borriello: 'It's increasingly the case that among young people a casual shag is part of the territory, it's part of of life'. Rather brilliantly he then added that SHAG now increasingly stood for Syphilis, Herpes, Anal warts and Gonorrhoea. Nice.

Their genius advice to young people is: to have fewer sexual partners and avoid overlapping sexual relationships. I think I know what they mean by that. They recommend condoms too - personally, I think I'll stick to that line rather than make moral judgements on my younger patient's sexual escapades.

The Sudocrem Medal of Honour

I can vividly recall a number of consultations when I was a callow youth and I was harangued by parents. The standard line being: 'you can't possibly understand because you are not a parent'. Reassuring these people (with their inevitably viral but otherwise well progeny) was a trial.
I resisted the temptation to say I had already seen several hundred sick children more than they ever would and I went on to get quite involved with paediatrics. I even went through some mild pain and got a nice piece of paper from the Royal College - a Diploma in Child Health to prove my worthiness.

But it means nothing. I now have children and I have achieved the ultimate badge of honour. We have finally finished a tub of Sudocrem. This is not an easy process and involves more babies nappies than I care to recall. I may have to add it to my appraisal folder. It is probably a more useful bit of evidence than 360 degree appraisal. Or I am thinking of nailing it to the surgery wall (the empty pot that is, not the appraisal folder).

It is a cheap shot but I always try to drop my children into the conversation with other parents. GPs don't have pictures of their children on their desk or wall because they want to gaze longingly at their offspring. They are there to aid the process of reassuring neurotic parents and currying favour with little old ladies.

Cartels - An Inconvenient Truth?

Ben Bradshaw may be a first-class headbanger and his "gentlemen's agreements" comments verge on insanity but is there a worrying kernel of truth? (BBC)

Consider this. A practice has a small group of individuals (GPs) running a business and taking the profits. How exactly does that differ from any private company? Well, one way it used to differ was all the GPs had to contribute to 24hr care of their patients. This helped ensure that the incentive to shrink partnerships was seriously curtailed. This 'guvnor' was removed in the contract when GPs gave up out of hours care.

When this happened most GP principals in our area breathed a collective sigh of relief then (I was going to say literally but infection rates would suggest not) washed their hands of their patients after 6.30pm and at weekends. The relief at shedding this burden may be partly reflected in the general disgust at the disgraceful behaviour of the government in strong-arming them back again to longer hours. It was certainly a painful commitment for GPs that seriously eroded morale and ultimately, the workforce over a period of years. However, it was also a towering moral responsibility and its loss will damage primary care over the next generation. David Haslam has elegantly summarised the brilliance of primary care here. (with thanks to Dr Rant and The Jobbing Doctor)

This guvnor mechanism has gone and that now means that there is nothing to stop practices from shrinking their partnerships. Some larger practices now look increasingly like private enterprises. Partners can employ nurses to do their chronic disease management and salaried GPs to see more complex patients leaving themselves free to concentrate on more 'worthy' areas (usually QOF targets).

I recognise that many practices are more enlightened and realise the holistic benefits of having partners with a full commitment to their practice. However, can there may be many practices out there that haven't given consideration to the option of replacing a partner with some kind of employee?

One problem is that some GPs will pick and mix their arguments here. They will unscrupulously use the argument of 'we are exempt from usual business models because we deliver patient care'. However, when it suits them I have seen them deploy the defence 'we are running a business' if they don't fancy the particular suggestion of the Primary Care Trust, patient, Department of Health etc.

David Jewell wrote in an editorial in the British Journal of General Practice in Jan 08:

Already a significant number of practices are being run by commercial enterprise employing GPs, and this trend looks set to expand. If a large part of the work is going to be done by salaried doctors, the arguments in favour of practices run by principals are weaker. For a salaried doctor, as for patients, it will make little difference if the practice is being run by a commercial company or by a partnership. The profession needs to consider whether the model that has been unchallenged until very recently is worth retaining. Perhaps the so-called independent contractor status has had its day.

He also added:

In England...a highly-centralised government agency and a salaried profession could turn out to be a toxic and damaging combination....The Department of Health should welcome robust debate about the best way of providing high quality health care for the population, rather than appearing, as it has done of late, to listen only to its chosen confidants while dismissing outsiders as speaking only for their own vested interests. As a profession we need to retain an independent voice. How we are paid may not matter, but it is vital that we do not collude in silencing ourselves.

And as Dr Haslam has pointed out it is vital we have a top notch primary care system. Personally, I don't want to be one of the ones colluding and not admitting there is an issue here.

No water, no toilet, no health.

I have to confess to a fantasy of being employed by the World Health Organisation (WHO). I dream of driving into the crisp air of Geneva in my open top sports car from my lofty alpine lodge each morning. I would save countless thousands of lives with elegant public health initiatives by day, sip fine wine by a log fire in the evening and ski stylishly in fine knitwear at weekends.

I expect the reality is more humdrum. But a GP can dream.

While I wait for the call I am prone to wandering the WHOs site. Water and poo are high on the list of priorities this month. The numbers are, as ever, mind-boggling. Apparently a mere 18%, 1.2 billion, of the world's population practice 'open defecation'. I presume this is WHO speak for crapping anywhere, or at least, not in a piece of the finest Armitage Shanks branded porcelain.

I also realise that if anyone else out there wants to save countless thousands then I suggest we need to re-train as engineers and stop fiddling about with our mildly raised blood pressures and modestly elevated cholesterols.

Modern medicine vs old fashioned GP

What would you rather have? High faluting investigations or a GP who knows you, your family and your community?

I won't launch into a polyclinic rant but I will highlight a recent incident that does make one wonder about the consistency of care across practices. Recently, I did a locum at a little semi-rural practice. I saw a middle aged chap and he explained his trouble. He tootles off up the hill from his house to get a paper and gets some pain squeezing him across his chest. He stops, it stops. A pretty decent story for angina. In other words, one or more of his coronary arteries might be getting a bit furry.

No problem. Let's do some basic tests, says I. I took the bloods myself (it is a small practice and no nurse or other staff). Next stop - let's get an ECG (electrocardiogram). I asked the receptionist to direct me to the machine. It has been a little while since I did an ECG myself but I was a junior doctor when the only other people working on the ward were nurses and I would have been castrated for asking them to do this job for me.

I was duly informed that the only way to get an ECG was to send a referral form in the post to the local hospital. The patient would then make a 40 minute trip to the hospital for a 2 minute test. I think I gasped out loud.

I am so used to ECGs being a routine part of general practice care that it hadn't occurred to me that a practice may not have one. (You can buy one here for a shade under £1500 and given the alarming mark up that medical equipment generally achieves that is a give away price).

I have no doubt this practice is loved by its patients. They get a personalised intimate service from a GP with a real sense of community. Not much sense of medicine in the 21st century though. Still, that might not be a bad thing thing either.

Howdo

Welcome to the blog. I am a GP working across several areas of primary care. Amongst other things, I have spent time as a salaried GP, as a locum, as an educator/appraiser and I have even worked in Primary Care Trusts for the dark side (management).
In common with most of the other GP bloggers out there I fundamentally appreciate having the opportunity to see patients. I totally believe in the importance of primary care in the NHS. That said, I am not a partner/principal in a practice and my perspective reflects this position.

Disclaimer

**UPDATE** 30th August 2008

My view
The views expressed in this blog represent my own opinions and not those of my employers or any of the organisations I have worked for as an independent practitioner.

Patient confidentiality
This is an area of concern for medical bloggers and an area of potential controversy in which I have no particular desire to push the boundaries. The moral and ethical arguments of free speech versus the patient’s right to confidentiality looks like a clash of prima facie ethical considerations. These are never usually pretty.

There is no doubt that patient contact is a fundamental prerequisite of a clinician’s perspective and I hope my blog reflects that. I read and enjoy a number of blogs that use patient contacts as a potent catalyst for discussion of medical issues. I feel that they make a valuable contribution to the many and varied debates surrounding healthcare and they should be nurtured where possible. Many authors reassure that those blogs take specific measures to protect the identity of their patients. I do not plan to blog about patients without obtaining their consent.

Conflicts of interest
I have no other conflicts of interest that I am currently aware of as potential issues.

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