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Tag Archives: General Practise

The history and the changing scenes of General Practise

Patients must be at the heart of everything we do- no decision about us ,without us

imageUnder the NHS Constitution, you have
“the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this.”

There are times when you need to make decisions about your health. This could be about which treatment is best for you, or whether you should have a screening test.
To address this patient decision aids (PDAs) have been developed to help support difficult decisions in which patients need to consider benefits versus risks.

Decision aids prepare patients for decision-making by increasing their knowledge about expected outcomes and personal values. The PDAs are not meant to be a substitute for discussion with a skilled Doctor or nurse but will supply up to date evidence to help a patient and healthcare professional come to a decision about the best way forward. It is hoped that their use in such discussions will result in better informed, patient-focused decision-making.

A patients idea of what is in their best interest may be quite different from what a health professional perceives as the best decision. The decision may be influenced by many factors such as previous experience, influence of the media or culture. However, it is important that the health professional during a consultation has up to date information concerning options and can provide. Realistic expectations.

Many patients are now more informed and are able to carry out their own research and in some instances this can form a useful platform of discussion.
I am frequently challenged about treatment following articles written in the ‘Daily Mail’ so much so that I always tell new students much to their surprise that at least 5 mins of their study time each day should be studying the health section in the Daily Mail! Also patients attend with print-outs or other references from the Internet.
steps of PDA use in consultations
1. Describe the clinical condition(e.g.atrialfibrillation)
2. Describe the treatment options (e.g. no treatment, aspirin, or warfarin) and outline the dilemma (all have risks and benefits, and different patients view the risks differently)
3. Offer a further, more detailed discussion. Some patients are content with the healthcare professional deciding, some prefer a joint decision, others wish the healthcare professional to provide the information but wish to make the decision themselves
4. Work through the PDA, explaining the images and adjusting for baseline risk if required
5. Allow the patient time to consider what they wish to do. They may wish to take away a copy of the PDA and discuss it with family or friends

Use of PDA’s is now recognised nationally and NICE recommended that people should be offered information about their absolute risk of cardiovascular disease and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that:
• presents individualised risk and benefit scenarios
• presents the absolute risk of events numerically
• uses appropriate diagrams and text

NHS Health Checks in Ealing, North-West London
The NHS Health Checks programme was delivered locally by Primary Care Trusts (PCTs) in England.(now replaced by Clinical Commissioning Group(CCG)
The Department of Health requires that all adults aged 40–74 years are invited for cardiovascular risk assessment by 2013.
Ealing has a relatively socio-economically deprived population of 375 000, with a high proportion of residents from ethnic minorities. The local Health Checks programme is delivered by practice nurses and health-care assistants in general practice. Disease-free individuals estimated to be at, or greater than, a 20% 10-year risk of a CVD event were targeted in the first year of the programme (1 September 2008 to 31 August 2009); the method of risk estimation is detailed subsequently.

The PCT provided each general practice with a list of patients to be invited in year one, and the practice then contacted patients by a letter inviting them to attend a Health Check. Each practice was responsible for completing a full Health Check, including appropriate laboratory tests and reminding non-attendees. The local programme started before the national roll out of NHS Health Checks in April 2009. Ealing went beyond the Department of Health requirements by including patients with diagnosed hypertension and those prescribed statins and commenced screening at the age of 35 years, due to the high burden and earlier onset of CVD and diabetes in the area. CVD risk estimates were based on the informationrecorded in the GP information system in the past 5 years.
The screening process has become increasingly sophisticated and those participating will be aware of the process and how other illnesses are taken into account, family history aswell as measurements of blood pressure,cholesterol,blood sugar, weight height and BMI. Exercise as mentioned in a previous blog is calculated by the GPPAQ (http://www.patient.co.uk/doctor/general-practice-physical-activity-questionnaire-gppaq) to determine if a patient is inactive or to what degree they are active and with all this information the cardiovascular risk (the risk of heart attack in the next 10years) is calculated. If a significant risk is identified the patient is seen by the doctor who will discuss treatment options discussing the reasons for treatment and evidence why it should be implemented and allowing the patient to reflect on this referring to a PDA.
imageThe risk is explained in this case using a Cates plot which is the use of 4 face categories to visually indicate the following:

People not affected by a treatment (green faces for those with a good outcome and red for those with a bad outcome)
People for which treatment changes their category from a bad outcome to a good outcome (yellow faces)
People for which treatment causes an adverse event and changes their category from a good outcome to bad outcome (crossed out green faces)
It is important to avoid framing the information, resulting in an unbalanced picture of either benefits or harms. As an example, consider the PDA for use of statins to reduce the risk of cardiovascular (CV) events in patients with a 20% 10-year risk of CV events. The Cates Plot looks like this
image
http://www.npc.nhs.uk/evidence/eidm4_shared/resources/how_to_use_pdas.pdf
We could say only ‘Over the next 10 years 80 people will not develop heart disease or have a stroke’, or we could say only ‘Over the next 10 years 20 people will develop heart disease or have a stroke’. The first phrase could create greater reassurance, and the second greater concern. Best practice recommends presenting the data in both ways. We also need to use words which convey that there is an irreducible uncertainty; it is impossible to know what will happen to any individual person and say whether he or she will benefit from the treatment or not.
These people will not have a CV event, whether or not they take a statin- green
These people will be saved from having a CV event because they take a statin- yellow
These people will have a CV event, whether or not they take a statin – red

When a CVD check is carried out you will be shown the Cates plot relevant to you.
This can be used in many situations where treatment is discussed with the patient so that they can make an informed decision.
More about this concept can be seen on http://www.nntonline.net/

An expanding directory is being made to cover a wide range of conditions for use by health professionals.
The same idea has been used by a well used website
http://www.patient.co.uk/brief-decision-aids and deals with more everyday problems

Smoking cessation. Tennis elbow. Carpal tunnel syndrome
Leg cramps. Enlarged prostate. Contraceptive choices.
Menorrhagia (heavy periods). Plantar fasciitis. Warts and verruca
Irritable bowel syndrome

They help people think about the choices they face in the testing, treatment or management of their condition. They describe where and why choice exists and provide information about the options available to them.

Typically a decision aid will provide, for each option, information on potential outcomes, benefits and risks, and the frequency and likelihood of these.

As many treatments relate to
Types of decision support:
There are two main types of decision support: extensive tools, which patients can access before and after seeing a healthcare professional; and shorter tools, which are used within the actual consultation.

Extensive decision support tools
These tools were the first and are the most common type of decision aid. As such, they have also undergone the most research.
They include:

patient information leaflets and booklets
DVDs and audio tapes
interactive media and
web based tools.

Brief in-consultation decision aids
Although these are relatively new, healthcare teams have found these brief tools to be extremely valuable in implementing shared decision making in clinical practice.

The clinical teams at Cardiff have focused on developing and testing Option Grids.
An Option Grid is designed for sharing with patients during consultation. It enables the patient to compare the various options available in relation to the factors that are important to them personally. The grid helps do this by providing side-by-side answers to the questions that patients frequently ask when they face important decisions.

All these have been developed during the past few years in a concerted attempt to keep patients at the heart of everything we do. In my experience involving patients in decision making improves compliance aswell as outcome of treatment. When I stated in Medicine the patient was totally at the mercy of the health professional making the decision thankfully this has changed.

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Work Experience

imageOne of the aspects of being a doctor that I have enjoyed during my career has been the opportunity to teach medical students and be supportive of younger doctors. I have also enjoyed having students from our local schools to work with us in the surgery helping with admin and office work as a work experience.The first student who came 14 years ago when most GP’s were cautious about allowing school students to be in the surgery. She was a friend of my daughters and I had known her for several years as she had come back after school for tea and been on sleepovers! I said she could come to the surgery but warned her that it was totally confidential and she must not tell anyone who,what she had seen when she came. She seemed thrilled at the idea that she could even tell her parents not to ask questions and her mothers feedback was that after 2 weeks she felt her had suddenly ‘grown up’ and she herself was determined to become a doctor despite doing my best to tell her all the disadvantages. Indeed, she went to UCL medical school and during her studies returned on several occasions to work in the surgery including being our first phlebotomist. She qualified and is now a senior registrar in medicine and next weekend she has asked me to attend her wedding as she feels that the experience at the surgery 14 years ago set her path for the future and her invitation is a way of saying ‘thank you’ so I shall look forward to this with great pleasure.
Since then each year we have had various students and several have gone on to medical school or found it a useful experience.
imageOur present work experience student is also hoping to study medicine and I have been impressed with her enthusiasm to see all aspects of the practise and ask plenty of questions to discover what goes on behind the scenes. She is a student from the Alec Reed Academy Year 10  and she wrote this statement for our blog:-
I was warmly welcomed into the surgery by all members of staff on Monday 15th July when I started my work experience at the Avenue Surgery. During the work experience I learnt a lot just by being in reception . With the help of the receptionists: Tega,Liz,Paramjit,Madhu,Debbie and Margaret have managed to understand that the reception work is a lot more than I thought. I witnessed their hard work in talking to patients, booking appointments, talking to the patients on the phone, making up new files,faxing papers and doing photocopying. To be honest, despite the sta ff having a lot to do each day everyone managed to answer all the queries I had and showed me around the surgery. They spared some time and showed me how to do certain jobs. Therefore,I would like to thank all the staff members at the reception for helping me out.

Not only that,nurse Mary had also managed to give me some time and explained her role at the surgery. She gave me an insight to all the different roles she had inside this surgery. She shared all her past experiences with me and told me a bit about herself aswell. This helped me as it gave me all the information that I might have not found on the computer or on google regarding what Nurse Mary does at The Avenue Surgery.

On top that Dr Bayer spent time discussing medicine with me. She told me about political issues associated with medicine. She taught me how the system of medicine works and the way a GP works. She also taught me how become a specialist doctor and how to become a GP. She took a small interview with me and gave me detailed responses on how to react to questions that I might be asked in future interviews.

Lastly , Sangeeta (the practise manager) had helped me a lot because she gave her approval and allowed me to work in the surgery. She allowed me to attend the Practise meeting. She completed the forms given by my school on time and provided me with an amazing team to work with.

I would like to thank all the members of staff who have helped me throughout my work experience and given me some of the amazing facts and information into work experience.
Thank you all
SP

SP is going off next week to India to work in a clinic as a volunteer and hopefully report back to us. We wish her well.
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Patient’s role in NHS England

As we all read the papers or listen to the news it is now blatantly obvious the NHS on its 65th birthday is in serious trouble.
The NHS is “about to run out of cash” – and faces a £30 billion funding gap by 2020, senior health service officials have warned.
It is down to NHS England to advise sweeping changes – a call to action……

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Formally established as the NHS Commissioning Board on 1 October 2012, NHS England is an independent body at arm’s length to the Government.
NHS England   will play a key role in the Government’s vision to modernise the health service with the key aim of securing the best possible health outcomes for patients by prioritising them in every decision it makes.
The main aim of NHS England is to improve the health outcomes for people in England.
    • We believe the new approach we are taking will really make a difference and deliver the improved health outcomes we all want to see.

      The new health and care system becomes fully operational from 1 April to deliver the ambitions set out in the Health and Social Care Act. NHS England, Public Health England, the NHS Trust Development Authority and Health Education England will take on their full range of responsibilities.

    • Locally, clinical commissioning groups – made up of doctors, nurses and other professionals – will buy services for patients, while local councils formally take on their new roles in promoting public health. Health and wellbeing boards will bring together local organisations to work in partnership and Healthwatch will provide a powerful voice for patients and local communities.
    • Central to our ambition is to place the patients and the public at the heart of everything we do. We are what we want the NHS to be – open, evidence-based and inclusive, to be transparent about the decisions we make, the way we operate and the impact we have
    • We encourage patient and public participation in the NHS, treat them respectfully and put their interests first. This allows us to develop the insight to help us improve outcomes and guarantee no community is left behind or disadvantage
    • We empower and support clinical leaders at every level of the NHS through clinical commissioning groups (CCGs), networks and senates, in NHS England itself and in providers, helping them to make genuinely informed decisions, spend the taxpayers’ money wisely and provide high quality services.
    • Engaging with our staff is equally important to us too. Our staff is what makes the NHS England an excellent organisation: an exemplar in customer focus, professionalism, rigour and creativity
    • Grounded by the values and principles of the NHS Constitution, we are an organisation who shares ideas and knowledge, successes and failures, and listens to each other carefully and thoughtfully.
    • At NHS England, we practice what we preach. By working collaboratively and building coalitions with partners everywhere means we can achieve greater things together and deliver the best patient service not only in England but in the world.

      *****************************************************************************

      At the same time this potential crisis reaches the headlines we as GP’s are asked to choose whether to liaise with the Patient Reference Group(PRG) to get ideas of how we can improve our services by increasing efficiency and cost effective commissioning. We as a practise have opted to participate in this Direct Enhanced Service (DES) and work with the PRG.

      Patient Reference Group
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      The purpose of the patient participation DES is to ensure that patients are involved in decisions about the range and quality of services provided and over time, commissioned by their practice. It aims to encourage and reward practices for routinely asking and acting on the views of their patients. This includes the patients being involved in decisions that lead to changes to the services their practice provides or commissions, either directly or in its capacity as gatekeeper to other services.It aims to promote the proactive engagement of patients through the use of effective Patient Reference Groups (PRGs) and to seek views from practice patients through the use of a local practice survey. The outcomes of the engagement and the views of patients are to be published on the practice’s website.

      Suggestions of aspects which may be discussed – NHS England
      One aspect that practices may wish to focus on is ensuring convenient access to the practice and also from the practice to other services in its role as coordinator of care, facilitating access to other health and social care providers.
      Access has many dimensions; the relative importance of these will vary according to the specific needs of the registered population. These dimensions include:
       lists being open to all
       hours of opening with the ability to be seen urgently when clinically necessary, as well as
      the ability to book ahead
       continuity of care
       range of skills available – access to different professionals
       a choice of modes of contact which currently includes face-to-face, telephone and electronic contact, but can be developed further as technology allows
       geographical access, enabling care as close to home as possible.
      Access must be flexible enough to meet the varying needs of individualsand requires sufficient capacity to meet the population’s needs. Details of access arrangements (including opening hours) should be made widely available to the patient population to enable patients to exercise choice.

      Patient Reference Group (PRG) may be an existing formal patient participation group or a similar group that is representative of the practice population, which would feed in its views alongside the findings from the surveys and agree with the practice priority areas for possible change. This would result in an action plan to be agreed between the practice and the PRG.
      Practices taking part in this DES will also carry out a properly constituted survey of a sample of the practice’s patients looking at a broad range of areas which could include convenience of access (opening times, ability to book ahead, ability to be seen quickly, telephone answering), patients’ experience of the treatment and service they receive, the physical environment in the practice and other issues specific to individual practices.
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      As I am sure some of you are aware we have already participated in having meetings with a cross section of patients during the past few years to discuss results of patients surveys addressing issues such as access to doctors, telephone access, car parking,email prescription requests, children in surgery and more recently patient education and we have attempted to improve our service and act on points raised in the survey. The minutes of these meetings are published on our website. This was formerly called the Patient Participation Group but will know be known as the Patient Reference Group.
      We have tried to make our meetings representative of the patient population but along with our GP colleagues we have found the numbers participating are small and some types of patients are not represented. Nevertheless, we are persevering to reach our patients by our website,written newsletters and survey sheets distributed over a period of time to a wide cross section of patients.

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      We will be announcing a PRG meeting in the next few weeks and conducting a survey with patients attending the surgery and strongly encourage as many people as possible to participate. Although it is good to hear favourable comments on things we are doing well it would be extremely useful and perhaps more so if we could have constructive criticism of things we are NOT doing well,and even better if we can have ideas of how we can provide a better service.
      When we obtain the results of the survey we will hold a further meeting to discuss the findings and hopefully come to an agreement as to how we can implement plans for changes to the services provided.
      If you have suggestions please contact the practise Manager,Sangeeta Kathuria by email(sangeeta.kathuria@nhs.net), appointment or by letter.
      We need everyone to pull together to keep our NHS continuing to provide a service to all who need it.
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We have registered with the CQC – We are now await an inspection

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Now we are one of the registered practises and we are awaiting inspection. As you may be aware most of the questions will be directed towards patients and staff to establish what they think of the service provided.
Many of us are aware there have been problems with the CQC in their reporting of problems in various hospitals. This is the first year that they have looked at Primary care services and GP’s.This is rather strange for older GP’s as for the most part have always thought of their practise territory as a private domain.Inspections only started in 2005 in a structured manner and they were carried out internally. Independent inspections are probably long overdue particularly for some seriously underachieving practises.We sincerely hope that there will be some constructive criticism but also trust that what we do well will be recognised.
As there were some patients who want to know what is happening I felt it was important to keep you up to date and there may be someone out there who will be asked at 48hrs notice to come along to talk with the inspectors.
Meanwhile,
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The outcomes that will be looked at are as below
Outcome 1: Respecting and involving people who use services
People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run.
Outcome 2: Consent to care and treatment
Before people are given any examination, care, treatment or support, they should be asked if they agree to it.
Outcome 4: Care and welfare of people who use services
People should get safe and appropriate care that meets their needs and supports their rights.
(Outcome 5: Meeting nutritional needs
Food and drink should meet people’s individual dietary needs.)
Outcome 6: Cooperating with other providers
People should get safe and coordinated care when they move between different services.
Outcome 7: Safeguarding people who use services from abuse
People should be protected from abuse and staff should respect their human rights.
Outcome 8: Cleanliness and infection control
People should be cared for in a clean environment and protected from the risk of infection.
Outcome 9: Management of medicines
People should be given the medicines they need when they need them, and in a safe way.
Outcome 10: Safety and suitability of premises
People should be cared for in safe and accessible surroundings that support their health and welfare.
Outcome 11: Safety, availability and suitability of equipment
People should be safe from harm from unsafe or unsuitable equipment.
Outcome 12: Requirements relating to workers
People should be cared for by staff who are properly qualified and able to do their job.
Outcome 13: Staffing
There should be enough members of staff to keep people safe and meet their health and welfare needs.
Outcome 14: Supporting workers
Staff should be properly trained and supervised, and have the chance to develop and improve their skills.
Outcome 16: Assessing and monitoring the quality of service provision
The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care.
Outcome 17: Complaints
People should have their complaints listened to and acted on properly.
Outcome 21: Records
People’s personal records, including medical records, should be accurate and kept safe and confidential.
Outcome 3: Fees
People who pay for a service should know how much they have to pay, when and how to pay it, and what they will get for the amount paid.
Outcome 15: Statement of purpose
People know that CQC is kept informed of the services being provided.
Outcome 18: Notification of death of a person who uses services
People can be confident that deaths of people who use services are reported to CQC so that, if necessary, action can be taken.
Outcome 19: Notification of death or unauthorised absence of a person who is detained or liable to be detained under the Mental Health Act 1983
People who are detained under the Mental Health Act can be confident that important events that affect their health, welfare and safety are reported to CQC so that, if necessary, action can be taken.
Outcome 20: Notification of other incidents
People who use services can be confident that important events that affect their health, welfare and safety are reported to CQC so that, if necessary, action can be taken.
Outcome 22: Requirements where the service provider is an individual or partnership
People have their needs met because services are provided by people who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
Outcome 23: Requirement where the service provider is a body other than a partnership
People have their needs met because services are managed by people who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
Outcome 24: Requirements relating to registered managers
People have their needs met because services have registered managers who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
Outcome 25: Registered person: training
People have their needs met because services are led by a competent person who undertakes the appropriate training.
Outcome 26: Financial position
People can be confident that the provider has the financial resources needed to provide safe and appropriate services.
Outcome 27: Notifications – notice of absence
People can be confident that, if the person in charge of the service is away, it will continue to be properly managed.
Outcome 28: Notifications – notice of changes
People can be confident that, if there are changes to the service, its quality and safety will not be affected.

Sangeeta Kathuria,our practise manager is working very hard to look at these outcomes in order to be as compliant as possible. Some of them may not be easily achievable but I have every confidence that under her direction we will be very near the mark.

Watch a video of Professor David Haslam explaining how they will check that we meet the essential standards. Please note: Prof Haslam is no longer our national advisor but has taken up a role as Chair of NICE.

Posted by Dr Bayer

 
 

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Whats happening to our NHS?

Recently I took some second year medical students to see one on our oldest patients in a local nursing home. I had rather taken to her as she comes from the same part of the country Lincolnshire as my grandmother did and responded with a wry smile when I referred to her as a “Lincolnshire Yeller belly ” She also had that typical manner just like my grandmother that she was only going to tell you what she wanted but don’t ask too many questions!

*(referring to those from Lincolnshire and recognising the proud tradition of early 20th century soldiers of the Lincolnshire Regiment who wore yellow tunics at they inning of the 20th century)

She had a classical history of heart failure -a medical students dream but I wanted them to see her as a person and for her to tell them something about herself. She was delighted to tell them how she had been a kitchen maid since her early teens in the ‘big house’ owned by the dentist, but then wanted to leave and the only way out was to marry the footman ; the mistress of the house then told her to leave as she were surely be pregnant in no time!Oh said one of the students does this mean that ‘Downton Abbey was based on real life!”

Indeed she soon became pregnant and she knew that that when the time came she would be taken to the ‘workhouse’ to deliver and then have to stay on to scrub floors or do other tasks to pay for her stay. The pregnancy was not going well and she was developing late complications but mysteriously she found that she was being taken to a private hospital and safely delivered and to this day does not know who paid. As my grandmother would have said if anyone had asked ‘never you mind’

She then went on to describe the horrors of the workhouse and the huge inequality of health care and then the absolute joy when on July 5th 1948 health secretary Aneurin Bevan opened Park Hospital in Manchester, as the launch of a hugely ambitious plan to bring good healthcare to all. For the first time, hospitals, doctors, nurses, pharmacists, opticians and dentists were to be brought together under one umbrella organisation to provide services that would be free for all at the point of delivery.

The central principles were clear: the health service would be available to all and financed entirely from taxation, which meant that people would pay into it according to their means.

THE NHS WAS BORN

Much of the story of the NHS is about the interaction of the three main parties involved: those needing care, those who deliver skilled care and those whose task it is to raise the money and see it properly spent. The peculiarly difficult triangular relationship between these interested parties has to be satisfactory if the health service is to function to the benefit of society. The story goes on if you want read more a fascinating account turn to http://www.nhshistory.net/

I embarked on a medical career embracing this vision and trained in Cardiff and South Wales to be proud of a health service which offered this totally unprejudiced care. I worked with men who carved coal out of the bowels of the earth where machinery could not go and as part of my training was taken to the coal face to admire the sparkling diamond-like anthracite coal which man could only gets to on his belly. It took days for me to get clean !! I went the steel works and sweated profusely as I stood for minutes by the blast furnaces watching men that would be there for hours upon end and watch the glistening liquid steel pour out. It was only by seeing this could I fully appreciate the conditions these men worked but how we laughed as they told their tales and still tears come to my eyes when I hear the soulful singing of the Male Voice Choir sing with hywl and watching ‘the boys’ playing rugby with such devotion. Everything stopped, life was on hold literally only contacting the doctor, even with a heart attack when the match had finished. Where I worked Spina bifida had the highest incidence in the World, cystic fibrosis was not uncommon and of course the lung disease from working underground was rife along with cardiovascular disease.

It is not surprising it took a Welshman to fight for the a National Health Service and I have to say private medicine barely existed at that time. The miners built the hospital with a Maternity ward. The nurses were natural nurses: they were brought up to nurse as the majority of families housed at least one sick member.
What a valuable experience to work in this setting and why I feel so passionate about a national health for all and why it grieves me to see it being abused by ‘those same three parties which we always knew had a relationship which would be ‘a peculiarly difficult triangular relationship.

Those needing the care would gradually take less and less responsibility for their own health and their family’s health. So that when George Bernard Shaw wrote in his preface of ‘The Doctor’s Dilemma’ 100 years ago when he despaired of the private health care it is ironic that the same despair for different reasons but also aimed at doctors should apply today after 65years of a National Health Service
“If you cannot have what you believe in,you must believe in what you have. When your child is ill or your wife dying,” when you are confronted by “the spectacle of a fellow creature in pain or peril, what you want is comfort, reassurance, something to clutch at, were it but a straw. This the doctor brings you. You have a wildly urgent feeling that something must be done; and the doctor does something. Sometimes what he does kills the patient.” The philosophy of the placebo effect.

Last Bank holiday weekend a gentleman brought his child to the out of hours clinic in the evening with a non complicated chickenpox. He wanted me to admit the child as he didn’t want anyone else to catch the disease especially as the extended family with their children had arrived from Leicester and were staying for the weekend. When I tried to explain that this was not necessary as the condition was not serious and it would be totally inappropriate as there are children in hospital seriously ill (perhaps leukemia ) and contact with them could be be seriously detrimental and even cause death to which he retorted ” couldn’t you put her in a side room? ‘ he persisted trying to make me give in but I stood my ground and as he left very annoyed as I had wasted his evening and it had cost him a lot in petrol. When I shared this with my colleagues they proceeded to relate similar stories. Constantly, we see streams of minor medical or social problems which we deal with patiently day after day and then try not to get caught out when the ‘real patient’ arrives. To make matters worse our reputation of unconditional healthcare has spread throughout the world and people use it as a stop off place to get free medical care and don’t appreciate the boundaries.

Nevertheless, many patients use the service with respect and maintain a good working relationship with health professionals and benefit greatly from all the amazing advances in medicine and the service provided. But sadly this does not make news.

Those skilled workers, doctors,nurses and other health care workers as part of this service dedicated their lives to providing health care to all. nursing sisters slept in a room on the ward, ruled their ward with pride and a rod of iron. when I was first qualified if I entered a ward I would have report to the sister who would then look me up and down to see if I was suitably dressed and my white coat was clean before allowing me near a patient. At the same time there was a mutual respect and the sisters and nurses shared their wealth of knowledge and knew the patients well and guided many doctors through those terrifying months of being a newly qualified doctor and rescuing them when they were unsure and had to be answerable to the consultant. Ask Mary our practice nurse, she will tell of the many junior doctors she has had to offer guidance and sometimes with great authority and they have obviously benefited as some now hold reputable positions as specialist consultants. But now there is a more liberal approach and there is more antagonism. We have all become preoccupied with status,targets, cost effectiveness, evidence based medicine and losing sight of the fact we are dealing with individual characters who have lives and stories to tell and how the same illness can effect different people in different ways.
However, when I talk to doctors in all sorts of situations albeit in hospital, A&E , in practice or in between lectures I am always reassured that for the most part they are ‘nice’ people wanting to provide and care for their patients in the best possible way and this keeps me reassured that for the most part values have not changed.also our medical schools are working hard to reinforce these ideals. But these health professionals are also people and deserve to have a family life and enjoy other aspects of life and I would not advocate bringing back those obscene long hours. Indeed, the modern doctor had taught me a lot about looking beyond the consultation room and I feel it keeps me much more in touch with my patients.

Those whose task it is to raise money and see it wisely spent have used health as a commodity to be bargained with and failed to take into account the services that cannot be measured the hours doctors pass dealing with patients mental health a rising malady which is predicted to be the major cause of illness in the next 5-10 years. Unlike blood pressure it can’t be measured or monitored in the same way and when I hear a mere suggestion that patients are to be limited how many consultations they can have each year my hackles bristle at the thought. I used to dread seeing a patient who was depressed and hopeless I instantly adopted the same feeling and then after more experience of life and all that it throws at you I began to feel more confident to support and guide people through a crisis. Moreover, following the advent of safer medication with faster action and less side effects I began to see patients emerge from that black hole and restore their lives which in turn encouraged me to recognise mental illness management as a important part of the treating patients.
However, when I see how our local musculoskeletal service run by GP’s and physiotherapists has grown from strength to strength and now provides an excellent exemplary service which is totally due to doctors working in partnership with patients and managers. By working together to effectively manage the service, using local resources, spending wisely it can work and the patients undoubtedly benefit.

If only those patients who work so positively with us in partnership and those caring doctors maintain their dedication and good care and the managers can spend wisely and manage effectively we could reconnect using that peculiarly difficult triangle to restore a NHS for the 21st century.
George Bernard Shaw 100 years ago lambasted the medical profession when he wrote in the preface of his play ‘The Doctors Dilemma’ “Until this body of men and women were trained and paid by the country to keep the country in health it will remain what it is at present: a conspiracy to exploit popular credulity and human suffering”.
After reading many statements from Jeremy Hunt accusing doctors particularly GP ‘s of causing the chaos in A&E and reading the Editorial of this months BMJ “Let the patient revolution begin” I felt I wanted to write a blog reflecting on my experience of working in the NHS for > 40 years.
The article refers to George Bernard Shaw in his claim of the medical profession having a conspiratory against the laity likening it today where disease and doctor centric health systems that are costly, wasteful, fragmented, and too often uncaring are provoking similar ire.
It goes on to say
“Clinicians and patients need to work in partnership if we are to improve healthcare and challenge deeply ingrained practices and behaviours. Doing this won’t be easy for either side after eons of paternalism, and many patients will prefer to maintain the status quo.”
Although I think we need to maintain the original principles we need to exercise it to be relevant today.
Many members of the population need to be educated into knowing how to cope with everyday health problems and how to improve their lifestyle to prevent illness. This was voiced by our patient participation group but again they favoured electronic information as well talks by clinicians. Many patients want to know more about their illnesses and take an active role in making a choice about treatment. No longer can we dictate how to treat a patient but we need to work together .many years ago I remember prescribing antidepressants which took 3 weeks to work when the patient returned after 10 days feeling no better I (and many other doctors did the same) would say which end of the capsule did you put in your moth first and the tell the patient to turn it around and come back in 10 days. ( it makes me shudder as I write this) In the article they quoted American examples of progress but I think we are making changes in our practice which are more relevant today such as the MSK clinics which are GP led and allow patients be seen much quicker than hospital and treated or only referred to specialist consultants. This has saved considerable amounts of money, expanded and most of all has had huge patient satisfaction. During the last year several Integrated care groups have been set up whereby the GP has an extended consultation with a patient with complicated medical/social problems and often are frequent attenders at A&E or outpatients. Together the GP identifies patient goals and clinician goals and both work together to achieve these and review after a set time. If some of the problems are proving difficult to address the case is taken incognito to a Multidisciplinary meeting which consists of specialist consultants, mental health and social service professionals and any other appropriate professionals and representatives of a group of practices. These meetings are held every month and during the last year. We have been discussing patients >75years and diabetics. During these meeting we have shared our problems of management, poor control of symptoms and control of diseases as well as identifying educational needs for all those attending. Lessons learnt in these meetings can also be used in similar cases.
Believe or not getting social services, hospital staff including psychiatrists and GP’s around the same table has been revolutionary.
We now need to educate our patient population. Medical students I teach in their 4th year have to do a project looking at health promotion. The students have looked at smoking cessation, healthy eating in schools, exercise in the elderly an even how providing socks for the homeless and how this can prevent cellulitis of the legs. We are holding more public health meetings and Sarah Jarvis not only appears on the radio but is up to date with her blogs on current medical concerns http://www.patient.co.uk/blogs/sarah-says
This website is a mine of information and also has an App I do recommend it if you haven’t found it already. There is a plethora of websites and Apps but it is important to keep to recommended sites which I attempting to do on these blogs. We have a long way to go but positive things are happening. I remain cautiously optimistic I trust this caution will get lessen as in time this peculiarly difficult triangle work together.
Watch out for more blogs on this subject!

The article referred in The BMJ
Editorials: Let the patient revolution begin
http://dx.doi.org/10.1136/bmj.f2614

The article referred in The BMJ
Editorials: Let the patient revolution begin
http://dx.doi.org/10.1136/bmj.f2614

Written by Dr Jacqueline Bayer

 
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Posted by on June 3, 2013 in Anecdotes...little stories, Current affairs

 

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