The five questions: what are they, and do they matter?

capture

In the most recent annual report from the Chief Medical Officer for Scotland, Dr Calderwood discusses the need to move towards a shared approach to clinical decision-making. Are we not already doing this? The evidence says not.

NHS surveys tell us that patients value highly the opportunities to discuss their care, the options open to them, and being involved in the decisions that shape their management. A survey undertaken by the Citizens’ Panel showed that while 92% of patients felt comfortable about asking their doctor about treatment, only 67% did so. Similar percentages were recorded for discussing risks and benefits. Why is there a gap? Patients report that the willingness of doctors, of how busy they appear to be, inhibit these discussions.

three talk

If we are to change our culture further (and it has already changed over the last fifty years) then we need to focus on how we enable these conversations. How often do we interrupt patients when they are talking? As well as restricting their narrative, it limits their expression of what is of concern. It emphasisis the agenda of the clinician and the pressures on their time. This needs to be more than tokenism, we need to really dig deep and learn better ways to do this. Having a good framework in which to conceptualise these conversations is important. One such structure is the three talk model. 

I also think that, as well as listening, and leaving space for debate and questions about management, we can coach patients to ask for better information. Some of this confidence comes from health literacy. Some comes from having the right words, the right questions to ask of clinicians as they leave our primary care consulting rooms and are passed on to secondary care colleagues, to other clinical teams.

This is where the five questions come in. The five questions were drafted by Choosing Wisely UK, which is part of global initiative to improve conversations between patients and their clinicians.  Five boards piloted the use of the five questions, encouraging people to ask clinicians about their management plans. Having the questions written down enables patients to take first steps in these discussions. The questions aren’t going to change the world, but they can empower patients to start these important conversations.

I have displayed these questions in practice leaflets, on the noticeboard in the waiting room, on lanyard cards, on signposting cards and on the practice website. I don’t know how well I would do with answering all of the questions all of the time. However, as well as providing concrete examples for patients, this produces an environment, a culture where patients are expected to discuss their care. This message is as powerful for my colleagiues as it is for patients.

A wise friend of mine, Dr Maria Duffy, commented that these questions appear very clinically orientated. They do not explicitly promote discussions around the social determinants of health. She works in Pollok and is a GP trainer as well as a GP partner. She is part of the Deep End group, practices who look after patients in more deprived areas, where there are higher proportions of patients whose social and economic background has a big influence on their health.

She would add:

  • Is going to the doctor the best way to address my problems?
  • What is there that I might change myself that would help?
  • How much do I expect to achieve by seeking a clinical solution?

While these questions do not focus on a shared approach to clinical decision-making, they encourage patients and clinicians to think outside the clinical box, to imagine other ways of tackling life’s problems.

However, it is not enough to parachute in to our surgery with the cards and the posters. The most important next step for me is to ensure that my colleagues understand the scope of what I am doing, that patients are engaged in the project, and that any practical top tips are spread to other clinical areas.

Letters to patients

As well as being a GP, I have been working in secondary care as a GP with a special interest in Dermatology. Around five years ago, I was feeling very annoyed with one of the practices that refers to the dermatology clinic. Patients were attending for review without having tried the treatment that I had suggested.

The dermatology clinic is usually rammed, and these appointments were adding unnecessary pressure on the clinic, wasting patients time, as well as adding a longer burden of ill-health due to skin disease. Nobody was happy.

I could have written to the practice and had a strop, but the practice involved was struggling to recruit partners or salaried GPs. They were relying on locum cover, and there didn’t seem to be an end in sight. In addition, other patients in other practices didn’t always seem to understand their treatment plans.

An aside here: most patients with chronic dermatological conditions have complex treatment regimens. This could include a pre-washing emollient, a soap substitute, a moisturiser, then a topical treatment, to be titrated up or down, and tapering to other treatments. Very few patients and GPs manage to get this all down at the first attempt.

I started writing my clinic letters direct to the patient with a copy to the GP, with consent. Nobody turned me down. The best responses were from relatives of patients with dementia, where a written care plan was useful for the team of carers. At the clinic, patients were advised to check with their practice for their prescription when they received their copy letter.

I didn’t do this as a proper improvement project, I didn’t measure follow-up outcomes, patient satisfaction, and I didn’t have a ‘spread’ plan. However, the feedback was immediate, and positive. GPs were in favour: they no longer have to contact patients to check up on new prescriptions. Patients were in favour, finding it helpful to have the treatment plan written down in the letter. Relatives were in favour, having a documented plan to follow. The secretary confirms that there is no additional work in doing the letters this way.

After 3 years of doing letters this way, I’m beginning to see other clinicians trying this out. Patients bring their letters to GP consultations, ready to discuss their treatment as more equal partners. I have been asked to advise other clinicians about how to structure their letters.

The biggest and best outcome is patients as equal participants in their treatment, and communication about their health. It is a culture shift, and it is gradual, and I am part of it.

Indication prescribing

I have come across something so simple, so easy to do, and so intuitive, that I can’t believe that I haven’t always done it. It helps patients understand their medication, and enables better conversations about concordance between patient and prescriber.

It is indication prescribing. I have always done this for PRN medications, without even thinking. For example, if I prescribe paracetamol, the prescription says ‘take two tablets four times a day for pain’.

Now, when I add a repeat prescription, I am adding ‘take one daily to treat high blood pressure’ or ‘take one tablet before meals to ease symptoms of irritable bowel syndrome’. So far, it has had good feed-back, it costs nothing, and it moves the responsibility for compliance, concordance, for treatment towards a more patient-centred model.

There will always be the patients who state that they only take four white tablets at breakfast, or one of my more memorable old ladies who used to keep her many medications in a bowl like pan-drops and helped herself to a few each day.

I hope, by making Indication Prescribing the norm in our practice, that these patients will become the outliers. For each medication review by prescribers and the practice pharmacist, an opportunity to make this become the way things are done around here.

A Primary Care Christmas Carol: Stave 5

By Dr Pete Aird, written for Resilient GP

Stave Five – in which we are given cause for hope

It was early morning when Scrooge woke. He sat up in bed and looked around the room. Everything appeared as normal and yet, within himself, he felt changed. Perhaps he was being naive but he felt a sense of optimism that he hadn’t known for years, daring to hope that things could get better.

It was then he remembered it was Christmas Day. ‘At least I think it is,’ he said to himself excitedly, ‘assuming that all three Spirits did indeed visit me last night and that I haven’t missed the great day completely’. He ran to the window and looked out. A light layer of snow coated the ground which heightened his excitement still further. And yes, a young lad was trying out a brand new bicycle, no doubt a freshly unwrapped Christmas present. Add to that the fact that one or two folk were making their way towards a church whose bells were ringing joyfully in the distance, it was, with the utmost certainty, Christmas morning.

But there was no time to lose. He had to check on Bob Cratchit. He dressed hurriedly and ran down the stairs and out into the crisp morning sunlight which reflected off the snow-covered ground. Scrooge got into his car and within a few minutes he was outside the house of his trainee. He knocked loudly on the door but there was no answer. He knocked again and, when there was no response, shouted through the letter box. Still there was only silence. Scrooge moved round to the side of the house and looked through the same window he had the previous evening, its curtains still only partly drawn. Cratchit was sat there, just as he had been when Scrooge and the Ghost of Christmas Present had left him earlier. Scrooge hammered on the window until, at last, he saw movement and a wave of relief surged through him. Slowly Cratchit stood up.

‘Open up Bob. Open up this instant. Do you hear?’ Scrooge shouted at him though the glass. ‘Open up. It’s Christmas Day!’

Cratchit, clearly half asleep and still the worse for the half bottle of whisky he’d drunk the night before, gradually stood up and made his way to the front door. Scrooge had never been one for outward displays of affection, but now, as Cratchit opened the door, Scrooge greeted him with a hug that was as welcome as it was unexpected.

‘How are you Bob? Are you alright?’

‘I’ve a bit of a headache if I’m honest. And not one that’s improved any by all your hollering. But why are you here? Has something happened? Have I done something wrong?’

‘On the contrary. If anyone is at fault it’s me, for not appreciating you more. And to show you that I mean it, what do you say to a partnership come August when you’ve completed your training? I’d be proud to call you my partner’

‘You must be desperate!’

‘Desperate? Of course I’m desperate! Have you seen the state of the health service? But that’s not the reason for my offering you a partnership. I would like you to help me change the way we do General Practice. It’s a conditional offer of course – conditional that is on you seeing some change. There’s no way I’d want you to commit to a lifetime of working the way we have of late.’

‘Well I guess I’ll have to think about it. But thank you. I didn’t realise that you thought I was up to the job’.

‘Of courses you’re up to the job. We all worry sometimes that we’re not though, so don’t be surprised if you find yourself questioning the fact – that’s normal! The trouble is that we’re all so anxious imaging that we have to be perfect. We’re not God you know – even though both the government and our patients sometimes expect us to act as though we were.’

‘Well I guess you’re right there’

‘Of course I’m right, I’m your trainer! Now, what’s with the whisky and the packet of antidepressants?’

Cratchit looked down at the ground. ‘I didn’t take any, just thought about it. I guess I was just feeling a little overwhelmed. I was being stupid”

‘It’s not stupid to feel overwhelmed. There’s no shame in being asked to do more than you can cope with. The only foolish thing is to not realise you need to say ‘No’ sometimes – that sometimes you need help and have to ask for it. I’ll try and make that easier for you from now on. Promise me though that you’ll not let your thoughts travel in such a dark direction again without letting me know.’

‘I’ll try not to – I promise.’

‘Excellent. Remember, we’re in this together.

Cratchit couldn’t quite believe what he was hearing and couldn’t stop himself voicing the question that was on his mind.’

‘Dr Scrooge,’ Cratchit began

‘It’s Ebenezer. Call me Ebenezer’.

Cratchit hesitated and then tried again. ‘Ebenezer.’ It seemed strange to hear the name spoken aloud, ‘I hope you don’t mind me saying this, but something seems different about you today. Has something happened?’

‘I rather think it has,’ said Scrooge. ‘As a profession we’re convinced everything’s wrong. A lot is of course, but I see now that if we can see what the problems are, then surely we stand a chance of making changes.’

‘But how?’

‘To be honest, I’m not quite sure. One thing would be our need to challenge the idea that medicine has all the answers. We need to say ‘No’ to the over medicalisation of life and be honest with both ourselves and our patients as to what we can and can’t do. Another thing would be that we have to be allowed to behave as the professionals we were trained to be. Once we were seen as people who could be trusted to make judgments in the best interests of patients. Now it seems we are seen as mere service providers, required to unquestionably follow guidelines regardless of how appropriate or otherwise that might be. It’s as if we’re not considered competent to try to decide what is best for our own individual patients. But one size doesn’t fit all. And so we need to fight to retain the doctor patient relationship that underpins good general practice and not allow it to be lost in the rush to conveyer belt medicine. We have to take back control over our work, make our own decisions as to how to apply medical knowledge to each individual situation and have the courage to resist the inappropriate demand to behave in ways that are imposed on us by government, pharmaceutical companies and society as a whole. That would mean better health for our patients and happier working lives for ourselves. That’s something I can aspire too, and knowing what it is I’m aiming for might just give me a chance of fathoming out how I might go about working towards it. At least, that’s my hope.”

Scrooge, in his excitement, had been pacing around the room. Now, pausing for breath, he sat down.

‘But that’s enough of all that for now. We can get together tomorrow and plan then just how exactly we’re going to do things differently. We’ll call it a practice away day. Just think of all the CPD hours we can claim! So, what are your plans for today?’

‘Well I had planned on a spot of revising for the CSA.’

‘Revising for the CSA. What nonsense – you’d pass that tomorrow with your eyes closed. Like it or not, you’re spending the day with me! We’ll have dinner at my house. I ordered a lorry load of food from Waitrose last week and there’s no way I can manage it all on my own. In fact there’s more than enough for two. Quick, go and get yourself sorted out. I’ve got an idea – one that might, for the first time in my career, satisfy my appraiser that my reflections have altered my practice!”

It wasn’t long before Cratchit was sat in the passenger seat of Scrooge’s car wondering where Scrooge might be taking him. A few minutes later they pulled up outside a block of flats and Scrooge led the way up the steps to the second floor. He knocked on a door.

“Who lives here?” asked Cratchit.

“Mrs Gray. She’s lived here alone since her husband, Timothy, died a few years ago. He was a short man. He had some kind of growth hormone deficiency I believe.’

Eventually, the door opened, and Mrs Gray stood there, evidently astonished to see her GP.

‘Good morning Mrs Gray. And a very merry Christmas to you.’

‘Well a very merry Christmas to you too Dr Scrooge. But what brings you here? Is it about the chocolates?’

‘Certainly not. We, that’s Dr Cratchit and I, have come to pick you up and take you off to my house for Christmas Day. What do you say? Will you come?’ Mrs Gray hesitated, uncertain if she should.
‘Please come, Mrs Gray. It would mean a lot to me’

‘But I’ve nothing to bring’.

Scrooge looked over her shoulder and saw the box of chocolates on the kitchen table. ‘What about those?’ Scrooge asked, ‘You don’t have to bring anything, but if you’d like to make a contribution…’

‘But I’m pre diabetic Dr Scrooge, I need to be careful what I eat’

‘Who told you that?’ said Scrooge, a broad grin forming on his face. ‘Not a doctor I hope. Believe me Mrs Gray, you shouldn’t believe everything we doctors tell you!’

With that, Mrs Gray tottered to the kitchen, picked up the chocolates and made her way back to the front door. Then, together with Scrooge and Cratchit, she made her way slowly down the stairs. Half way down, Scrooge stopped.

‘You go on Bob, I’ll catch you up in a moment. It’s just that I have a feeling that, as a GP, I am, for once, ideally positioned to reduce hospital admissions’

He ran back up the stairs and knocked on the door of the flat opposite that of Mrs Gray. A man opened the door.

‘I don’t want to appear interfering,’ Scrooge began, ‘but your son will develop a rash later this morning. When he does, try wiping it off with a damp cloth. Trust me, I’m a doctor!’

With that Scrooge turned and headed off back down the stairs leaving the man speechless behind him.

…………………………………

A couple of hours later, the two doctors and their elderly patient sat around a dining table enjoying Waitrose’s finest. As the meal drew to a close, Cratchit turned to Scrooge

‘I think I’ve made my decision’ he said.

‘What decision is that?’

‘I’d like to accept your offer of a partnership, if I pass the CSA that is’

‘That’s wonderful Bob, simply wonderful!’ Scrooge stood up and shook Crachit warmly by the hand and then, for the second time in the day, embraced him warmly. ‘This is excellent news – for me and for the practice. We should organise a party!’

Scrooge dashed out of the room and returned with a sheet of paper on which were listed all the practice staff, their names and telephone numbers.

‘And a party we shall have,’ declared Scrooge handing the list to Cratchit. ‘Start ringing round and invite anyone who’s free to join us here this evening. Perhaps someone will bring some of those Prosecco and pink peppercorn Pringles – are they really a thing? Only don’t let me drink too much. The last time I did that there was an incident at a local supermarket, the details of which you don’t want to know!’

‘Can I say something Dr Scrooge?’ Scrooge turned around and saw that Mrs Gray had got to her feet. With one hand she steadied herself by holding onto the table and with the other she was holding a glass of wine. ‘I’ve had a lovely time today and I want to thank you for all your kindness. I’d like to propose a toast, to both of you, the practice, and the NHS as a whole. It’s something my late husband used to say.’ She raised her glass higher. ‘God bless us, every one’, she said.

‘God bless us, every one’, repeated Scrooge and Cratchit, smiling as they raised and carefully tapped their glasses together.

…………………………………

In time, Cratchit passed his CSA and joined Scrooge in partnership and when Scrooge came to retirement he did so reluctantly. He considered himself to have been a fortunate man to have had the career he did. Cratchit continued on, the practice grew and new partners were appointed. Though their processes and procedures didn’t always meet with the full approval of the CQC, the partners always enjoyed strong support from their practice population. Scrooge’s experiences that night may not have changed the state of the NHS as a whole, but they did change how the NHS was manifested in one small corner of that great organisation. Scrooge never had any further encounters with spirits – he had no need of them. Afterwards it was always said of him that he was a doctor who cared for his patients more than he cared how he was thought of by people in power and that he knew how to support others and how he needed the support of others himself. May that be truly said of us all.

And so, as Mr Gray observed, ‘God bless us, Every One!’

A Primary Care Christmas Carol: Stave 4

By Dr Pete Aird, written for Resilient GP

Stave Four – in which the future appears far from bright.

Alone again, Scrooge, out of force of habit, checked his phone for notifications. No red circle had appeared in the corner of the Facebook icon to indicate that someone, somewhere cared about what was on his mind. This was not unexpected as it had been a long time since anyone had ‘liked’ him – still longer since he’d been loved. It was a surprise to him, therefore, when the phone vibrated alerting him to the arrival of a text message.

‘This is to remind you that your appointment with the Ghost of General Practice Yet To Come is scheduled for now. Please access your Babylon Wealth account and prepare to speak to somebody with no soul’

Scrooge noticed a new app had appeared on his phone’s home screen. It glowed menacingly, demanding to be tapped. Scrooge couldn’t help thinking that ‘Babylon’ was a curious name for a company to chose to call itself, recalling, as he did from his days in Sunday School, how Babylon represented all that was evil, ‘the mother of earth’s abominations’ and a ‘dwelling place for demons’. Perhaps, he concluded, it was strangely fitting after all.

Against his better judgement, Scrooge opened the application and was greeted by a disclaimer making it clear that any advice given was only valid for minor, self limiting medical conditions and any harm that resulted from Babylon clinicians failing to appreciate a more serious underlying problem was not their responsibility. Those experiencing more complex health concerns were directed to approach less forward thinking health providers. Scrooge was requested to indicate his acceptance of these conditions and, having complied, the screen gave out a burst of light and there then appeared what looked for all the world to be a businessman dressed in an executive suit.

‘Welcome to Babylon Wealth,’ the man announced. ‘where your health needs are our business opportunity’. He smiled a self-satisfied smile, which Scrooge did not find reassuring.

‘Are you the Spirit of General Practice Yet To Come?’ Scrooge enquired.

The spirit’s smile wavered a little. ‘Is that what The Ghost of Christmas Present called me? She is so yesterday. I’ve been rebranded and, from now on, I am to be known simply as ‘The Future’. Exciting isn’t it? Now, how can I profit from you?’

‘I believe you’re supposed to show me my future’

‘Yes of course, but I don’t have time to talk to you about that in any depth. So, in the interests of efficiency, I’d like to request that you utilise this corporate video feed. If you’ve any further questions you’ll be required to make a further appointment. You will receive an invoice for the services I have provided today and your account will be automatically debited the requisite amount. Thank you for using Babylon Wealth. Have a nice day.’

Lost for words, Scrooge tapped the link that had appeared on his phone and continued to gaze at the screen at what seemed to be, if such a thing was possible, a broadcast from the future. It began with an aerial view of a huge featureless building over which an audio commentary played. “Welcome to the world’s first fast health outlet. – Where health is cheap and time is short”. A notice board at the entrance of the building came into focus revealing that ‘The National Wellbeing Centre’ was open 24 hours a day, 365 days of the year. Two enormous panels straddled the entrance bearing images of the Secretary of State for Health and the President of the National Pharmaceutical Board. They were pictured smiling benignly down upon the multitude who were milling around a large reception area.

As the camera roamed around, the audio commentary explained how no appointment was necessary but that, on arrival, patients were required to utilise electronic panels positioned in the foyer to answer a series of questions by way of ‘Yes’ or ‘No’ answers only. As a result of the responses that were given, each individual would then be assigned to a wellbeing advisor. If, and only if, it was deemed necessary that face to face contact should ensue, they would then wait outside one of the 666 consulting rooms housed within the complex until their allocated interaction was scheduled. Patients were advised that only objective quantifiable, symptoms could be dealt with and that treatment options would be determined solely on the basis of the medico-economic considerations pertinent to each individual case. Reassurances were offered that a number of payment options were available.

Around the foyer, electronic panels displayed information for consumers alongside a number of company disclaimers:

“Due to many drugs now being of limited availability, if medication is advised, the sourcing of that medication is entirely the responsibility of the customer.”

“Please be assured that we respect your anonymity and consider it of paramount importance to maintain the highest levels of confidentiality. In order to guarantee this, no wellbeing advisor will consult with the same client on more than one occasion and no personal communication is permitted between clinicians. A mask can be worn over the face if desired.”

“The National Wellbeing Centre cannot accept responsibility”

“Strict quality control measures are in place to guarantee the optimal outcome of each clinical interaction. Each consultation is electronically monitored and any deviation from company protocols will result in disciplinary action being taken against the clinician concerned.”

The announcements seemed endless, each, it appeared to Scrooge, alienating the individual in need still further from the connection they craved with somebody who just might care enough to show a little concern. Patients were managed without any warmth or compassion – processed by a system that existed solely for the benefit the state that had created it.

As Scrooge continued to watch, the announcements kept flashing across the screens, hypnotising those whose eyes were drawn lifelessly to their incessant messages. Dehumanised, everyone became the same – And that same was nothing more than a reservoir of data.

“Please be aware that displays of emotion are not encouraged in consultations and tissues are therefore not provided in the consultation rooms.”

“Customers will not be permitted to leave the centre until the requisite post interaction forms are completed. Not only does the filling of these forms provide the essential feedback necessary to identify suboptimal clinician performance, the personal data requested allows us to identify those agencies from whom we will profit most by our facilitating their communication with you.”

“Everybody here at the National Welfare Centre wishes you, and your purchases, a very merry Consumertide.”

And then, finally, before the cycle of messages started once more, one last announcement:

“Turmeric is available from the kiosk in the foyer”

The camera returned to a view of the outside of the building and Scrooge caught a glimpse of a small panel attached to the wall next to the main entrance. He paused the video and expanded the image to take a closer look. He could just make out the words that were inscribed on the ill maintained copper plate.

‘This facility was erected on the derelict site of what was once known as a GP medical centre. Drs J. Marley and E. Scrooge worked here for many years providing a form of medical provision which today is only of historical interest. The medical centre operated with the quaint intent to provide medical care that was responsive to patient needs. Dr Marley’s untimely death left Dr Scrooge struggling as he found it impossible to replace his former partner. He continued for a time supported by a series of doctors in training, but, after a personal tragedy struck the medical centre, it was no longer considered fit to remain a training practice. Dr Scrooge continued alone for a brief time, but the pressure of working in such an inefficient manner soon proved too much and he himself succumbed to a stress related illness. Happily, his demise proved the catalyst for the development of the progressive wellbeing centre that we benefit from today.’

Scrooge could not believe what he had witnessed. It struck him that there had at no point been any mention of there being any doctors present in the running of the well-being centre. It was almost as if there was now nobody providing a professional opinion, nobody making a judgement, nobody applying a bit of wisdom and that clinical algorithms were being used to make each and every decision. Were there, he wondered, any doctors still in existence at all? Perhaps, in the future, nobody wanted to be one. The questions kept coming. Was this really the future of the health service that once, years previously, he had been so proud to be a part? What about Cratchit? What did the ‘personal tragedy’ refer to? And what of his own future? Could any of this be changed?

Scrooge tapped frantically on his phone seeking a further appointment with the Ghost of General Practice Yet To Come. Fortunately, for all the faults of Babylon Wealth, having made the appropriate additional payment, an appointment was easy to come by, and soon, the business-like figure of the spectre, who had been so brusque with him earlier, appeared on the screen once more.

‘Good Spirit’ Scrooge implored, ‘Assure me that I may yet change these shadows you have shown me by an altered life’

The spirit laughed. ‘It’ll take more than one doctor changing to alter the future of the health service. That’s the trouble with you people. Too often you think it’s all down to you’. The spirit made a poor attempt at a Clint Eastwood impersonation, ‘A doctor’s got to know his limitations.’

‘And besides, what’s your problem? What we’re doing merely reflects the ideology of the nation – that everything comes down to money. We measure and record data because data sells. What we understand at Babylon Wealth is that people are commodities. For example, we record an elevated cholesterol solely because we know there is somebody out there who is selling a product to reduce lipid levels and is willing to pay for the information we collect. We don’t care about people, only the wealth that they generate for us.’

‘But it’s not all about money’, Scrooge insisted.

‘Isn’t it?’ countered the spirit. ‘It seems to me that everyone has a price Dr Scrooge. Are you really the exception?’

‘Well maybe I do have a price, but if I have, it’s at least partly because, in recent years, with so much of the joy having been sucked out of the job, the only way that I’ve been in any way rewarded for my efforts is financially. There’s no appreciation from those who call the tune, no recognition of how difficult the job has become and nothing but constant demands that I must do better. Take appraisal – if a requirement to show year on year improvement doesn’t amount to saying that we’re not good enough as we are, I don’t know what is. Something has to change’.

‘Well good luck to you with that, Scrooge. I concede that, as a profession, challenging the status quo rather than capitulating to the spirit of the age whilst all the while laudably endeavouring to deliver its impossible demands would be a step in the right direction. But I can’t see it ever happening – you’re all too busy just trying to keep your head above water to organise a concerted campaign for change.’

‘But let me try, spirit. Let us try. I have learned my lesson well this night. Perhaps things need not turn out the way you have shown me”.

And with that, Scrooge deleted the Babylon Wealth app from his phone, never to be installed again. He got back into bed. He’d seen and heard quite enough.

A Primary Care Christmas Carol: Stave 3

By Dr Pete Aird, written for Resilient GP

Stave Three – in which our tale takes (trigger warning) a darker turn

In the few minutes he had to think before the next ghostly visitor was due to arrive, Scrooge reflected on the events of the evening so far and wondered if he should try to claim a few hours of CPD. However, anxious as to how his appraiser might respond to such revelations and fearful that his reflections may be used against him, he concluded, as many before him, that it would be best not to put his thoughts down in writing.

He then realised that it was almost half past two. Was he not to be visited again tonight after all? But within a moment of his beginning to wonder this, he was woken from his reverie by the sound of his bedroom door bursting open and the arrival of a rather flustered looking figure entering the room. She was carrying a pile of papers in one hand whilst tapping into the mobile phone she held with the other.

‘I’m sorry to keep you waiting’, the spectre began. ‘I’ve been so busy tonight and the last chap I visited had several issues that he wanted me to provide spiritual insight on. Blow me if he didn’t have a list! Now what seems to be the problem? I am the Ghost of General Practice Present. Did you have any ideas, concerns or expectations as to how I might haunt you?’

Scrooge looked back at the apparition somewhat non-plussed. He hadn’t asked for the visit and, other than his previous encounters that night, had no experience of consulting with individuals from beyond the grave. Though highly concerned by the present turn of events and expecting to find the whole thing highly disagreeable, he had very little idea as to quite how the encounter should progress. Consequently, Scrooge said nothing.

‘Oh dear,’ said the ghost, unnerved by Scrooge’s silence, ‘This is awkward. I told Marley that there was little point in my visiting you without you being willing to see me. You see it’s so hard to help somebody unless they realise they have a problem and want to be helped.’ Still Scrooge found himself lost for words.

Rather than using the silence as a technique for therapeutic communication, the ghost laid the papers that she had been carrying down upon Scrooge’s bed and started flipping through the pages. ‘I’m sure there is a guideline for this situation somewhere. Give me a minute and I’ll be with you as soon as I find it. I don’t want to get this wrong.’ A few minutes passed, at the end of which the ghost seemed to have found what it was that she was looking for. ‘Ah yes, that’s it – come with me. I’m to show you how Christmas is being spent by others this year. Only I’m running short of time so we’ll have to make it quick’.

Once again, Scrooge was taken by the hand but, somewhat to his disappointment, she led him down the stairs in the conventional fashion before continuing through the front door and out into the night. ‘I’m afraid that these days we don’t employ the use of magic flight’, the spirit explained, ‘There’s no evidence for it, you see. It’s all evidence based hauntings these days’.

The fog had thickened making it difficult to see where they were going but the ghost still had hold of her phone and had entered the post code of their destination into Google maps. Before long they reached a block of flats and proceeded to climb the communal stairs. On the second floor, they passed through the wall into the home of a young family, the spirit assuring Scrooge as they did so, that the Celestial Institute for Ethereal Excellence had approved, in highly selected cases, what was known in the profession as quantum tunnelling, provided said cases met stringent eligibility criteria.

The flat bore witness to the fact that it was Christmas Day. The mantelpiece and sideboard were covered with Christmas cards and coloured paper chains were hanging from the ceiling. In the corner was a Christmas tree under which a three year old boy was happily making good use of the colouring set he had recently unwrapped. He stood up and walked into the kitchen where his parents were preparing dinner. They turned to him and noticed that he was covered in red spots. Immediately his mother emptied the pint glass of Prosecco she was drinking and used it to perform the ‘tumbler test’, her anxiety being heightened all the more when the rash failed to disappear. She pressed the speed dial button on her phone and called ‘111’.

‘I’m worried about my son – he’s covered in spots’ she exclaimed to the call handler. ‘No – he seems well in himself…No – no vomiting or fever…No – no headache or tummy pain…No – no catastrophic loss of blood and No – he has just the one head’. The list of negatives continued until the questioner focused in on the rash. ‘Well it’s almost as if he’s been marking himself with a red felt tip pen!’ The women listened to the call handler for a few moments longer before ending the call.

‘What did they say?’ her partner asked.

‘Something about a non-blanching rash being possible meningitis and that it’s better to be safe than sorry. They’re sending an ambulance.’

‘Bloomin’ right too. Now let me refill your glass, we can’t have you sober when it arrives!’

The Ghost of Christmas Present indicated to Scrooge that it was time to move on. Their next stop was just across the stairwell. Passing once more through the walls of the property, Scrooge recognised Mrs Gray, the frail elderly lady who lived there, as one of his patients. She was nearing the end of her life due to her having advanced metastatic disease. A single Christmas card lay face down on the dining room table, alongside of which was a box of chocolates she had bought for herself in an attempt to make Christmas Day, the fifth she’d have spent alone since the death of her husband, at least a little special. She knew it would probably be her last. As Scrooge looked on, the woman picked up the chocolates and shuffled slowly across the room and then, for want of anyone else to give them to, placed them in the kitchen bin.

‘What’s she doing?’ Scrooge asked the spirit.

‘She doesn’t think you’d approve if she ate them’ replied the ghost, who then proceeded to point to a letter held to the fridge door by a magnet commemorating the Queen’s Silver Jubilee. It was from Scrooge’s medical practice informing her that her recent routine blood tests had revealed that she had a slightly elevated HBA1c and that she was therefore classified as ‘pre diabetic’. Included with the letter was a leaflet giving helpful advice on healthy eating.

Scrooge stood staring at the woman. He realised that, though if asked to relay the ins and outs of all her most recent blood tests he would have been up to the task, in recent years at least, he’d not really known her at all.

The spirit had left the flat and Scrooge hurried to catch her up. They walked together without talking until they came to a house that Scrooge had never visited before. Here they stopped and stood outside the window of a dimly lit room. Peering in through the poorly drawn curtains they could see the figure of Bob Cratchit. He was sat, his head in his hands, surrounded by various medical text books. To his left was a half empty bottle of scotch and a packet of antidepressants. He was writing a note.

Scrooge turned to the Ghost of General Practice. ‘What’s he doing?’ he asked.

‘Struggling’ she replied.

‘But why? He’s such a good doctor’.

‘He is indeed. But he doesn’t know it. He has come to believe that he has to be perfect – that every guideline must be followed and a failure to do so will result in legal action being taken against him. He’s taken on the burden that comes from believing that medicine has the answer to every problem experienced by a broken society. He thinks it’s all down to him. He has been worn down by the constant demand from both society and the profession that he must perform better – that good enough is not good enough. He’s exhausted by the never ending assessment of his performance and crushed by the weight of the responsibility he feels. He lives in the constant fear that it’ll all be his fault if anything bad ever happens. He too feels all alone this Christmas.’

‘But this afternoon? He asked to leave early to spend some time with his family’

‘Indeed he did but the truth is that he hasn’t much in the way of a family – just a couple of friends he thinks of as family. In reality he had hoped to meet those friends for a drink but things didn’t quite work out the way they were planned. When he left the surgery late yesterday he went back to check on one of the patients he’d visited. Their condition had deteriorated and he arranged an admission but he was left feeling guilty and anxious. As a result he didn’t think he’d make very good company. And besides, he was worried about his CSA exam and thought the time would be better spent preparing for that.’

‘But he’ll pass the exam easily’ Scrooge exclaimed. ‘He’s come on leaps and bounds since that unfortunate misunderstanding the first time round. The patients love him – and the staff. He’ll make a great GP’.

‘Have you ever told him that?’

Scrooge fell silent. Perhaps he could have been a bit more supportive, encouraged a little more. Perhaps he could have helped him steer a course through the mass of expectation and enabled him to distinguish between what was genuinely important and what could appropriately be ignored. Perhaps he could have been the kind of trainer Fezziwig had been to him – one who, despite the changes enforced on the profession, could still see the joy of working in general practice and convey a little of that to the next generation – one who would fight for what was worth fighting for rather than retreating into cynicism, bitterness, and resentment.

‘I never knew he felt so alone. I never knew he was finding it so hard.’

‘Did you ever ask?’

Scrooge’s head fell. ‘Can I speak to him now?’

‘I’m afraid not. He won’t be able hear you, and what’s more our time is up. We must go.’

‘But I must do something’

‘That’s as maybe – but you have another appointment to keep. You must meet the Ghost of General Practice Yet To Come.’

The ghost started back towards Scrooge’s home. Scrooge himself lingered a little longer at the window in the hope that Cratchit would see him and appreciate his concern. Finally he turned his back on the scene and trudged slowly after the ghost who was now some yards ahead of him. Behind him, Cratchit slipped silently into the deepest of deep sleeps.

The spirit accompanied Scrooge back to his room but, before she left, she had one small request.

‘I’d be most grateful if you could fill in this form by way of giving feedback on my performance this evening. And it would be very helpful if you could indicate whether you’d feel able to recommend me to your friends and family…’

Regretting the choice of words even as she spoke them, an awkward silence arose between them. The spirit looked at Scrooge – Scrooge looked back

‘…or perhaps just an acquaintance…a passer by even?’

Sensing that now was clearly not the time, the Spirit said a hurried goodbye and left, leaving Scrooge alone with his thoughts. He couldn’t stop thinking about what he’d seen. He tried to convince himself it was all a dream, that none of it was real. Had things really become this bad? And could the future be worse? He had a feeling he was about to find out.

A Primary Care Christmas Carol: Stave 2

By Dr Pete Aird, written for Resilient GP facebook page

Stave Two – in which Scrooge fondly remembers

Shortly before one in the morning, Dr Scrooge woke in a cold sweat and sat bolt upright in his bed. This was not unusual for, in recent weeks, the stress associated with an impending visit by the CQC had frequently disturbed his sleep. Moments later, however, his thoughts were diverted from the need to get on and write those mandatory protocols on the secure overnight storage of hand towels and the safe use of the stairs, as, at one o’clock precisely, his bedroom door creaked open and a strange looking fellow crept into the room. Over a woollen cardigan he wore a tweed jacket complete with leather patches on the elbows. On the end of his nose was perched a pair of pince nez glasses and in his hand he carried a battered black Gladstone bag.

‘Are you the spirit, sir, whose coming was foretold me?” asked Scrooge.

‘Indeed I am’ the apparition replied. ‘I am the Ghost of General Practice Past. I’ve come straight from a meeting of my celestial Balint Group. And my what catharsis we enjoyed there this evening. Your former partner, Jacob, was in attendance. He’s a good chap, a jolly fine fellow. But enough of that,. Come along with me – he has sent me to show you what General Practice once was.’

The spirit held out his hand and Scrooge instinctively took it. As he did so, Scrooge felt himself being lifted, as if weightless, from his bed. The spirit led him to, and then through, the wall of the bedroom and then on into the night air. They journeyed until they found themselves in the oak panelled surroundings of what appeared to be a gentleman’s club. A number of elderly men sat together in high backed leather chairs. All were doctors, enjoying a glass of port after a drug sponsored Christmas meal. With them was a medical student who was attached to one of their number.

‘Listen to these chaps’, the spirit said to Ebenezer, ‘Each and every one is a fine fellow – a jolly good chap. You could learn a thing or two from what decent sorts like these have to say.’

The men were taking it in turns in regaling the medical student with tales of their working life.

‘Of course, these days, the youngsters have it easy. They only work a mere seventy two hours a week you know. In my day it was eighty one’
‘Eighty one hours? You had it easy. It was all internal cover when I did my house jobs. In real terms, I did a hundred hours a week’
‘Only a hundred hours a week? Luxury. I was running a GP practice single handedly by the time I was 23.. On call every hour of every day.’
‘That’s right. We had it tough as GPs. One hundred and sixty eight hours a week we worked – and, of course, we had to provide all the obstetric care – home deliveries every day’
‘And most of those were C.Sections – we had do the operations with only kitchen utensils for surgical instruments and a bottle of brandy for an anaesthetic’
‘Aye – and if you tell that to the medical students of today, they’ll not believe you.’

The spirit indicated that it was time to move on and Ebenezer readily agreed. He’d heard it all before. The walls of the room blurred and faded and gradually, as things came back into focus, Scrooge realised that they were now high above rolling hills. Passing over snow covered fields and lanes they travelled until they came at last to a small town and then on to a house that Scrooge recognised as his childhood home. Outside the dwelling, a car pulled up. The familiar figure of his family GP clambered out of the vehicle and made her way up the garden path to the front door. A woman was waiting anxiously for her arrival. They exchanged a warm greeting from which it was clear that these two individuals had known each other for years and that each liked and respected the other. The woman led the doctor up the stairs to a room in which a boy lay, pale and in obvious distress.

‘Thank you for coming doctor, I know you’re busy but I didn’t know what to do. Ebenezer’s usually such a healthy child but he seems now to be struggling with his breathing.’

‘It’s no trouble Mrs Scrooge – let’s take a look at him.’

The doctor knelt down by the bedside and smiled at the boy who managed to smile weakly back. Ebenezer liked the doctor. He’d visited her a number of times over the years but this was the first time she’d ever visited him. The doctor asked a few questions and then carefully examined the boy paying particularly careful attention to his chest. When she was done, she turned back to his mother and gave her her diagnosis.

‘I’m afraid it looks like we’ve a case of pneumonia on our hands. He’s really quite poorly. He’ll be needing the help of my colleagues at the hospital. We best get him there as soon as possible.’

Scrooge looked on and wondered how she could say such a thing without a computer and a pulse oximeter to enable her to assess any risk of sepsis. She hadn’t appeared to even consider a CURB-65 score. None the less, a few phone calls were made and, before long, the doctor, having given an assurance that an ambulance would soon arrive, an expectation Scrooge thought fanciful in the extreme, placed her hand on Mrs Scrooge’s shoulder as if to say that everything would be alright, and made her goodbyes.

‘Do you remember that day Ebenezer?’ asked the Ghost of General Practice Past.

‘I do,’ Ebenezer whispered, taken aback at how emotional he was now feeling. The spirit smiled to himself as he sensed that Scrooge was close to tears. He loved catharsis – catharsis was good. ‘She was such a lovely doctor’, Scrooge continued. ‘Always so kind and reassuring. She’d become almost a part of the family having visited so frequently during the last days of my fathers final illness. She always seemed to have time. It was because of her that I decided to become a doctor. The way she practiced medicine made it seem to me like such a wonderful job to have. She seemed to me to be a fortunate woman.”

‘A fortunate woman indeed’ agreed the spirit. ‘A fortunate women and…’ he paused, thrown for a moment, ‘…a good chap’. The spirit hesitated again and then added, as if to try and reassure himself, ‘She’s was a jolly fine fellow.’

With that the ghost again took Scrooge’s hand and soon they were once more travelling through the night sky. On and on they flew until they came to a village hall decorated brightly with all manner of coloured lights. A Christmas tree strewn with tinsel and still more lights stood by the entrance door. Inside Scrooge recognised the staff of his GP training practice. Some talked, other laughed and a number danced enthusiastically to music being provided by a band. All were clearly enjoying the opportunity to relax and have fun together. A portly man then stood up and called for a bit of hush. It was Dr Fezziwig, the senior partner of the practice and Ebenezer’s one time trainer.

‘A moment’s silence if you please everybody. If I might say a few words. Thank you all so much for coming this evening. I hope you’re having a good time.’ He paused a moment and then, with a feigned suggestion of doubt in his voice, questioned the crowd, ‘You are having a good time, aren’t you?’ Those gathered gave the desired response with cheers and roars that left nobody in any doubt that indeed they were. Fezziwig continued. ‘I want to thank you all for all your help this past year. The partners all appreciate your hard work, doing what can be a very difficult job. We couldn’t do it without you.’ More cheers followed together with a few calls for a pay rise. Fezziwig then concluded by wishing everyone a very Merry Christmas and insisting that everyone took advantage of the free bar that he and the partners were glad to provide. ‘Only keep an eye on young Dr Scrooge. He’s a fine young doctor but Ebenezer’s not as experienced as we older GPs and I’m not sure he can take his drink! We don’t want a repeat of last months incident when he woke up naked on the delicatessen counter at Sainsbury’s!’

‘Now HE does seem like a good chap – a jolly fine fellow’ declared the spirit, beaming as if the natural order had been restored to where chaos had once threatened to reign. ‘He’s a good, fine, decent, jolly chap of a fellow sort if ever I saw one.’ The spirit turned to Scrooge and looked him straight in the eye. ‘But what of him?’

The Ghost of General Practice Past drew his companion’s attention to a young man who was accepting the gentle ribbing at the hands of the senior colleague he respected so highly. He was sat laughing alongside various members of staff with whom he was sharing a table.

‘I was so happy then’ Scrooge told the ghost. ‘He was such a wise man and so willing to share what he had learnt. And we were such a great team, all so eager to support one another. Back then there seemed to be so much more time. Why did everything change? And how did I become so resentful of the job I used to love?’

‘Something certainly changed – something that shouldn’t have’ replied the ghost. ‘At least, not in the way it has. Perhaps something needs to change again. Perhaps something needs to be recovered. But it is for you to decide what and how. As for me, my time is up. We must return. You have other guests to welcome tonight.’

And in less time than it takes for EMIS to crash on a busy Monday morning, Scrooge was back in his room, alone with his thoughts. It was nearly two in the morning.