Holidays

I love holidays. I don't love coming back from holiday.

Just about all GPs have a collection of patients who will only see one particular GP. They'd rather wait until you come back from holiday to be seen rather than see one of your partners. You'd think that we should be flattered by this. The problem is that they tend to be heartsinks.

When I return from holiday, I can write down a list of no more than 20-25 patients. I can guarantee that half of the patients I see on my first day back will come from this small group.

I think I'll go on holiday again.

Drugs and Therapeutics Bulletin

One of the more readable journals that helps keep Dr Phibes up to date is the Drugs And Therapeutics Bulletin.

It is an independent journal, advising about the most effective treatments for a wide variety of medical conditions, and for years has been circulated free of charge to GPs with the help of government sponsorship.

Now that sponsorship is being withdrawn.

So now Dr Phibes will need to pay a subscription to continue to be able to read it.

But why is that sponsorship being withdrawn? Possibly because it is too independent, sometimes openly criticising that other "independent" body NICE.

Nutramigen

I was reading Dr Jest's Caseblog. He posted on the topic of breastfeeding which reminded me of this situation that occurred to me recently.

Mrs Ward came to see me with her 10 week old baby boy. He was grizzly and appeared in pain every time he took a feed, and she thought he was not only lactose intolerant, but also soy product intolerant. She requested I prescribe him Nutramigen.

The thing is Mrs Ward had been here before with her older child. They had been referred to paediatric dietitians before a diagnosis of lactose intolerance was made, and nutramigen prescribed with good effect.

The history of the latest Ward child's feeding problems had been relatively short lived. What to do? Strictly speaking I should have referred to the dietitians again, or at least left things a little longer.

To complicate things however, Mrs Ward was clearly not coping, had had postnatal depression with her previous child, and was showing signs that this was happening again.

So I prescribed. The result is a much happier baby. But would things have settled down by themselves? The problem now is trying to convince Mrs Ward that her baby may not need Nutramigen. I've suggested a trial with normal formula milk, but to restart nutramigen at the first signs of problems. Perhaps understandably Mrs Ward is not keen in her current emotional situation.

Tricky one.

More on the NHS crisis in Bournemouth

Following on from my post yesterday, more reporting in Bournemouth's local paper about the crisis beteen the PCT and hospital.

NHS Deficit

So the NHS makes the headlines again for running up a huge deficit, estimated at £512m.

So how does the NHS lose money? Essentially the NHS is made up of lots of independent parts, all trying to balance the books.

Government gives money to the various PCTs around the country. The PCTs then have to prioritise how they spend this money; paying GP practices, paying for the cost of drugs, and, of course paying the hospitals for the care they provide.

Dr Phibes' attention has been drawn to a particular problem down in Bournemouth. It would appear that Bournemouth hospital have been doing a sterling job at treating patients. The problem is that the government has not given Bournemouth PCT enough money to pay for all this treatment. This means that either Bournemouth Hospital will be underpaid for the work it has done, or Bournemouth PCT will be overspent. In other words somebody has to lose.

Whose fault is it?

Well who is stoking up demand, promising that all patients referred to hospital will be seen within a certain time, while at the same time saying it has to be done with an inadequate sum of money?

Admittedly some trusts seem to deal financially better than others, but in order to balance the books this inevitably is going to lead to a cut in services, or longer waiting lists. If you read the above newspaper article, Bournemouth stress they have the capacity to deal with the work, it's just they're not going to be paid for it.

So it's divide and conquer. When 2 NHS organisations are arguing like this with each other over funding, what chance has everybody else got?

GP Star Ratings

It happened to hospitals, and now it is coming to a GP surgery near you.

I talk, of course, about today's suggestion that every GP practice should undergo regular assessment and be awarded "Michelin style stars".

On the face of it, why shouldn't you know how good your GP is compared to the surgery down the road?

The answer is "If only it was that simple".

History tells us what a disaster the hospital star ratings system has been, too crude to accurately portray how good or bad a hospital really is. Why should it be any different when applied to GPs? The fact that a star rating system has to measure something means that when it comes to medicine it is doomed from the start. Medicine isn't an exact science.

And who's going to do all of these assessments? Us GPs amongst others apparently. Has anybody tried to figure out how much time nationwide this process will take? It's going to take two days to assess each and every practice. Practices will cancel surgeries to fit these in. At a time when demand for appointments continues to rise, this just seems like madness.

Let's hope this is another idea that withers and dies.

Lazy GPs

Recently the press was full of information about how GPs were all earning £250,000 for doing less work.

I gather that there are about 6 out of approximately 30,000 GPs earning this amount. But I digress.

Newspapers and websites ran stories about it, such as the BBC. They also invited people to pass comment on "have your say".

There was the inevitable variety of comments, some positive, some negative. What made me sad were several comments suggesting that all GPs are lazy fat cats.

As I've said above there are approximately 30,000 GPs. Of course some will be lazy. But all of us? I don't think so.

So why the perception to some that we are all lazy? Perhaps they couldn't get an appointment as quickly as they wished. Maybe a request for a home visit was declined.

The conclusion I arrive at is that the complainers are ignorant as to what a GP actually does with his or her time. They can't see beyond the time that a doctor spends seeing patients in surgery, i.e. if we're not seeing a patient, we're not doing anything. They don't account for the administrative tasks we have to do, which takes over 50% of our time. Do the prescriptions sign themselves? Do the referral letters write themselves? And so on.

Are we worth the money we are paid? I would say yes, obviously, but this could be debated sensibly.

But are we lazy? Definitely not.

Chaperones

When it comes to GPs performing intimate examinations on their patients, there is an abundance of advice and guidance about the need for chaperones; see here from the General Medical Council, but also local PCTs.

The recommendation is that chaperones are offered for every intimate examination, and should be medically trained.

I must admit that this is one topic Dr Phibes take very seriously..... for my own sake.

There are already enough things that can go wrong practising medicine, without subjecting myself to an accusation of an inappropriate examination. But even then there is only so far you can go towards the gold standard mentioned in the link above.

Firstly, what constitutes an intimate examination? For me it's relatively straightforward; breast or vaginal examination of a female patient. In these situations it's relatively easy to find another female to chaperone. But what about my female partners? They regularly perform testicular or penile examinations on men without a chaperone. Partly because it's arguably different, but mainly because there are no spare men to act as chaperone.

Secondly is the qualification of the chaperone. Ideally they should have some medical qualification. But in a small branch surgery where the only staff are you and the receptionist, this is also not practical.

And that's before you start to consider same sex examinations in homosexual doctors.

And what about chest examinations of my female patients with coughs and colds? Going by the textbook, a patient should be naked from the waist up for a respiratory examination. But I can't see that suggestion going down too well with many of my female patients.

So where do we draw the line? Do we get written consent for every examination we do? Some have suggested we video every consultation! I can see it now "Yes Mrs Smith, just to document that I'm not a perv, I'm going to video this."

Dr Phibes has his own way of dealing with the problem; he avoids doing them whenever he can. If during a consultation it becomes apparent that the patient needs an intimate examination, I discuss this need with them. Obviously if the patient needs to be examined immediately, I will bite the bullet and do it (complete with chaperone). But, not infrequently, there is no immediate need to do the examination, and I give them the option, and even encourage them to see one of my female partners. As a quid pro quo my female partners send me men needing testicular or rectal examinations.

And it seems to work very well.

Late for appointments

If Dr Phibes was asked to name the one thing that patients do that is really annoying, he would say it is arriving late for their appointment.

At the outset I should stress that this is a personal opinion, and not that of my colleagues in general.

If I was a GP who always overran, I'd be hypocritical to expect my patients to be punctual, but I tend to run to time.

Robert was my first patient of the morning. I sat waiting for him to arrive. My consulting room backs onto the car park, and I could hear somebody on their mobile phone talking very loudly just outside my window. When this person referred to themselves by name, I realised that it was Robert. He continued for the next 10 minutes to arrange delivery of something to his office.

He didn't finish his phone call until his appointment time had finished, by which time I had called the next patient in. I asked Robert to rebook his appointment, which he wasn't very happy about.

The point is that unless I make up time, for every minute that Robert, and others like Robert, is late, every subsequent patient is automatically the corresponding number of minutes late. That is hardly fair on them when they have had the decency to turn up on time.

So if you have an appointment with Dr Phibes, don't be late!

Trigeminal neuralgia

I've just seen Rose who has trigeminal neuralgia.

She presented classically with left sided facial pains. She described toothache even though she wears dentures, marked pains across her forehead, and pain across her jaw.

All pain stopped at the midline.

The diagnosis today was easy.

But looking back through Rose's notes, I realised that she came to see me back in November with an odd sensation of pins and needles in her mouth. She had just had some new dentures fitted by her dentist, and it had been assumed at that time that this was the cause of her symptoms.

In fact a lot of medical problems can present like this. Initially the symptoms can be vague and non specific, but as they develop the actual diagnosis becomes more and more obvious. The patient may wonder why the doctor did not make the diagnosis earlier. Delay in diagnosis is a common cause of complaint against GPs. Hindsight is a wonderful thing.

Primary Care Trust (PCT) Inefficiency.

For agreeing to use Choose and Book to refer patients to hospital, my PCT has offered Dr Phibes and his partners some funds to purchase some extra IT equipment for the practice. We were given a figure and told that we could buy whatever we wanted for the practice as long as it was IT related.

Dr Phibes scoured Froogle for some good deals on printers and PCs.

Having got quotes electronically, we approached the PCT about buying them.

This is when the problems started. In the past, for transactions such as these, the necessary quotes would be sent to the PCT. They would OK or reject them, we would make the purchases, and then get reimbursed later on presentation of a receipt.

But not this time. The PCT said they had to make the purchases for us, and, despite the fact that we were dealing with the IT department, they could not do any online ordering. They would have to purchase any products through their regular suppliers.

It came as no surprise to me when the PCT stated that it would cost more to buy the identical printer through their supplier, but this was the only way that they were permitted to do it.

Is it any wonder that the NHS is in the financial state it's in when it works as inefficiently as this, spending more than is actually necessary on even straightforward purchases like printers and PCs?

What It's All About

Jim came to see me yesterday afternoon.

He has a mixture of Chronic Obstructive Pulmonary Disease (COPD), and Congestive Cardiac Failure (CCF) secondary to his Ischaemic Heart Disease (IHD).

Jim is always short of breath, but has been more so of late. He is seen occasionally at the hospital, but more often by Dr Phibes.

When he goes to the hospital, he is often recommended a change in medication, with a further appointment in 3 to 6 months time. Jim is one of those patients who is intolerant of a large number of medications, and he often comes to see me shortly after a hospital appointment saying that the latest change is causing intolerable side effects. Yesterday was no exception.

As I looked back through his medication history, we discussed possible alternatives.

"Dr Phibes, you're making this up as you're going along aren't you?" said Jim.

"Yes." I said. We both started laughing at this point.

But there are a couple of serious points that arise from this.

There are people who say that GPs are failed consultants, only able to deal with coughs and colds, and needing to refer everything else on. They say we don't need GPs, and that everybody should be able to refer themselves straight to a consultant, or could be seen by a nurse. Jim's case is complicated, but the bulk of his management is done by me. There is no way he could be seen purely by a consultant because of the frequency he needs reviewing. And there is no protocol or algorithm that a nurse could use to manage him adequately, hence the "making it up as you're going" comment.

This type of consultation is, in fact, the real bread and butter of General Practice. In the view of Dr Phibes, General Practice is much more about managing chronic diseases, than acute illnesses.