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.

This is Bad Enough

This is bad enough
So please …

Don’t give me
gobbledegook.

Don’t give me
pages and dense pages
and
“this leaflet aims to explain … ”

Don’t give me
really dodgy photocopying
and
“DO NOT REMOVE
FOR REFERENCE ONLY.”

Don’t give me
“drafted in collaboration with
a multi-disciplinary stakeholder partnership
consultation
short-life project working group.”
I mean is this about
you guys
or me?

This is hard enough
So please:

Don’t leave me
oddly none the wiser or
listening till my eyes are
glazing over.

Don’t leave me
wondering what on earth that was about,
feeling like it’s rude to ask
or consenting to goodness knows what.

Don’t leave me
lost in another language
adrift in bad translation.

Don’t leave me
chucking it in the bin.

Don’t leave me
leaving in the state I’m in.

Don’t leave me
feeling even more clueless
than I did before any of this
happened.

This is tough enough
So please:

Make it relevant,
understandable –
or reasonably
readable
at least.

Why not put in
pictures
or sketches,
or something to
guide me through?

I mean how hard can it be
for the people
who are steeped in this stuff
to keep it up-to-date?

And you know what I’d appreciate?
A little time to take it in
a little time to show them at home
a little time to ask “What’s that?”
a little time to talk on the phone.

So give us
the clarity, right from the start
the contacts, there at the end.

Give us the info
you know we need to know.
Show us the facts,
some figures
And don’t forget our feelings.

Because this is bad
and hard
and tough enough
so please speak
like a human
make it better
not worse.

by Elspeth Murray

Link workers and Realistic Medicine

My last post was a poem that really struck me. I’ve been wondering why, and I think it was because it articulates the need for help to be practical, to be real, and to have relevance and credibility for the person accessing that help. Just wanting to help, wanting to be useful, is not the full story.

What attributes would an effective link worker have? They’d have to be comfortable around people, good at connecting with professionals, community groups, officialdom and patients. They’d be able to gain trust, and then walk alongside people who may be disempowered in the face of the clinical professions, enabling communication. They’d need to be enquiring, able to find out and keep in contact with key people within organisations, to understand how to get the best from them. They would be able to understand the needs of each person that they support, and advocate for those needs to be met.

What evidence do we have that individuals need this kind of support?

% who can ask

We know there is a gap, data tells us that even though patients tell us they could raise questions in a consultation, in reality, this doesn’t always happen. For 10% of patients, they know they won’t ask if they don’t understand. For a further third, they think they could ask, but in reality they don’t. It is those with the least health literacy that need this support the most, otherwise realistic medicine is going to be beyond their grasp.

The new GP contract includes an aspiration for employing link workers so that every General Practice has access to a link worker, and that link worker can work with patients without need for a separate referral. It remains to be seen whether the people that need this support the most get the most access.

So, it seems to me that our link workers could be powerful allies for patients, decoding the language that is already building up around the concepts of Realistic Medicine, and keeping it basic, keeping it real, and keeping the patient at the heart of our consultations.

We don’t have a link worker identified in our area yet, but she or he will be on the project team.

Liason Coordinator

With thanks to Dr Duffy, who shared this with me and with whom I have done a practice exchange – I worked for her last week in the Peat Road Medical Practice, which was a great experience. I’ll blog more about this later.

By Tom Leonard, from Ghostie Men

efturryd geenuz iz speel
iboot whut wuz right
nwhut wuz rang
boot this nthat
nthi nix thing

a sayzti thi bloke
nwhut izzit yi caw
yir joab jimmy

am a liason co-ordinator
hi says oh good ah sayz
a liason co-ordinator

Just what this erria needs
whut way aw thi unimploymint 
inaw thi bevvyin
nthi boayz runnin amock
nthi hoossyz fawnty bits
nthi wummin n tranquilisers
it last thiv sent uz
a liason co-ordinator

sumdy wia digree
in fuck knows whut
getn peyd fur no known 
whut thi fuck ti day way it

I must add – the social interventions from this practice were nothing like this. It was joined up, aimed at getting the best from available resources, ensuring people got the best help from the right people.

I’m already thinking of going back…

Poetry as a way of seeing another perspective, in carefully chosen words.

Precious 10 minutes

The GP stands at the door of his room,
shakes my hand, asks me how I am.
I always smile and say fine, except for…
this niggling problem
or I’m just here for a checkup
or a repeat prescription
or something.
He listens.
He’s a cautious man,
gets me tested
just in case: ‘Let’s be sure.’
He sounds me out about an ongoing condition:
if I can live with it
he can live with it.
‘As long as you can do the things
you want to do.’
He knows I’m a worrier.
I don’t feel rushed.
It’s a conversation.
It all seems as it should be.
Hamish Whyte

Health inequalities in Rural Scotland

I wrote this essay after attending a discussion about health inequalities in Scotland. It isn’t directly about Realistic Medicine, but it sets the background.

INTRODUCTION:

17% of Scotland’s people live in remote and rural areas, nearly a million people, double the population of Edinburgh. (1, 2). They live in one of the most beautiful places on the planet, with one of the lowest population densities in Europe. All of them have a right to be registered with a GP and have access to healthcare that is safe, effective, person-centred, equitable, timely and efficient, as outlined in the Chief Medical Officer’s annual reports. (3)

However, the current challenges facing remote and rural health care teams are barriers to meeting these aspirations. Existing good practice seems to be undervalued, and the principles of the new Scottish GP contract do not seem appropriate for very small and remote clinical teams.

CONTEXT AND BACKGROUND:

We have a shortage of GPs in Scotland, with many areas reporting longstanding and significant levels of vacancies. With shrinking clinical teams, it becomes harder to deliver the additional extras, the enhanced services that were a feature of the previous GP contract; enhanced service contracts became the mechanism for encouraging GP practices to take on additional work for additional income. Increasingly, GPs across the UK have been concerned about secondary care work being shifted out into primary care without adequate funding or support.

In response, the new Scottish GP contract has pared back the requirement for GPs to undertake non-core services, so that they can focus on the core work of providing primary medical services. At the same time, some of the clinical work currently done by GPs could be done by others, such as physiotherapists, pharmacists, psychiatric nurses and others, and the new contract asks health boards to change to this model.

In our rural practices, with small numbers of patients scattered over wide areas, GP practices have been the only realistic option for providing health care services without travelling huge distances. Small teams based round one or two GPs have provided a very wide range of services, taking on additional roles to provide a holistic service. Recruitment, retention, and support appropriate to the area would sustain services.

The rural GPs that I know are proud of the excellent services they can provide to their communities. Being a member of such a community means that rural GPs identify very highly with their patients, their difficulties and aspirations. They are advocates for local health services, with a deep knowledge and understanding of the local population. There is a strong culture of stewardship, of using the resources of the NHS wisely and appropriately for the best outcomes. Rural General Practice has been delivering Realistic Medicine for many years before it was branded and marketed by the Chief Medical Officer for Scotland.

Published data shows that Scotland’s rural areas have a static and unacceptably high level of fuel poverty, (4) with nearly two fifths of residents needing to spend more than 10% of their income to heat one room of their homes to safe levels. Fuel poverty is associated with worse health outcomes.

Populations are older too. In the Western Isles, for example, a quarter of the population is over 65, retired, less economically active, and this number is set to rise to over a third in the next fifteen to twenty years. Older populations have higher rates of multi-morbidity, cancer, falls and frailty, with complex health and social care needs.

Within the last year, the new contract for primary care in Scotland has been voted on and implemented. It has been a radical revision of the way that medical services are provide out with hospitals, aiming to address the shortfall of GPs by increasing access to other healthcare professionals in the context of multidisciplinary teams.

It has come with a new allocation formula, claiming to improve funding for teams providing care for older patients, and improving funding to practices where GP income is low.

THE NEW CONTRACT – DOES IT ADDRESS HEALTH INEQUALITY AND GP RETENTION AND RECRUITMENT?

The new contract has left many rural GPs feeling devalued and disheartened. Their professional raison d’etre has been to provide a holistic service, going the extra distance to ensure that care can be delivered by clinicians who know their patients well, delivered by teams that are stable and supportive.

By breaking these teams up, telling GPs that their enhanced services are no longer required, whilst parachuting in a number of peripatetic staff each working one session a week in each of multiple practices, this all feels like a betrayal. The contract does not value the extended services that make rural practice so effective in delivering rural Realistic Medicine.

While no practice in Scotland will receive less money initially, the Scottish Allocation Formula makes it clear that some practices are more deserving than others. In rural practices and in ‘deep end’ practices, there is little in the way of hope of an uplift. The formula does not  recognise adequately the additional costs of running a rural service, the cost of addressing the health needs of rural poverty, of fuel poverty, the personal health and financial cost of travel to care, or the additional costs of professional training and networking.

The striking map below illustrates where practices are getting an uplift in funding in green dots. It was put together by Dr G Wheeler, North Uist Medical Practice, from data from the Scottish Government. (5)

the right map

At the same time, the impact of other policies is still being felt. Scotland’s broadband and mobile phone networks were designed to reach the majority, rather than the populations that needed them most. Even though broadband roll-out has been trumpeted widely, on the ground in rural areas, the infrastructure is incomplete. Rural practices still don’t have access to new data-collection systems, and wifi is still limiting participation from remote areas.

The new contract does not address rural health inequality and may be contributing to reduced retention. The allocation formula does not address the additional costs of providing health care in rural areas, the need to provide care to small and isolated populations all day every day, the need to provide realistic care in the case of widespread multimorbidity. If a multidisciplinary team is led by a GP now, expanding the team by adding fractions of WTE staff to many practices, makes co-ordinating that team more complex, without solving the recruitment needs.

The new contract in rural areas might mean many more clinical staff each offering only a tenth of a whole time equivalent each, never meeting to form a team. Accommodation for small rural teams doesn’t include space for expanded teams, and there seems to be no plan to address this.

The new contract does not seem to address deep-end health inequality either; their patients suffer from multimorbidity at an earlier age, before funding catches up. Their barriers to engagement and access may be societal rather than geographical, but poverty in both settings makes it harder to overcome those barriers.

The new contract cannot be accommodated easily in rural practice, and many practices feel they stand to lose much of the work that they held in highest value, the ability to go further to address clinical need and provide patient centred care in patients’ own homes and communities.

CONCLUSION

Addressing health inequalities in Remote and Rural, and in Deep-end practices should not be an afterthought. Bolting on solutions after the fact doesn’t seem secure. Is Rural Health Care really an additional extra?

Health policy should address the needs of the most vulnerable people in our country. Addressing the challenges first means that provision is fit for all, not just for the central belt. This ‘Rural First, Deep-end first’ approach is appropriate in many ways, from consultation, to creating policy and developing infrastructure.

Consultation for hard-to-reach areas needs to be more enquiring, more inclusive, more investigative. Relying on representatives means that only the views of a politically minded few are heard. Most GPs are in the service to provide health care, and as our ranks are depleted, fewer and fewer find time to get engaged in political lobbying and research.

Scotland sets itself out as a country where the Government listens to GPs, a country where it is the best place in Britain to be a GP. For those GPs who are working in the poorest, most deprived, most rural, most remote areas, these aspirations are not yet being met. Whatever we set out for the people of Scotland, it should work as well for the people of Barra, as for Barrhead and Bearsden.

REFERENCES:

  1. http://www.gov.scot/Publications/2018/03/6040/5 (accessed 06.06.2018)
  2. http://www.gov.scot/Publications/2011/09/29133747/2 (accessed 06.06.2018)
  3. http://www.gov.scot/Publications/2018/04/4249/0 (accessed 06.06.2018)
  4. https://www.eas.org.uk/en/fuel-poverty-overview_50439/ (accessed 14.10.2018)
  5. http://ruralgp.com/2017/12/mapping-out-the-proposed-scottish-gpcontract-allocation-formula/ (Accessed 15/10/2018)

Another list

I do like a list. I’m also partial to spreadsheets. This is a list of things to blog about, in no particular order. .

    • Why Realistic Medicine is so important to me
    • Realistic Medicine – why call it that
    • My project Charter
    • Who should I have on my project team?
    • Scottish Health Council
    • Twitter
    • My practice exchange
    • Continuity of care
    • A driver diagram
    • ‘It is the patient stories that I remember, that are my most powerful inspiration.’
    • The House of Care
    • Finding Patient Leaders
    • A review of the PBSGL module