RSS

Tag Archives: GP

Blogs concerning the work of a General practitioner (doctor) and the changes which are taking place at the present time with references to the history of General Practise.

Are you or do you know someone who is finding it difficult to get to the GP surgery?

image

Healthwatch Ealing is the new independent consumer champion created to gather and represent the views of the public In Ealing. Healthwatch will play a role at national, regional and local level and will make sure that the views of the public and people who use services are taken into account.

Address: Healthwatch Ealing, Lido Centre 63 Mattock Lane West Ealing
London W13 9LA United Kingdom

Web: http://www.healthwatchealing.co.uk

There are many elderly or disabled people who find it difficult to get to their GP’s surgery for routine visits as there is no public transport, taxis are expensive and they don’t have friends or family available to take them. By attending the surgery they can see the GP who will have easy access to their medical records, be able to see other health care professionals as well as the fact that appropriate examinations  are often much easier to perform and a chaperone is usually available. For some this may be a welcome social outing!

To address this the Ealing Clinical Commissioning Group are providing the  ECT with funding for the following pilot project.

PlusBus for Health

What is PlusBus for Health and can I use it?

PlusBus for Health is a new trial service offered by ECT to transport people to and from GP surgeries. The service aims to reduce the number of GP house calls and no-shows at surgeries, and simultaneously improve the well-being of patients by providing the opportunity to leave their homes and increase social contact.

The service is not currently available to everyone. GP surgeries are referring people who are eligible to ECT.

This is a shared service which will run to provide FREE transport for as many people as possible.

To find out more, please speak to your GP to see if they are taking part in the trial, or alternatively call 020 8813 3214 or email plusbushealth@ectcharity.co.uk.

NB we are participating in this trial

Advertisements
 
Leave a comment

Posted by on February 22, 2015 in Training and Advice

 

Tags: , , , , , ,

ARE WE IMPROVING WHOLE PATIENT CARE?

Visiting doctorAs a GP for many years if I visited an elderly person on a Friday or after 3.30pm in the afternoon and although their illnesses could be treated in the home if they were living alone I would often have to admit them into hospital.
Social services would often need 48hrs notice or more to implement social care in the way of carers or meals on wheels etc. We relied on the goodwill of neighbours or relatives dropping everything to travel long distances to the rescue.

Earlier in my career and sometimes latterly there have been occasions when I have made a meal, waited for relatives to come, the neighbours to return from work, rung the Cat Protection League to get the cat sorted out, hung out the washing, visited several times a day and night all simply to keep a person out of hospital. This is what many older GP’s did and in some areas of the country probably still do.

Alas, the situation has changed considerably, in that more older people are isolated with neighbours working longer hours and keeping to themselves and close relatives often scattered around the world as well as people living longer and with more complex medical needs.

Doctors have an increased work load and the consultations needing to encompass health prevention and screening and there an increased need for documentation by computer to record every aspect of the consultation. Also, with the introduction of more medications  and patients surviving severe medical illnesses longer GP’s are now responsible for their management. When the final year students are attached to the practise for 2 months each time they express their surprise of how many complex cases are managed in Primary Care.  Lloyd George fileGone are the days of a scribbling remark in a handwritten file in a packet – the Lloyd George file and the rest of the information being retained in the doctors head and if a patient’s condition became in anyway complex they were whisked away to experience a prolonged hospital admission.

It is a long time since I wrote the following abbreviations in patients notes!

  •       GOK ( God Only Knows)
  •        TEETH – Tried Everything Else; Try Homeopathy
  •        PIN (pain in the neck)
  •        SALT – Same As Last Time.
  •         FLD – Funny Looking Dad.
  •         ATSWWT – Always Thinks Something’s Wrong With Them.
  •         VIPIA – Very Important Pain In the A**.
  •         FFFF – Female, Fat, Forty and Flatulent.

These changes have resulted in more ‘social’ admissions which are often prolonged and can lead to a decrease in a persons independence when they are ready for discharge as the ward they are admitted to does not have the multidisciplinary team to avoid this.
Incredibly health and social care have worked totally independently. I remember when I was a junior doctor (SHO – Senior House Officer – the old nomenclature ) the consultant at the time commented that if I wrote letters for the patient they were rehoused very quickly and what was my trick. “Sir, (as we addressed our seniors in those days) could it be that she signs herself as the Senior House Officer, piped up the Registrar!”

At last this is being addressed and following the formation of the Ealing Clinical Commissioning Group (ECCG) in April 2011 plans implement patient-centred plans to provide the right care at the right time and at the right place for the residents of Ealing.

The ECCG launched these plans on 16.05.2012 in a document:-

Better Care, Closer to Home (2012 – 2015)

http://www.ealingccg.nhs.uk/media/633/NHS%20Ealing%20CCG%20-%20Out%20of%20Hospital%20Strategy.pdf

A three-year strategy for coordinated, high quality care out of hospital
Our objective is to provide the right care at the right time and at the right place for the residents of Ealing. This was carefully thought out by a comprehensive team of people from all social and health disciplines lead by Dr Mohini Palmer an experienced GP
In their document they quoted:-
“Our vision is to ensure that our health care system keeps patients well and at home and, when patients do become unwell, provides cost- effective, evidence based and timely care at the right place appropriate to their needs.
As demand rises with increasing health needs and the development of new treatments, we need to respond to the challenges while delivering the highest quality of care. We need to build and preserve what we do well and continue to look for new developments to deliver the best standards of care.

There are times when we use hospitals to provide care for patients when that care could be provided closer to their home and in the community. Developing the right care outside hospital is a key part of how we will continue to maintain the provision of quality and cost effective care for the residents of Ealing.

This is our three-year strategy to design and deliver out of hospital care.

To achieve this, our out-of-hospital initiatives will be:​

  • Inclusive: We want our services to be inclusive and for this to happen we will involve patient and public groups in our proposals. As we develop our initiatives it should be clear to all users how we are developing our plans.
  • Integrated: We will work with all our stakeholders who provide out of hospital care e.g. primary care, community services, social care, nursing homes, voluntary groups to provide joined up care.
  • Sustainable: Our approach will be sustainable and we will invest when we need to deliver the care.

Our strategy aims to improve quality and efficiency across the system, the experience of all patients, and make the best use of our resources.
We recognise this is a different and substantial shift from how we deliver health today. In the coming months we will be meeting with patient and public groups to explain our plans and to fully involve you as we develop our initiatives.
We need to continue to respond to the challenges we face and to evolve to deliver the best sustainable health care for the residents of Ealing.”
As demand rises with increasing health needs and the development of new treatments, we need to respond to the challenges while delivering the highest quality of care. We need to build and preserve what we do well and continue to look for new developments to deliver the best standards of care.

There are times when we use hospitals to provide care for patients when that care could be provided closer to their home and in the community. Developing the right care outside hospital is a key part of how we will continue to maintain the provision of quality and cost effective care for the residents of Ealing.

We need to change the way we deliver care. At present access to care and the quality of care are variable across the borough. Improving the access, quality and scope of out of hospital services will require new ways of coordinating services, investment and greater accountability. Exhibit 1 sets out reasons for transforming out of hospital care.”

Further details are found in NHS North West London’s Shaping a Healthier Future programme in the following document:-

 

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/Factsheet_for_Ealing_residents_0.pdf
How have we delivered better care, closer to home?

The examples of the initiatives:-

*Urgent Care Centre: this is already providing 24 hour urgent care to patients at Ealing hospital
*111 and single point of access
*Improving access to GPs – at our surgery we have cooperated by
– providing extra slots for emergency appointments
– providing a later surgery ( Wednesday evening until 8pm)
– introduced by Ealing CCG. If you feel unwell on Saturdays and Sundays, you can call NHS 111 for medical help and advice. If the trained adviser thinks you need to see a GP, they will direct you to the practice in your area that is open. We are part of the rota of GP’s

*Integrated Rapid Response Service: started in July 2012 and provides a response to patients to provide care in their home and to support them on discharge from hospital.

*A new service started in October 2012 called ICE (or Integrated Care Ealing) which cares for patients at home if they are not sick enough to be admitted to hospital but are too unwell to stay at home without extra care. The service provides nurses, physiotherapists, and health care assistants, under the clinical leadership of Ealing Hospital Consultants. In 2013/4 there has been an increase in the number of staff and types of clinical conditions that the service manages.
Dr Livingston and I have used this service on many occasions and proved it to be extremely useful and helped in avoiding unnecessary hospital admissions.

*We also have a GP wards – Rosemary and Magnolia Wards at Ealing hospital totally geared to manage the acute condition eg urinary tract infection, which although treatable in the home can present with confusion, which settles after 24-48hrs and admitting a patient for 1-2 days and then discharging with a care package saves a prolonged admission. We also have the ICE team who are a multidisciplinary team with nurses, physiotherapists again linked to social services.

*We have Community Matrons allocated to each network  and they coordinate the multidisciplinary team to attend patients with complex medical problems.
* All  patients older than 75years of age now have an allocated named GP who oversees their holistic management.
* In our practise we have seen many of elderly and formulated care plans which not only look at their physical and mental health needs but their social  aswell. These patients are reviewed at monthly intervals to note any significant changes in their status. It is also a chance to look at future planning particularly ‘end of life care’ so that whilst a patient is reasonably well they can have a say in their advanced care planning. Many people have welcomed this whilst others want to discuss it with their families or simply want to take life as it comes but at least they have a choice.

* Children’s nursing service: Ealing CCG have developed a children’s nursing service to provide care for children closer to and in a more convenient location for them and their families.

* Palliative care service: ECCG are working with the Marie Curie service to provide a rapid response team to assist and support those people who wish to die at home. We are able to get urgent access to McMillan nurses until 8pm so that a visits can bee arranged.

* Psychiatric liaison: ECCG have funded a psychiatric liaison service at Ealing hospital to provide a rapid response to patients who need this care. Dr livingston and myself have been working very closely with the appointed Community Psychiatric liaison Psychiatrists to achieve greatly improved outcomes especially with our complicated psychiatric patients – improving their care aswell improving our own learning needs in this challenging aspect of medicine.
We as GP’s have much improved access to psychiatric services aswell as a range of psychological services using:-
The Ealing IAPT (improving access to psychological therapies) service offers support for common mental health problems such as depression, anxiety and panic. Referrals can made by:-
– making a request to a GP or another health professional
– self referral by calling us directly on 020 3313 5660

How we are working together

The ECCG have identified better coordination of services as a priority in order to improve care. For example:
Ealing GPs now work in six Health Networks ensuring care is clinically led and consistent across GP practices
Within our six geographical multi-disciplinary groups, the Integrated Care pilot to provides integrated care across health and social care
We now work closely with partners in community and social services to support patients to use health and social care services effectively
A service providing coordinated and joined up care to Ealing residents who are in nursing homes evolved last year so that a group of GP’s take responsibility for their care and are accountable to the CCG.

We as practise and part of a network ( a group of nearby practises which are part of the commissioning group which includes Ealing, Acton ,Southall and Northolt have been actively taking part in many initiatives to improve patient care. Healthcare and social care professionals are working together much more closely.

We are actively seeking out patients that have complex medical/social problems and discussing how we can improve their care. We can now contact social services much more easily and over longer hours to effect urgent social care.

We are improving our liaison with hospital consultants including mental health and this has brought about an ongoing and active improvement in management of care as well sharing and educating each other about the management of common medical problems eg heart failure, anticoagulation, chronic obstructive pulmonary disease in the community.

We have a community diabetic team who liaise with GP’s to provide improved care for our large number of diabetics aswell as providing management they provide patient education.

We have increased our communication with social services gathering around a table to discuss these types of patients and share the problems and understand each other’s way of dealing with health problems with social issues.
Now we can access social services at weekends and late in the afternoon and it works! It is sad that it has taken an economic crisis and a need to save money to promote these changes. There have been many years of struggling, stamping feet and despairing to get social support to avoid hospitalisation of a patient who often took up an acute medical or surgical bed for weeks.

How has change been supported

* employing and having advice from experts
* peer to peer reviews – GP’s getting together in their networks for planning and using the expertise in a network to formulate initiatives.
* change of IT systems to to improve working together and monitoring progress of performance
* liaising with the public to establish needs of the geographical area by public meetings
* improving health education by liaising with Ealing council
* the right contracts and incentives to improve care, to underpin the new ways of working have been put in place.

These are many of the challenging initiatives that have been commenced in the last three years. Aswell as the superb work of our CCG governing body there has been a lot of work from many hard working GP’s and practice managers who attend meetings after their surgery’s in an attempt to improve our services.

As I wrote this I felt quite uplifted by what has been achieved and feel that in Ealing every effort is being made to shape a healthier future.

If you want to find out more about Ealing CCG and how it is evolving and to see what is in store for the future log in to website:-
http://www.ealingccg.nhs.uk

 

Tags: , , , , , , , , ,

NOT JUST A FUNNY TURN………

When Mary O’Brien came the surgery last week and said she had difficulties getting her words out, was confused for a short period of time and couldn’t give someone basic directions this was:-image

 

Every year at least 46,000 people in the UK have a TIA or Transient ischaemic attack (also known as mini-stroke) for the first time and although the symptoms may not last long, a TIA is still very serious.

It’s a sign that a person is at risk of going on to have a stroke. That is why a TIA is often called a warning stroke yet too many people are unaware of the link between TIA and stroke and are not getting the services and support they need.

Every three and a half minutes, someone in the UK has a stroke. It is the killer disease that’s been ignored for too long.

There is no way to tell whether a person is having a TIA or a stroke when the symptoms first start. Stroke is a medical emergency. The quicker the person gets access to specialist assessment, investigation and treatment, the more likely they are to make a better recovery.
Our message to the public
999

If you, or someone else, show any of the signs of stroke you must call 999.

The ambulance staff in London are aware of the 4 specialist units in London and will automatically take a patient to the nearest specialist stroke unit.

Ambulance blue light

The symptoms of TIA often pass very quickly so the public – and some health and care staff – may mistake them for a ‘funny turn’. Rapid access to specialist assessment, investigation and treatment is still important even if the symptoms have stopped.

If you think you have had a TIA and have not sought medical attention, see your GP urgently. Urgently investigating and treating people who have a TIA or minor stroke could reduce their risk of having another stroke.
image

 

image

 
 

Tags: , , , , , ,

What should you expect from your doctor?

We are all aware of the escalating complaints against doctors and read regularly stories of poor treatment. I always feel concerned when I read these articles as when a person develops an illness or medical problem and have to seek medical advise it creates an added anxiety as to whether they are going to receive good treatment or if they are going to be taken seriously.
The number of complaints to the General Medical Council(GMC) – which oversees doctors practising medicine in the UK – increased by 23% from 7,153 in 2010 to 8,781 in 2011 – continuing a pattern which has been rising since 2007.
About two thirds of these complaints are from the general public the remainder are from other public bodies such as the police or coroner services and others healthcare professionals.

However, although there is an increase in complaints it is important to put the figures into context. It is estimated that there are over 100 million patient-doctor interactions each year in the NHS. This ‘complaint-rate’ of less than 0.001% per interaction is something of which most industries would be envious.
Also, as the GMC points out, the rise in complaints may not be due to worsening services, but could be the result of rising patient expectations and an increased willingness to complain.

Nevertheless, we would all like to think that there were no complaints and it is not helpful to hear these figures if you have a serious complaint to make but I thought this would be somewhat reassuring to those who may be having to face medical treatment in the near or distant future.

What are the commonest complaints?

  • concerns with investigations and treatment, such as failure to diagnose or prescribing inappropriate medications
  • problems with communication – such as not providing appropriate information or not responding to people’s concerns
  • perceived lack of respect for the patient – such as being rude or dishonest

Many members of the general public are probably not aware that we are now appraised on an annual basis and every doctor since 2012 will have to go through a revalidation process every 5 years. The appraisal has to show that we are maintaining an up to date portfolio of attendances at educational meetings and literature we have read. We have to discuss how we communicate with our patients, our practise staff and medical colleagues and any complaints we have had and how we have addressed them as well as any accolades we have received. We have produce written proof that all these aspects are being addressed.

In this practise, for more than 10 years we have had a range of medical students assigned to the practise and I am always grateful to patients who are prepared to see them. When they start I am very anxious that they simply get used to talking to all ages and different types of people and learn to extract information in a respectful but effective manner.
I took a group of students to see one of our rather garrulous patients who albeit had a fascinating medical history. One delightful student, a highly intellectual Oxford Graduate in philosophy, who had decided to change tack and study medicine was asked to take this lady’s history. He was amazingly patient and an excellent listener and I decided to not interrupt for about 20minutes. Then I asked him to finish and we thanked the patient and left. When we as a group analysed what information he had extracted it was evident that he had extracted the smoking history of every member of  her family going back two generations and what had happened to them but we weren’t quite sure whether she had ever smoked. We had established how long she had been living in the flat, the price and the prices over the years and who had lived there before including a lady who had put her head in the gas oven and that’s why there was an electric cooker but not much more despite her having numerous medical problems.

I then said to him, “Suppose she then collapsed and you had to report to your senior colleague her main medical problems what would you say?” He then realised his gentle,caring listening manner had been his downfall.

As a group we all learnt from this as to how to focus a patient to get the correct information. As a group we worked with that student who eventually was able to use his listening talent effectively but also extract the relevant information teaching us all important lessons in history taking.
I often ask patients to write down all their concerns in a list to be discussed. This is also useful when attending hospital appointments.

Communication is a dialogue between two people and also involves interpretation of facts obtained.

When I was in practise in Wales patients would frequently report having had a “pull” and this could mean absolutely anything from pain of any sort to collapsing and as it involved careful questioning as well as close observation of the patient’s body language and knowledge of something about them to find out what they meant. Moreover, I soon learnt never to ask what brought them to the doctor to avoid the ramifications of the mode of transport that was or may have been available of ask how they were because the reply could be anything and often not medical!

We all know how difficult it can be to get anything but a grunt from a teenager and in one consultation I had to resort to asking a grunting 14year old boy to tell me what football team he supported and as he said “Chelsea” I flashed an Arsenal key ring in front of him and then words fell out of his mouth.

I have to say that in some parts of the country for example the’ Black Country’ (West Midlands)’ where some of my family come from it is impossible to understand what they are trying to say. As my mother would have said , ” don’t they have a broad accent?”

The Daily Mail were totally misguided when they implied that the communication problem was due to foreign doctors as figures do not support this and after all I was a GP in a Welsh speaking part of Wales!

Surgeons can be particularly poor at communicating as they are ‘doers’ and I have known brilliant surgeons who have weak communication skills. If I am aware a patient is going to have surgery or a procedure I often suggest that if they don’t get or understand the answers or explanations they need or want they can be seen by the GP to get this information. We can phone, email or write to or even meet the consultant face to face to get that information. They are more often than not charming and only too glad for us to liaise with them.

When it comes to rudeness or lack of respect, in the same way patients should not be rude of disrespectful then there should be zero tolerance for a doctor to behave in this manner.

imageThe GMC lays out very clearly the duties expected of doctors and I have reproduced this from literature which is sent annually to every doctor registered with them:-

Duties of a Doctor

The duties of a doctor registered with the General Medical Council
Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and make sure your practice meets the standards expected of you in four domains.

Knowledge, skills and performance

  • Make the care of your patient your first concern.
  • Provide a good standard of practice and care.
  • Keep your professional knowledge and skills up to date.
  • Recognise and work within the limits of your competence.

Safety and quality

  • Take prompt action if you think that patient safety,dignity or comfort is being compromised.
  • Protect and promote the health of patients and the public.

Communication, partnership and teamwork

  • Treat patients as individuals and respect their dignity.
  • Treat patients politely and considerately.
  • Respect patients’ right to confidentiality.
  • Work in partnership with patients.
  • Listen to, and respond to, their concerns and preferences.
  • Give patients the information they want or need in a way they can understand.
  • Respect patients’ right to reach decisions with you about their treatment and care.
  • Support patients in caring for themselves to improve and maintain their health.
  • Work with colleagues in the ways that best serve patients’ interests.

Maintaining trust

  • Be honest and open and act with integrity.
  • Never discriminate unfairly against patients or colleagues.
  • Never abuse your patients’ trust in you or the public’s trust in the profession.
  • You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

I have to say for the most part I find my fellow doctors fulfil these duties honourably and I am proud to be part of the medical profession.
We are all patients and I trust that we all do our part to be as helpful in providing relevant information, cooperating appropriately and working with them to manage our medical problems.

If you do have a complaint please address them to the practise manager or PALS – the complaints procedure is on the website.
http://www.102theavenue.co.uk

 

Tags: , , ,

PPG MEETING – OCTOBER 17th 2013

image

The Patient Participation Group held a meeting at the surgery on October 17th 2013 in the surgery . The full minutes are on the surgery website:-
http://www.102theavenue.co.uk/files/download/5843a082abe3f19

We reported on outcomes of planned achievements from last year – 2012/13

  • Passing on of information
    We have managed to obtain 500 patient email addresses to be able to inform patients of current changes in the NHS. Following last years meeting I started this blog in an attempt to let patients and others know about national changes aswell as local events and changes. It has also been an attempt to educate readers about medical topics aswell as some stories relating to my life as a doctor and tying it in to more recent advances in medicine.
  • Clinical Systems We have been in negotiation most of the year with other doctors in our network and having agreed on a system which would be more patient friendly it has been decided to Ho over to this system after April when the busy winter months are over.
  • Patient education Arranging events in the form of talks has been difficult due to patient’s availability but by continuing with posters , providing links on our website, patient leaflets and now deciding to focus on particular at risk groups such as the mentally ill we hope this will be an ongoing
    provision.PLANS FOR 2013/14

    We have brought up 3 subjects to consider and will sending out a survey completed anonymously to gather information from a wider section of patients

    PREMISES AND MERGER
    image
    With reference to a paper brought out earlier in the year in the magazine Commissioning Success a bi-monthly magazine from the team behind Practice Business, aimed at helping clinical commissioners get the best outcomes from clinically-led commissioning.
    Collaborative healthcare ‘groups’ and informal alliances can work better than formal mergers, says NHS Confederation.
    Published: MAY 1, 2013

    “The new options for governing through healthcare groups set out in this paper can strengthen rather than reduce the connections to local people, and help maintain safe local services. They could also mean less upheaval for staff and for patients, many of whom worry that they will lose a valued service or even their job.”

    We discussed the present situation of general Practise and how small practises are becoming less viable and ways in which we could consider keeping the personal touch we have created in a small practise. However, being realistic we must now consider sharing facilities with other nearby practises and with a new computer system where access to notes would be more obtainable by other doctors we could reduce waiting times and share resources.
    We have already begun to collaborate with other practises in our network (about 10 practises) in Commissioning services such as anticoagulation and community run musculoskeletal-skeletal services but we need to think of ways to facilitate services at a practise level for more everyday services and how we can satisfy CQC inspectors with regard to standard of premises.
    The survey will provide more feedback from our patients on this topic.

    OUT OF HOURS and A&E
    image
    This has been an ongoing topic in the national news for some time and recently I have been asking patients what they would do if they needed a doctor out of hours and was surprised at the lack of knowledge. This prompted me to write the blog on 111 and please read this if you haven’t already done so. The NHS is wasting phenomenal amount of money asking highly qualified health professionals to deal with health problems which could be dealt with in the home or visiting a local pharmacy. Splinters, common cold, flu, simple cuts, bruises and sprains and domestic worries are not reasons for attending A&E or calling an ambulance. Believe it or not that is what I see every time I do an Out of Hours session at one of our local hospitals. Again refer to this blog which outlines what to do if you have a medical problem out of hours.

    https://102theavenue.wordpress.com/wp-admin/post.php?post=1109&action=edit

    PRESCRIBING AND MEDICINES WASTAGE
    image
    Another topical cause of concern has been medicine wastage and we need to educate patients how to avoid this. We as doctors meet regularly with a prescribing advisor and we work closely with a prescribing pharmacist to find ways in which we as doctors avoid waste and to consider cost-effective prescribing. By doing this there is more chance that there will be money in the pot for expensive medication for conditions such as cancer. It is also helpful if patients buy over the counter products such as paracetamol when appropriate.
    See blog:- Do you use your inhaler as an air spray? https://102theavenue.wordpress.com/wp-admin/post.php?post=381&action=edit

The next step is to send out our survey both by hand in surgery and online and then analyse the results and meet again to discuss.
image

 
Leave a comment

Posted by on October 26, 2013 in Training and Advice

 

Tags: , , , , , , , , , ,

OUT OF HOURS ACCESS TO NHS SERVICES

Outside normal surgery hours you can still phone your GP surgery, but you’ll usually be directed to an out-of-hours service. The out-of-hours period is from 6.30pm to 8.00am on weekdays and all day at weekends and on bank holidays.

If it is not an immediate emergency then call NHS Direct on 111.
I appreciate that when this when this was launched there were many problems but it has improved during the last few months and when I asked those that attended the Patient Participation Group there was good positive feedback.

imageNHS 111 is available 24 hours a day, seven days a week.
When you call 111 a receptionist will ask you various questions to assess the urgency of the problem and your needs.

  • If it is advise you need the receptionist will transfer you to a doctor or nurse practitioner.
  • If you wish to see a doctor they will make an appointment for you to see a doctor or nurse at the Urgent Care Centre(UCC).
    The nearest UCC in W13 & W5 is Ealing Hospital. This open 24 hours every day of the year.
    imageDetails of this or other local UCC can be obtained on the following website:-
    http://www.nhs.uk/Service Search/Urgent%20Care/LocationSearch/0If you are given an appointment it is important to turn up or cancel the appointment as the the receptionist has the responsibly to chase you up to find out to find out what has happened before removing a patient off the screen. Having been alongside a receptionist making enquiries as to why the patient has not turned up to hear answers such as ‘the child went to sleep’ or ‘the patient is better and they have gone out’ or ‘we called an ambulance because we can’t afford a taxi’ is not helpful in making a service efficient.
    If you turn up in A&E it is possible that you may be directed to this service but may have to wait longer to be seen. Hence it is in your own interest to phone 111 to make an appointment.

If the doctor seeing you feels you need further investigation or a specialist opinion they will consult their specialist colleagues at the same hospital or another local hospital and arrange for you to be seen. You will not have to queue again in A&E.

  • If for some reason you are unable to leave your home for medical reasons ( bed-bound or terminally ill) the receptionist will refer you to a doctor working alongside them to arrange for one of the mobile doctors to visit. Although the doctor does NOT have access to your medical records the details of the telephone conversation, consultation or visit including any treatment given is recorded and then faxed to your usual doctor for them to receive the following morning. Dr Livingston and myself read these before a morning surgery and if we either need to see you will telephone or write to you but you may be told to see your GP next day. The record is then scanned on to your computer record.
    By doing this we are attempting get good continuity of care.
    I occasionally work in one of the local centres( much to patient’s surprise when faced with me) as do many of our local GP’s and it gives me a chance to appreciate how the system works.
  • If it is a serious injury or illness then call 999 but if you are unsure call 111 first and they can arrange an ambulance or for you to be seen urgently.

image

A&E departments assess and treat patients with serious injuries or illnesses. Generally, you should visit A&E or call 999 for life-threatening emergencies, such as:

  • loss of consciousness
  • acute confused state and fits that are not stopping
  • persistent, severe chest pain
  • breathing difficulties
  • severe bleeding that cannot be stopped

I viewed this on the NHS Choices (http://www.nhs.uk) website and thought it would be good for all to view:-

If an ambulance is needed, call 999, the emergency phone number in the UK.

You can also dial 112, which is the ambulance number throughout the European Union.

Major A&E departments offer access 24 hours a day, 365 days a year, although not all hospitals have an A&E department. At A&E a doctor or nurse will assess your condition and decide on further action.

Dental Problems
Emergency dental service is available Monday to Friday 6pm – 10pm, Saturday, Sunday and Bank Holidays 9am – 10pm.
Tel: 020 3402 1312
Otherwise phone 111 to ask advise.

Mental health emergencies

If a person’s mental or emotional state quickly worsens, this can be treated as a mental health emergency or mental health crisis.
24 hour support line: 0300 1234 244
SANELINE on 0845 767 8000 – open 1pm – 11pm every day
If you use the services of the Gender Identity Clinic and have an urgent issue, please contact your GP.

If it is a medical emergency, please call 999. If you are in acute emotional distress and your GP is unavailable, please contact the Samaritan support group on 08457 90 90 90 or visit http://www.samaritans.org.

image
If you are worried about a family member or someone you care for whose health has suddenly gone downhill, you can also call the Samaritans or our 24 hour support line for help and advice.
In this situation, it’s important to get help as soon as possible. Contact NHS 111 to find out where help is available. If you feel the person is in immediate danger then call 999.

Contraception
Emergency contraception can stop you becoming pregnant after having unprotected sex. Two methods are available, the ‘morning after’ pill and the copper intrauterine device (IUD). The pill can be taken up to 72 hours after sex and is available free from your GP and most family planning clinics. It is also available from some pharmacies. The IUD is a plastic and copper device that is fitted into the woman’s womb by a doctor or nurse within five days of having unprotected sex.
If you need to find a pharmacy who may supply ‘morning after pill’ the following link will be helpful
http://www.nhs.uk/Service-Search/Pharmacy/LocationSearch/10
Also refer to our website to find out where the nearest Family planning clinics are located.
http://www.102theavenue.co.uk/

Walk in clinic
If for any reason you are not able to attend your GP surgery or need medical attention you can either walk in to the Urgent Vare Centre at Ealing Hospital open 24hours.
Or
Our local clinic is at:-
Featherstone Road Clinic, Southall UB2 4BQ

Tel. 020 3313 9880

Mondays to Sundays

8:00am – 8.00pm

PLEASE USE THE NHS CAREFULLY WE WANT TO PROVIDE AN EXCELLENT 24 HOUR SERVICE BUT WE NEED YOUR HELP!
image

 
Leave a comment

Posted by on October 19, 2013 in Training and Advice

 

Tags: , , , , , , , , , , , ,

THE DOCTORS CLINICAL GAZE HAS CHANGED

image

When I decided I wanted to become a doctor as a young person my main reason was that I wanted to help and care for people, but also I had a great fascination for the workings of the human body and how it could be healed. I was always involved in numerous other activities in and out of school as well as community projects. I was passionate about entering the medical profession and despite being told on many occasions that it would be difficult because I was female, I was involved in too many extracurricular activities, I didn’t come from a medical family and it was a long hard course I was arrogantly determined to succeed. On one occasion my headmistress took me aside to persuade me to apply for another profession such as social work or biochemistry but I was insistent and persistently urged her to make sure my application form went off promptly by daily enquiring at the school office.
I did get a place at medical school first time, one of 11 women in the year and thoroughly enjoyed being a student and I have appreciated not only the privilege of serving and caring for patients but also the challenge of working to solve the diverse biopsychosocial problems which seem to get more complex as the years pass. Originally my gaze was solely on the patient and their needs but my concern is that we are being coerced into working within a computerised and performance managed healthcare and it is getting increasingly difficult to maintain that patient-centred gaze. The consultation flow and purpose tends to be dictated by what appears on the computer rather than allowing the patient to present their personal concerns.
I have to say I had no objection to the introduction of computers as it made it much easier to produce prescriptions with fewer errors and a more organised way of keeping track of patients with chronic illnesses aswell as adhering to evidence based guidelines. For example, after very few clicks taking seconds it is possible to find out how many diabetics there are and whether they are up to date with their monitoring which in turn can prevent serious complications and therefore means we can focus on those patients that need more in depth care and need to be encouraged to attend for guidance.
However, if each patient is not seen as individual and they are not consulted holistically and facilitated to work with the healthcare professional the outcome will be no different. The buzz word is ‘motivational counselling’ which involves encouraging the patient to find a way and to see the benefit of changing their behaviour to improve their health. I have heard this brought up on numerous occasions when we have been discussing the complex medical problems associated with a patient. Time and time again the major conclusion to improving diabetic control or reducing hospital admission has been the suggestion to carry out ‘motivational counselling’ to encourage increased exercise, reduce weight or stop smoking or take their medication regularly.
But it can mean that when we see that patient we can be so concerned about their monitoring, their weight , blood pressure, blood tests etc which is what the computer reminds us to do that we overlook to ask about how they are feeling and why they want to see a doctor.
image
David Loxterkamp in his BMJ Essay this week described similar concerns. Loxtercamp was an early adopter of the electronic health record and thirteen years ago wrote with enthusiasm about it’s use now he says” With the practice computer we have created a monster that now directs the patient encounter, and which itself needs care and feeding.
Doctors are experts at knowing what to know in order to pass the test, he says. And if they are rewarded for collecting data rather than talking to patients, that’s what doctors will do. Space for talking, or more importantly listening, to patients is squeezed out by the pressure to complete chronic disease flow charts and checklists of overdue prevention measures.
Perhaps this would matter less if there were a real sense that such activities improve health. But we know that routine health checks don’t reduce mortality or morbidity. And Loxterkamp lists many other interventions that have been foisted on an unsuspecting public in the name of preventive health but subsequently have been found to be useless or even harmful.”
I think it would be impossible at this stage, which I am sure even Luddites and sentimentalists would understand as being able to measures outcomes and fosters research gives us a way affording some sort of reality check as to what we are providing as a health service for our patients. Indeed, it has been by the use of data that the recent catalogue of disasters in our hospitals have been exposed and no doubt there are more to come when they begin to analyse and inspect General Practise more closely and how some drugs have resulted in serious side effects or shown to have life-prolonging effects
Meanwhile, I felt all was not lost when I heard that the CQC inspectors will be more interested in patient and staff satisfaction by interview rather than simply looking at computer generated achievements.
The importance of the medical consultation is often by the placebo effect. Turner and Brody have shown that placebos consistently deliver “good” or “excellent” results in 64-75% of recipients, especially where subjectivity is involved (such as with pain or depression). The benefits are magnified by the doctor who actively listens, shows empathy and concern, provides satisfactory explanations, and creates a treatment plan with the patient at the controls.
A common sentence I have heard over the years” I feel much better after speaking to you doctor.” confirms this.

I was reassured this summer when we had two work experience students who were keen to study Medicine and were motivated in the same way I had been more than 40 years ago with the same desire to make a difference in people’s lives and the fascination for workings of the human body. They were just as determined and involved themselves in initiatives with community projects. Despite being discouraged by others around them they were both arrogantly determined and had that naivety which somehow helps you maintain the determination.
During the past few years I have been teaching medical students who have decided to change career because they feel they want to serve people more closely with an interest in healing. They have changed from a wide variety of walks of life; a chef, an Oxford Don, biochemist, business managers,lawyer and teacher to name a few. They feel they want to deal with people rather than data or profits: I hope they won’t feel disappointed.
I also particularly recall the final year medical who was keen to become a neurosurgeon at the start of his placement. He was a handsome young man skilled and charming, could have been the star of any medical ‘soap’! One day towards the end of the placement he came to talk with me to review a patient he had seen and seemed worried. When I enquired he told me that the ver ill patient we had seen the previous week had particularly asked to see him as she didn’t want to waste a doctor’s time. She had been diagnosed with terminal cancer and as there was nothing any doctor could do for her but she wanted to talk to someone she had thought he might help. As he listened to her tears had rolled uncontrollably down his face and his reaction had been to hold her hand to reassure her. He was worried he had been unprofessional on two accounts crying and holding her hand and was wanting my advise as to how to act in this sort of situation.
I told him he had discovered empathy and should be pleased he had discovered it so eárly in his career. Later he went on to tell me that perhaps he would be seriously thinking of becoming a General Practitioner instead of a Neurosurgeon.
image
There will always be doctors who will see the patients who are aloof from the World Wide Web and the type of doctor who will consider a patient’s individual medical and social needs.
However,we also need those doctors especially the younger more digitally aware who will collect and harvest data using this vital new tool to provide guidelines for care and deliver it where appropriate and deal with e-patients who need not be mere recipients of care but can become key decision-makers in their own treatment process.
I recall when I was assisting in the paediatric leukaemia clinic and remember children barely five years of age who entered the rooms reciting relevant symptoms, the size of their spleen, discussing their latest blood counts and appropriate management in a dispassionate way. They were like virtual e-patients collecting information and being part of their own management. That worked very well until things didn’t go to plan and then the same doctor had to discuss plans foe end of life and talk with the extended family. This demanded an empathetic doctor skilled at listening, showing concern and finding ways of empowering the patient and family to cope following a new direction.
I do think the doctors clinical gaze has changed but hopefully this combination of doctors and simply an awareness a new type of gaze that doctors can continue to perceive that
“patients are not only data fields for the doctor to harvest, objects to be imaged, or problems to be solved. They are also our neighbours asking for help.”

image

 
Leave a comment

Posted by on October 6, 2013 in Training and Advice

 

Tags: , , , ,

Aside

imageNEXT PATIENT PARTICIPATION GROUP MEETING
WILL BE HELD  ON THURSDAY  OCTOBER  17th

image

AT
11.00am

IN THE SURGERY

image

NEXT PATIENT PARTICIPATION GROUP MEETING

 

Tags: , ,

PATIENT PARTICIPATION GROUP

If you read the main website on the following link http://www.102theavenue.co.uk/patient_group/ you will be able to view the practise profile and what actions have been taken following previous PPG meetings.
Last year was directed at health education and a major reason for starting this blog.
image

THE PURPOSE OF PATIENT PARTICIPATION GROUPS

• To give Practice staff and patients the opportunity to discuss topics of mutual interest in the Practice.
• To provide the means for patients to make positive suggestions about the Practice and their own healthcare.
• To encourage health education activities within the Practice.
• To develop self-help projects to meet the needs of fellow patients.
• To act as a representative group that can be called upon to influence the local provision of health and social care.
• To involve further patients from the wider population.

imageAs I am sure you are all aware the NHS has become NHS ENGLAND and has reinvented itself with the prime aim to improve the health outcomes for people in England.
http://www.england.nhs.uk/

STATED AIMS OF NHS 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.

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 wehave.

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 disadvantaged.

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 are what makes 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.

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

It is with this in mind that we are continuing to develop our PPG and your views as patients will be important when we have our CQC inspection.
We need your support during the changes that are anticipated and feedback from you to establish what is going well and we need your positive suggestions as to how we can make improvements to the practise and your healthcare.

Small practises such as ours are under threat and we are finding ways as to how we can work more closely with other local practises and have started to share resources such as anticoagulant management,lung function measurement,children’s phlebotomy and nursing home patient care as well as training our staff. We recently held our cardio-pulmonary support training session with staff from other practises and patients were also invited.

We have joined a network with other local practises to meet to discuss care pathways for patients with complex medico-social problems as well as finding learning needs and addressing them.
Doctors and/or practise manager always attend CCG meetings so that we keep up to date with local and national changes and a chance to meet doctors from other networks to formulate ways of improving health care by commissioning.
The 2013/14 prosectus and links can be found on the following website http://www.ealingccg.nhs.uk/media/3881/ealing_prospectus_-_final_310513.pdf

Following the CQC inspection there will inevitably be suggestions of actions that need to be actioned. You may have noticed certain changes such as all staff wear name badges including me when I remember! Also there are EXIT signs and all staff are being trained in more advanced health and safety including fire safety. All staff are trained regularly in first aid and life support and awareness of patients with particular needs.
We have all been alerted to the special needs of patients with learning disability and sensory impairment and are attempting to find ways of accommodating them sensitively as advised by healthcare professionals who are expert in this field.

What are our priorities and vision for the future?
Ealing CCG has seven overarching priority areas of work, as follows:
*A better start in life – increasing breastfeeding initiation, reducing avoidable childhood injuries, and increasing childhood immunisations.
*Increasing life expectancy – reducing cardiovascular disease deaths, reducing cancer deaths; and reducing alcohol-related hospital admissions.
*Shifting unplanned care towards planned care – increasing the amount of services delivered in a community setting, improving unplanned care services in Ealing, and reducing the delays in hospital discharges.
*Reducing variations in primary care – better early diagnosis and treatment, and reducing variations in hospital referral patterns by GPs.
*Improving recovery – increasing the range and access to rehabilitation services.
* Enhanced mental health services – increasing the provision of community services.
* Improving care at the end of life – increasing the proportion of deaths in preferred places.

These are the areas of work which we are discussing in our CCG meetings and implementing in our networks and in the practise.

The main areas a PPG can help are:-
image
*Improving services provided by the surgery
Carrying out surveys into a whole variety of subjects eg health needs/expectations and major cause of ill-health in a particular area.
• To explore the changing needs of patients.
• Measure patient satisfaction.
• Gather ideas for improvements or modifications needed for the delivery of services.
• Discussions at meetings.

*Offering support to other patients
e.g Befriending service, Carers Group

*Improving facilities at the surgery
• Fundraising for new furniture, toys or decorating.
• Keeping the plants or gardens of the surgery maintained.
• General environmental improvements.
A BIG THANK YOU TO THOSE WHO HAVE CONTRIBUTED IN THIS WAY

*Providing health promotion and education
e.g diabetes awareness day,contributions to the blog and notices added to our notice board.

* Supporting voluntary organisations in the area
e.g Age UK, MIND, Heart Foundation, Cancer UK, Dementia Concern
We have several patients who make contributions to these and other organisations

This year the CCG want to particularly want to focus on Carers
CARERS
Many people who are caring for someone do not necessarily see themselves as a ‘carer’. Rather they are mothers, fathers, daughters, sons, partners, husbands, wives or neighbours. However, being identified as a carer by the council can help you get the right support you need to look after the person you care for.
To understand what support can be given to Carers the following website is helpful
imagehttp://www.ealing.gov.uk/info/200379/carers/851/useful_links_carers

image

 

Tags: , , ,

Aside

image

Originally General practice  attracted a fee for services and the doctor would treat people who couldn’t afford the the fee on a charitable basis as his contribution to the community.

image
I entered General Practice in 1979 and was in partnership with Dr Noel Thomas who was the fourth generation of  a well established practice in a South Wales town called Maesteg. The population I cared for were miners, steelworkers as well as farmers and their families. They were hard working and there were many diseases which were particularly common in this part of Wales- miners contracted pneumoconiosis as a result mining coal alongside silicon rock and heart disease was rife. Also, back problems and other orthopaedic problems were common due to high number of men in heavy manual work. There was a high incidence of cystic fibrosis and spina bifida in children.
The surgery had about 5,000 patients and  Dr thomas and myself were full time and Dr Noel Thomas father Dr Ralph Thomas whom I succeeded continued to do one surgery each week. We had 2 nurses who acted as receptionists and nurses and 2 other part- time receptionists. One of the nurses, Vera had been an A&E sister and had a vast experience of trauma medicine including experience of mining accidents and the other nurse, Mary had been a paediatric sister and I particular remember her describing how she nursed children in iron lungs during polio epidemics. We also cared for our patients who were admitted to the cottage hospital for acute medical reasons or to the attached Maternity unit. We also had patients in  a long stay hospital LLynfi which was for the chronically ill patients.
Dr Thomas Thomas the great grandfather of the medical partner I was with in Maesteg, South Wales had practised in the days when he relied on fees for his services. and in the town there remains a water pump which was dedicated to him for his work in the Cholera epidemic of 1860.
It was at this time that his son Dr Bell Thomas  started to treat workers particularly miners and steelworkers in General practice. General practice covered workers under the Lloyd George’s National Insurance Act of 1911, but not their wives and families, whose proper demands were restricted by the need to pay fees for service.
When they were sick, it was the GP to whom people wished to turn. The work of the GP had been described in idealistic terms by Lord Dawson in his report of 1920, which laid out the structure a health service might take.
The GP
*.should be accessible,
* attend patients at home or in the surgery,
* carry out treatment within his competence
* obtain specialist help when it was needed.
* attend in childbirth
* advise on how to prevent disease and improve the conditions of life among the patients
* play a part in antenatal supervision, child welfare, physical culture, venereal disease and industrial medicine.
 Nursing should be available, based with the doctor in the primary health centres Dawson envisaged.
This picture was in stark contrast to the day-to-day pattern of the GP’s life.
In inner cities overcrowding led to domestic violence, lice infestation and skin diseases such as impetigo.
 CAH Watts, a GP writing of his experiences in a mining community before the second world war, recalled the waiting room with rows of seats for about 60 patients who sat facing a high bench like a bank counter.
Behind the counter stood the three doctors and behind them the dispenser. The doctor called the next patient to come forward. Having listened to the complaint, he turned to the dispenser to order the appropriate remedy. There was rarely any attempt at examination.
Even when I started in practise it was considered unusual to examine a patient .
(This was the case in a practice not far from here 15yrs ago! Even worse was the GP  who was bed-bound and her unqualified daughter Gloria saw the patients, diagnosed their condition, wrote the prescription and ran upstairs to get the it signed by her mother)
Visits usually numbered about 50 and were made on a bicycle. This had decreased to between 10-12 by the time I started in practise.
Diphtheria was endemic and every sore throat was viewed with suspicion. Antiserum was one of the few active treatments available to the GP, and if given within 24 hours of onset the results were excellent.
Otherwise, the mortality was about 20 per cent.
In the practice we have an elderly patient who has described  to several of our medical students her experience of having diphtheria as a child and how those that died around her or who carried off to hospitals never to return.
Patients with  diphtheria or scarlet fever were taken away in a yellow ‘fever van’ to the infectious diseases hospital for at least six weeks often known as the ‘ Isolation hospital ‘ which were situated on the outskirts of small towns;
 no visitors were allowed.
Lobar pneumonia was common, and with the more fortunate patients there was a crisis about the seventh day. It struck terror into the patients’ and the doctors’ hearts, for the mortality was thought to be at least 50 per cent and the sulphonamides given were invariably  not curative.
My predecessor, Dr Ralph Thomas son of Dr Bell Thomas when I worked in Maesteg South Wales described many of these experiences often referring to a patient he noticed coming through the door.
He related the anxious moments of how he had to wait by the bedside to see if the patient ‘pulled through’ . By the time I had qualified more antibiotics were available and this occurrence was less frequent but did occur.
My nearest experience to this was when treating a young person with heart failure (secondary to heart valve disease following rheumatic fever) in their home by injecting  intravenous diuretics and waiting for the chest to clear and the breathing become easier. Unfortunately on several occasions I had to experience a patient dying before my eyes as the medicine failed to take effect. The local hospital was 20 miles away and in the Winter months roads were blocked, ambulances were poorly equipped by modern standards and medication was  less sophisticated.
Major  surgery was only possible if the patient was willing to travel to London 200miles away with no Motorway. Only the most advanced heart cases were referred to London and then the waiting list  was long and the prognosis was poor and many never returned or if they did come back it was with a stroke or other serious complication.
Alternatively , heart surgery was performed by the general surgeon overseen by the general physician who took ECG’s during surgery and cared for them postoperatively. I recall a physician showing me an amazing ECG which went flat as the surgery was performed and as the heart was repaired  the  rhythm  returned to normal as the heart recovered.

At that time nearly about 35years ago it was found that a patient would have a better chance of survival staying at home rather than being admitted to hospital.

Most dreaded was tuberculosis, blood in the handkerchief after a fit of coughing. Some families were especially vulnerable and it tended to strike young people. The course could be lingering or extremely rapid, with death within weeks.
Lung cancer was rare. If it occurred, it would probably not be recognised.
Miners were particularly vulnerable and I remember doing an attachment at Sully Hospital outside Cardiff which was built for the purpose of admitting TB patients who had 6-12 months stays. Every patient had an amazing view of the sea from their hospitaI bed. It was a pleasant place to work but the downside was that each morning we had to check everyone’s sputum on a daily basis reporting a full description! But again treatment was evolving and immunisation  for TB had become available, hence there were fewer cases.
Chest problems when I worked there were mostly attributed to pneumoconiosis a disease contracted by miners and incredibly debilitating, nevertheless an interesting group of patients to work with – full of tales, humour and of course great voice if they still had breath to sing.
Almost half the babies were delivered at home, mainly a matter for midwives. Pain relief in labour, although available in hospital, might not be provided in the home.
 When things went wrong the GP would be summoned, because procedures such as breech birth or manual removal of the placenta might be required.
Most GPs used chloroform as an anaesthetic though some felt it was quicker and safer without.
As they might have neither the skills nor the equipment to handle problems, in many places obstetric flying squads, based in the hospitals, had been established. These could deal with haemorrhage, shock and eclampsia (fits during late pregnancy, labour and the period shortly after), transfuse patients, give anaesthetics, and undertake operative obstetrics in the home.
In Maesteg the miners  had raised money to build a hospital with a maternity unit but I remember the ‘Flying squad ‘ going out to Obstertric  emergencies. Sadly a street in my practise in Cymfelin near Maesteg had the highest incidence of spina bifida/ anencephaly in the World. Now virtually totally prevented by taking folic  acid  supplements and  I along with other doctors at  that time were involved the original trials.
Tales of obstetric disaster, haemorrhage after delivery and problems with forceps were all too common, although remarkably many women survived crises which would be unthinkable today. Serious infections (puerperal sepsis) killed mothers after childbirth, particularly during the winter months when streptococcal infections were endemic.
Pain and discomfort were accepted as part of life to be endured with stoicism. The family doctor had to be tough to get on with his many interesting and rewarding tasks.
If he had access to a hospital, he might set a simple fracture or reduce a dislocation. Working class people did not expect to be comfortable.
Most went hungry and their undernourished children showed evidence of rickets until vitamin D supplements, provided by welfare clinics, controlled it. Many were miserably cold in winter unless they were roasting in front of the coal fire in the kitchen. I remember patients describing these events when children ran around in bare feet and men fought over food for their families.
Although screening is considered part of modern NHS I was inspired 35 years ago by Dr Julian Hart , a neibouring GP in his practice in Glyncorrwg, Wales, as his practice was the first in the UK to be recognised as a research practice, piloting many Medical Research Council studies. He was also the first doctor to routinely measure every patient’s blood pressure and as a result was able to reduce premature mortality in high risk patients at his practice by 30%. Inspired by this as soon as I became the Principal at the Avenue I performed a new patient check on every patient who presented  and this now continues for all new patients. The Government as just announced it in today’s headlines ‘Free health checks could save lives, Jeremy Hunt says’
I remember in the first year I diagnosed 19 new diabetics including an 18 year old and many new patients walking around with high blood pressure.
Successful treatment by the family doctor was accepted with gratitude and the many failures were tolerated without rancour or recrimination.
Patients’ expectations were not high. The death of children from infectious disease was the way of the world. Mothers of feverish children expected, if the child was not to be admitted to the fever hospital, to be told that bed rest was crucial until the fever had fully subsided.
GPs’ hours were long, as most practices were single-handed and deputising services were non-existent.
I remember working alternative days and nights with my GP partner  aswell doing daily ward rounds at the geriatric hospital and the Cottage hospital.
image
There were no McMillan nurses and terminally ill patients were seen up to 4 times daily ( last visit 10pm)  to administer pain relief. We got to know these families well and the reward was simply managing the situation and showing empathywithe patient and the family  throughout and after the distressing illness.
 Local rota systems operated on a ‘knock-for-knock’ basis to make a half-day practicable. A car and a telephone were desirable – but not essential. If it mattered enough there was always a way of contacting the doctor sooner or later.
People did not trouble GPs without good cause. If someone phoned I was able to say how urgent was the call and if not very urgent I could finish my supper first and patients respected that you were someone who had a life. I did my own on-call until 2005 when the Government encouraged us to opt out.
 Most had to pay for the doctor and the medicines. The professional attitude to working class patients was frequently robust, and sometimes downright rude, but this was accepted with tolerance. In middle-class practices there were greater courtesies. However, where I worked in Wales the working classes were respected as their work in the mines and steelworks was tough and the Miners funded the Cottage hospital which had a maternity suite, general ward, operating theatre and a children’s ward and supplied ‘the opening medicine'( laxatives ) in the form of a delivery of stout each day!
There was the ritual preparation of a napkin, a spoon and a glass of water for the doctor’s visit. There might be five shillings (25p) on the mantelpiece for the fee; three and sixpence (17½p) if the family was not so well off.
High up the social scale the doctor might be treated as a rather superior type of servant. Patients often paid in ‘ kind’ by leaving home grown vegetables or hand-knitted garments at reception or even on your doorstep.

Medical diagnosis was often of academic rather than practical importance. Treatment was limited to insulin, thyroid extract, iron, liver extract for pernicious anaemia, digitalis, the new mercurial diuretics, barbiturates, simple analgesics, morphine derivatives and harmless mixtures.

In my experience medication such as Ipecac et Morph ( for coughs ) or Gentian ( tonic) Mist Pot Citrate ( known as cockles water) for cystitis Mist magnesium trisilicate ( ant- acid for indigestion) ,mandrax and barbiturates for sleeping and intravenous heroin for heart attacks , adrenaline for asthma were medicines I prescribed and administered regularly.
It was difficult to keep track of prescribing, all prescriptions were hand written often illegibly and I am sure compliance and abuse was not uncommon.
image
Records were in Lloyd George wallets and belonged to the Secretary of State and for written records this is still the case. Electronic records only started to evolve in 2001. Generally record keeping was poor and frequently doctors wrote inappropriate remarks on the notes such as PIN ( pain in the neck ie difficult patient) or a diagnosis of GOK ( God only knows) but this stopped when patients were allowed access to notes after 1990.

Entry into a practice was generally by purchase of goodwill, the usual price being one and a half times the annual income.
GPs started with a substantial debt. On average about 1,000 national insurance patients generated about £400-£500 per year, an income boosted by the care of the families who were not covered by national insurance.
Most  GP’s had no pension, waived fees or never received them from poor patients and I they retired due to severe ill- health or died  they spent the rest of their lives in poverty. A Benevolent Fund was established , fund-raising carried out by doctors wives. I remember local women coming for afternoon tea always on a Tuesday afternoon  at  the doctors house, raising money for doctors left in poverty.

The NHS Act 1946 provided a family doctor to the entire population. The Bill emphasised health centres that were to be a main feature. At public cost, premises would be equipped and staffed for medical and dental services, health promotion, local health authority clinics and sometimes for specialist outpatient sessions. The programme was aborted before it even started.

Whereas Bevan had persuaded consultants into the service in part by merit awards, the GPs had been unwilling to join until virtually the last moment. The public, however, were encouraged to sign on with those doctors willing to enter the scheme, leaving others with the choice of joining as well or losing their practices. Within a month 90 per cent of the population had signed up with a GP. Twenty thousand GPs joined the scheme as they saw private practice disappear before their eyes.

The NHS Act made it illegal to sell ‘goodwill’; instead a fund was established that compensated GPs when they retired, but it was not inflation-linked. The GPs’ contracted for a 24-hour service, the nature of the complaints procedures and even the patients’ NHS cards were virtually unchanged (and still are). GPs, fearing that they might be no more than officials in a state service, argued successfully for a contract for services rather than a contract of service. As a result they remained independent practitioners, self-employed and organising their own professional lives. The Spens reports determined pay, which was entirely by capitation.

GPs’ income depended on the number of their patients; even their expenses were averaged and included in the payment-per-patient. Their independence thus assured, GPs were taxed as though they were self-employed, yet, unlike most people in small businesses, they could not set their fees. With a few exceptions, such as payment for a medical certificate for private purposes, no money could pass between patient and doctor. This system, combined with a shortage of doctors, provided no financial incentive to improve services, but neither was there any incentive to over-treat patients.

Now many doctors are salaried working for self employed doctors or in PCT(CCG) health centres.

In 1966 the Royal College of General Practitioners submitted evidence to the Royal Commission on Medical Education. This was to prove of decisive influence in shaping the recommendations of the Commission when they were published in 1968 (Todd Report). The Report made a powerful case for the recognition of general practice as a separate discipline within medicine, requiring its own form of postgraduate training organised by general practitioners. The fulfilment of the College’s work came in 1976 when parliament approved legislation making vocational training a requirement for any doctor seeking to become a principal in general practice and set up new national organisations to administer the act.
I was one of the first doctors to be selected to be part of a Vocational Training Scheme which took 3 years to complete and involved 6 months in 6 specialities. I worked as a junior doctor in General Medicine/ respiratory medicine, obstetrics & gynaecology, paediatrics, orthopaedics and trauma and ENT and General practise and at the end of this received the post graduate degree MRCGP following an external examination.
I decided to work for a further year in paediatrics before becoming a Partner in a practise in Maesteg,South Wales.

I have to say I loved those days in General Practise and  felt it an honour to serve that community  and it was with great joy that a bus load of staff and people I worked with  travelled up to London to my wedding  when I married my clergyman husband.  Even though the rumour which went around the Thursday market was that I was  marrying a missionary from East  Africa rather than  a vicar from East Acton! Also they were very concerned that I was going to live in London- would I be safe?
I did arrive in London to a very different General Practise and I took several years to get used to a multicultural society and a’part-time service but more conducive to married life!
image
But as we all keep hearing the world has changed and we are forced to change with it but hopefully we can take the good things from the past recognise vast medical progress. People are more aware of their health and health prevention, communication and recording our work using IT has allowed us to better define the problems we face in order to improve the quality and efficiency of our work.
We can all be a Dr Tudor Hart recording results and findings on to  Dr Foster website.  (Foster Intelligence is a provider of healthcare information in the United Kingdom, monitoring the performance of the National Health Service and providing information to the public. It is a joint-venture with the Department of Health and was launched in February 2006. It aims to improve the quality and efficiency of health and social care.
It monitors the performance of the National Health Service and provides information to the public)

It makes sense to direct services where they are needed Southall needs more diabetic consultants and cardiologists than Reigate. Also to find out what we are doing well and what we are struggling to do effectively .
Based on results of this analysis and other audits it has become apparent how costly it is to use secondary(hospital) care if it can be done more or just as effectively and less costly in primary care.

However, it is paramount to knock down barriers of communication between hospital and primary care staff and I have seen great changes to improve this. Does a patient need to attend a hospital to hear everything is fine?

Blood tests can be carried out in general practise. Type 2 diabetes without complications does not need a specialist diabetic consultant and a mechanical back strain does not need an orthopaedic surgeon to treat. A few examples but there are many more and this has convinced both parties that a more rationale approach is needed to decide where a patient is best managed. Albeit, there are still health professionals out there who are vehemently hanging on to what they have always done but each year they are getting less and -at meetings those voices are disappearing.

The new NHS is evolving – the sun is rising.
image
Integration has been the NHS buzzword of choice in recent years, and unsurprisingly, features heavily in the college’s blueprint for primary care –

The 2022 GP.

The 20th century model of healthcare – splitting up hospital and community-based care, as well as health and social care, is ‘outdated’, the report says.

‘We are moving instead towards a 21st century system of integrated care, where clinicians work closely together in flexible teams, formed around the needs of the patient and not driven by professional convenience or historic location.’

GPs will increasingly work in federations, leading multidisciplinary teams encompassing nursing and hospital staff, using electronic records to support co-ordination of care.
image
Contractual arrangements will be varied, with many GPs employed in salaried roles by federations, foundation trusts, and third or private sector providers, alongside independent contractors, the report suggests.

As the NHS celebrates its 65th birthday, it is entering what the RCGP identifies as a new era.

Over the next decade, patients will face ‘more complexity, morechoice and more uncertainty and will rely on the expertise, skill and compassion of their GP like never before’.

The college has called for 10,000 more GPs and a sharp rise in funding to help the profession absorb the pressure.

But to remain fit for purpose, it says, general practice must evolve, not simply expand.

So what is the RCGP’s vision for general practice in 2022 and how
realistic is it?

Adapted GP role

The RCGP is clear that as part of this shift, ‘the role of the GP will need to be adapted’. The report, co-authored by RCGP chairwoman Professor Clare Gerada, outlines a vision of the 2022 GP as an ‘expert generalist’.

This new breed of GP will be trained to manage increasingly complex patients with chronic conditions and polypharmacy, handling ‘urgent and routine needs’, and providing ‘first-contact care to the majority of children and those with mental health conditions’.

GPs can no longer stick to the 20th century model, in which they are considered ‘omnicompetent independent doctors’, the RCGP argues. Instead they will need to work ‘as part of a family of interconnected professionals’ that could include hospital specialists given additional generalist training.

Many Medical students now do 4 months in General Practise as part of their registration which now takes 2 years. until a few years ago it was 12 months and was 6 months general medicine and 6months general surgery. Two thirds of medical students will become GP ‘s.
During the past year we as GP’s are meeting with specialised consultants to discuss complex patients and consultants are visiting GP’s to discuss management of particular conditions and communicate which type of patient needs referring.

Meanwhile, GPs will train to take on extended roles in core areas that need ‘a generalist approach’ – perhaps care of those with dementia, homeless patients or those in nursing homes.
This month care of all nursing home patients in the defined Ealing CCG area has been taken over by a group of GP’s who will manage the care of residents and be accountable for the standard of care.
This model will be extended to other groups of patients if it is successful.

Complex needs

Practices will also need to reshape their services to meet the needs of more and more patients with complex chronic conditions.
Forming ‘micro-teams’ that bring together primary care, social care staff and clinicians from other specialties, such as paediatrics or mental health, could help provide continuity of care to named groups of patients in need of extra support.

This team-based approach may also provide the solution to rising rates of doctors working part time, the report suggests, through an ‘increased focus on team-based continuity’ and more ‘buddying up’ arrangements between doctors.
This has been attempted over many years with great resistance but the climate is changing and those not wanting to comply will be under great pressure from CQC inspectors.

The standard 10-minute appointment slot will become a thing of the past. GPs of the future will offer ‘flexible lengths of appointments, determined by need’ and will need to ‘adapt their working day to offer fewer but longer routine appointments for review of patients with complex needs’.

Online NHS

A generation of patients brought up with the internet will mean many ‘will expect to interact with their general practice team virtually’, with traditional face-to-face GP visits ‘no longer accepted as the default way to access care’.
We already use emailing as a a way of communicating with patients and ordering repeat prescriptions. Also more recently patients will check their own blood pressure in a pharmacist, supermarket or using there own machine and having face-to-face much less frequently. Pre-consultation questionnaire will be used to prioritise what needs to addressed in the consultation.
My only concern is that opportunistic screening and the doctor- patient relationship will be limited. However, with doctors working less hours and larger practises the norm and finances strained this will be seen as the only way forward.

Better planning across federated practices will improve co-ordination and continuity of out-of-hours care, although GPs will not be required to offer direct patient-to-doctor access out of hours.

The RCGP vision also sets out plans to train GPs to have a better ‘understanding of the needs of their practice population’. This could help shore up the profession’s role in commissioning, amid Labour pressure to hand more control to local authorities.

Funding

Professor Gerada and her co-authors acknowledge that without substantial investment to expand the GP workforce and premises, ‘the vision will be made much more difficult or will become impossible’.
Small practises will not be viable and CQC will have the power to lose a surgery that does meet the required standards. This will encourage mergers of small practises but in my opinion it is better to look around and plan this before someone else does. Working in these multidisciplinary groups at present is helping finding like minded GP’s that can work together. There are some delightful caring young GP’s in the area who I would have no problem working with and they need to be nurtured.

Step one is winning the battle of ideas – an action plan in the report highlights a need to ‘promote greater understanding of the value generalist care brings to the health service’.

RCGP council member and deputy GPC chairman Dr Richard Vautrey believes this battle will be won over time, simply because no alternative exists. ‘It is economically essential for the NHS to be built on a primary care base, it’s in politicians’ interest to value it as the way the NHS can survive and thrive long term,’ he says.

The RCGP vision is realistic, he says, because many of the innovations in the report are already being delivered by GPs in parts of the UK.
We have formed a network ( a smaller section of the ECCG consisting of all local practises and meet regularly 1-2 times each month with other health care professionals to discuss complex cases and we have found ways of sharing resources and experiences which have most beneficial in managing patients biopsychosocial needs aswell addressing our own learning needs.

But he adds: ‘One concern is that as practices struggle with workload, it is hard to develop in the way they want to, because they don’t have the resources. Resources are crucial.’

The ball is in the government’s court – it must invest and build on the innovation and modern working of GPs across the country, or miss out on what The 2022 GP calls ‘a historic opportunity to harness the power of general practice to transform the health service we will have in 2022’.

image

GENERAL PRACTICE – THE EVOLUTION

 
Leave a comment

Posted by on July 30, 2013 in Current affairs

 

Tags: , , , , , , , , , , , , , , , , , ,