Guidelines and the burden of treatment.

Nearly a quarter of our patients are over 65 years of age. Many of them have multiple long-term conditions; as people age, the number of conditions that afflict them increase.

Long term conditions such as chronic obstructive airways disease and diabetes don’t go away. Management, rather than cure, involves routine work to avoid exacerbation events, detect and avoid recurrence, and to mitigate – and sometimes prevent – disease progression. For each condition, there are guidelines for the best management, and these guidelines have become a yardstick to measure performance of clinical teams.

If you have many conditions, each one with guidelines, and specialist nursing teams and clinics, then the work of looking after each condition becomes considerable. For our rural patients, each trip to the surgery or hospital can be costly and hard to arrange, calling on favours from friends and family. Medications all have side effects, and monitoring with blood tests puts clinicians in judgement of the success of your labours and of your compliance.

Over the last five years, there has been discussion in the journals about how to manage this dilemma. How should we measure burden of treatment, and how should we minimise it? There are measurement tools such as PETS (Patient Experience with Treatment and Self-management) – but this has 48 questions, and is surely devised as a research tool rather than something that can be slipped into General Practice

How do we optimise the workload for patients? The answer lies in the following big ideas:

  • Patient-centred rather than disease centred care.
  • Good communication about risks and benefits, including the treatment burden of each intervention.
  • Patient-centred goal-setting based on good communication.

It will be interesting to see how well we can move more in this direction as we contemplate ‘going live’ with House of Care this spring.


Preparing for the Benbecula House of Care

We are preparing for a new way of working in our practice. The idea is that we take what we do, and we supercharge it. Some of it sounds quite obvious.

Take the review of chronic diseases. At the moment, patients get called in for a pre-appointment check, then come back to see the nurse practitioner for a review of their condition.

The change is quite simple and also completely revolutionary. After the pre-appointment check, the patient is sent an update on their health, including any important areas to discuss, and space for them to consider what the key issues are for them. When they come to meet the nurse practitioner, the patient gets to choose which aspect of their health is most important for review, and for choosing which goals to set for the year ahead.

One of the key steps is how we reframe the review appointments. I personally believe that this is crucial: if we as a practice don’t understand and embrace this step, then all of the other changes are not going to be fully effective. This is the goal, the inspiring change.

I was very pleased to come across an article in the British Journal of General Practice: Setting goals with patients living with multimorbidity. Even the title is great – the goals are set with the patients, and they are the ones who are living with multimorbidity. The full article is in depth, and qualitative. The authors analyised 10 hours of VC to determine how goal setting is done. They describe ‘bearing witness’ to the patients goals. They conclude that this process requires a lot of time and energy from both parties, and it worked best when both GP and patient were prepared in advance.

I’m keeping that summary in mind, both for when we attend our training in Harris, and for when I prepare the staff-room QI noticeboard.


I attended the recent RCGP meeting that debated the role of General Practice in addressing the Health Inequalities that afflict many communities in modern Scotland. The papers presented were the product of years of reflection, effort and involvement. The debate was free-ranging and well-informed, there were many ideas to assimilate, and many questions that arose.

This is my personal reflection on the day (and yes, this is going into my appraisal portfolio).

What is deprivation? The term socio-economic deprivation refers to the lack of material benefits considered to be basic necessities in a society.

Deprivation, poverty and adverse health outcomes: The meeting discussed various aspects of deprivation, poverty and adverse health outcomes, but the relationship between the three is complex. For example, rural fuel poverty creates very real suffering, but the communities that it affects do not always suffer from lack of a supportive society, which mitigates this. Rural life expectancy is longer than might be anticipated given the compounding effects of isolation and financial difficulty, but dispersed deprivation is a lonely place, and is becoming more prevalent. Pocket deprivation is evident, but it is not so easy to compare the adverse outcomes from pocket deprivation with blanket deprivation. The three are linked, but the outcomes are not predictable. 

Austerity has had a significant impact, through the exacerbation of poverty, and the entrenchment of deprivation. It is therefore no surprise that the policy of austerity has been associated with worsening of health outcomes, especially in areas of blanket deprivation. Austerity has affected individuals in our communities through reducing their economic freedom, and it has also affected those who wish to mitigate and counter deprivation by reducing their resources and effectiveness.

Core General Practice: My experience of exchanging roles with an urban practice taught me that the core strengths of General Practice lie with Barbara Starfield’s ‘4Cs’; first Contact accessibility, Coordination, Comprehensiveness, and Continuity . They are as effective in rural and urban settings, in areas of affluence and of deprivation.

An effective partner in all primary care settings has a deep connectedness with their community, a commitment to co-ordination of the care for their population. This long-term relationship with a community and the individuals who reside within it brings benefit to everyone. This is as true of rural as it is of urban general practice. The hardest part of participating in my exchange was the feeling of being disconnected with the follow up of new clinical relationships, the inability to sustain the contact into continuity, or to affect the comprehensive nature of care, or its co-ordination.

A principal GP has ownership of the problems and solutions for the delivery of health care in their practice.

I also learned much about how the exchange practice has addressed their challenges of providing effective health care in their setting. Meeting their link worker was inspiring and I have made some lasting friendships.

A forest or a bonsai collection?

We talked about how expansion of the multidisciplinary team is part of the effort to support General Practitioners, to free their time to lead primary care. The models that the envisioned MDT is based on include projects like Govan SHIP. The link workers, pharmacy support, physio and CPN teams, treatment room teams and vaccination programs need accommodation, and the sense of membership of the team.

Underfunding these MDTs, failing to provide adequate accommodation, or resource for the IT, is a substantial risk. A tree in a small pot, with only just enough water each day, and with growth pruned to stay within the resource, is a small and contorted tree. If we want General Practice to provide a forest canopy of health resource across Scotland, we need to nurture it with strong roots, and the space and resources to grow.

Investment in the General Practice of the future must address accommodation as well as teams.

Moving forward: Tackling the hard problems

The Deep End project has shown us that tackling the hard problems, or even just one hard problem, provides benefit for all, the evidence shines a light on how we work. There is great potential for spread of good practice through the worked example. This is a model for moving forward; resourcing the right people, and giving them appropriate goals. More funding for General Practice is not just about fair pay, it is about building resource, supporting and inspiring GPs to use that resource to tackle their own hard problems.

We also need data, and we need to ask for the data that describes where we are, and can be used to show change. An important part of the way forward is to ask for information and data, and to share that unflinchingly, to create a landscape of information that can show where we have been, and where we should direct our attentions.

Heroes and pedestals: As I sat in our meeting, I heard many eminent people speak honestly about their aspirations for what General Practice can deliver. I had arrived feeling an imposter, I had not produced a paper, or had time to assimilate the many papers that arrived in the few days before the meeting. I have not been elected to a high office, nor am I an academic GP. It then struck be that if we put our heroes on too high a pedestal, they become remote, and we fail to see that we are like them, and lose the courage to believe in our own contributions.  I had been invited for a reason, because I have something to add to the conversation.

Being a GP partner fulfils my idea of myself as a clinician, and I would advocate that demonstrating and describing this fulfilment should be a beacon to the young GPs who will become the leaders in our profession in the future. We must continue the work of identifying and describing the methods whereby future General Practice can bring the best healthcare to all of Scotland’s people. We must also show that what we do is achievable and applicable everywhere. We must harness the ambitions of GPs to drive forward our agenda, the high energy of collective ambition.

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.

A Primary Care Christmas Carol: Stave 1

By Dr Pete Aird, written for Resilient GP

Stave One – in which Scrooge reveals how burnt out he is

Old Dr Marley was dead. As dead as the NHS would be within a couple of years if things didn’t start to improve soon. And, as far as Dr Ebenezer Scrooge was concerned, Jacob Marley was better off out of it. Scrooge and Marley had been partners for years and Scrooge greatly missed his former colleague who had died several years earlier. This was not the result of any affection he had for the man , that was not in Scrooge’s nature, but rather on account of the fact that, due to the national shortage of GPs, he had been unable to find a replacement and his workload had consequently increased beyond the point of being manageable.

It was Christmas Eve and Scrooge was sat at the desk in his consulting room. It was nearly three in the afternoon. Morning surgery had only just finished and this was now what was laughably called his ‘lunch break’. An email flashed up on his computer screen. It was from the CCG wishing him a merry Christmas.

‘Bah!’ muttered Scrooge to himself. ‘Humbug! If they really wished my Christmas to be merry, then perhaps they and NHS England could have agreed that I didn’t have to make up the Advanced Access hours, lost from not opening the surgery on Christmas Day, later in the week. Every idiot’, he continued, ‘who goes about with ‘Merry Christmas’ on his lips should be submitted to unnecessary colonoscopic examination and be forced to reflect on the experience for the purposes of revalidation.’

Dr Scrooge was not one to enjoy Christmas, and being encouraged to be merry served only to darken his already black mood still further. The situation was not helped by the arrival of a receptionist who announced her presence with a knock on his already open door.

‘Sorry to trouble you Dr Scrooge, but the Salvation Army band are playing Christmas carols in the car park and are asking if you would like to make a donation.’ She handed him a leaflet informing him that this Christmas many people would not have anywhere to sleep due to the lack of hospital beds resulting from years of chronic NHS underfunding. Scrooge sighed – this was nothing he didn’t already know. Only that morning he had been asked to arrange review over the holiday period of a patient that was about to be discharged, a little earlier than was ideal, from the local hospital. His refusal then had been unequivocal and he was no more minded now, at his own personal expense, to start financially propping up a system, left destitute by the establishment. As far as he was concerned he already paid quite enough tax and, given that he was learning that the security of his pension was now somewhat precarious, he felt it was unlikely that he would change his mind on the matter. He stood up and slammed the door in his informant’s face. Sensibly, the receptionist interpreted that as a ‘No’ and scuttled back to where her colleagues were celebrating with a box of mince pies and a tube of Prosecco and pink peppercorn Pringles – the latter, notwithstanding the alliteration, surely an ill advised flavour choice, regardless of the season.

Scrooge had been invited to share in the festivities but he had no desire to do so. Neither did he have time. Instead he returned to his computer screen and started the never ending task of clearing his inbox of lab results, hospital letters and prescription requests. He’d barely started when there was another knock at the door. Scrooge barked out a ‘What is it?’ and the door swung open to reveal the ST3 who had been with the practice since August. Dr Robert Cratchit was a highly capable doctor though one who lacked confidence in his own ability. To Scooge’s dismay he was wearing a Christmas jumper.

‘What do you want? Can’t you see I’m busy?

These words were not unfamiliar to Dr Cratchit, who, over the previous five months had heard them frequently from the man who purported to be his trainer. In fact, so frequently had he heard them that, for a time, he had used them to start all consultations with patients imagining them to be the profession’s approved opening words for all doctor patient interactions. A failed attempt at the CSA and the associated considerable expense of applying to sit the exam again had, however, taught him much. Familiarity however did not make it any easier for Dr Cratchit to approach a man who never offered advice without showing contempt for the one who asked for it. For although Scrooge had indeed received training on giving feedback, he had, much to the dismay of his appraiser, consistently failed to demonstrate any change in his behaviour as a result of such practice improving activity.

‘I was j-just wondering if it would be convenient if I w-went.’ Cratchit stammered. ‘I’m only supposed to do one clinical session today and, though the planned patch t-tutorial for this afternoon has been cancelled, I thought that, since you allocated me all the visits, you m-might let me skip off a little early this afternoon. It is Christmas after all and I would so appreciate having the extra time to be with m-my family.’

Scrooge glowered. ‘Of course it’s not convenient. And I don’t suppose you’ll be offering to work a couple of extra Saturday mornings in lieu of the day you’ll no doubt be taking off tomorrow. That’s the trouble with young doctors these days. No commitment’

The ST3 smiled faintly and waited nervously. ‘Go on then, leave’ Scrooge eventually conceded, ‘But if anything goes amiss this afternoon and I’m compelled to reflect on some significant event or another, I know where my reflections will lay the blame. Just make sure you’re in early on Thursday.’ Cratchit thanked Scrooge and slipped away, leaving the burnt out old clinician alone with his thoughts and the prospect of a three hour afternoon surgery.

As things turned out the rest of the day was mercifully quiet with Christmas Eve being the one afternoon of the year which provided the practice population with something more interesting to do than seek medical advice regarding their minor health concerns. As a result Scrooge locked up the practice early and arrived home before nine. He’d stopped on the way home to pick up a bite to eat but having consumed it en route, the only thing he had to look forward on arriving home was, as most evenings, the prospect of going to bed.

As he got out of his car, a fog hung about the driveway of the old house that years previously had been converted into flats. Scrooge approached the communal front door, the fog seeming to cling to him as he walked. It was then that he noticed, in place of the ancient door knocker, what was clearly the face of his old partner, Dr Marley. The apparition lasted but a moment before Scrooge, unsettled by the sighting, hurried on, unlocking the door and subsequently forcing a pile of unsolicited medical periodicals to one side as he entered his own flat. He locked this second door behind him and climbed the stairs to his living quarters.

Scrooge undressed and put on his night attire. As he sat gazing into the middle distance contemplating once more the strange appearance of the door knocker, there came an unexpected ringing sound that filled him with inexplicable dread. However, as the callers number was withheld, Scrooge, as was his custom, ignored what was almost certainly a nuisance call and continued his preparations for bed. And then he saw it. A sight that caused him to be more horrified than he he’d ever been before – more horrified even than that morning when his appointments included seven heartsink patients and three more complaining of being ‘Tired all the time’. Before him, as unwelcome as critical emails from the head of Medicines Management, stood the ghost of Dr Jacob Marley.

Scrooge, nothing if not a man of reason, rose up and spoke to the spectre in an accusatory tone.

‘I don’t believe in you’ he said.

‘You don’t believe in most NICE guidelines and yet they exist’ countered the phantom.

‘That’s true’, Scrooge was forced to concede and with that he sat back down in his chair. He paused a moment then, looking the ghost full in the face and acknowledging his existence, asked the reason for his visit.

‘I have come to warn you Ebenezer. There is yet a chance that you may escape what has become my fate. I am condemned to walk the earth for all eternity burdened by these chains – chains composed of nonsensical bureaucratic demands imposed on me by those who understand nothing of medicine and seek to use the profession for their own political ends. You have forgotten, Ebenezer, what being a doctor is really all about. You have forgotten the joy that your work once brought and now you practice as a mere shadow of the clinician you once longed to be. You’re burnt out Ebenezer. Something needs to change.’

‘Blimey!’ said Scrooge, ‘like that’s going to happen’.

‘You will be haunted by three spirits,’ continued the ghost, ignoring Scrooge’s sarcasm. ‘They will teach you all that you need to learn. Without them you cannot hope to shun the path I now tread. Expect the first when the clock strikes one’.

And with that the ghost of Jacob Marley departed, groaning incoherent sounds of lamentation and dragging the weight of his chains behind him. Scrooge stood motionless for he knew not how long before, mindful of his need for rest, he climbed into bed. Picking up a copy of the BJGP he fell asleep upon an instant.

…to be continued – possibly.