It's an Emergency

I first started working in an NHS GP practice over six years ago. One of the first challenges was to try and get a grip of unscheduled care of our patients; people phoning us or turning up 'at the desk' demanding immediate care usually in the form of "seeing the doctor... now". Being an 'outsider' and a novice, I reached for ... The Contract. This was, and supposedly still is the document that defines what we had to do to fulfil our responsibilities as an NHS general practice. It didn't help.

It told me that we should provide urgent care when it was needed and so I entered the wonderful Heller-esque world of Catch 22. How do I tell which patients need urgent care? I'm not a clinician. Neither are my reception team. The only people who can decide whether something is urgent are doctors or senior nurses and that's precisely what the person at the desk wants. Thus we ended up in the situation that the way to get urgent care was simply to say: "it''s urgent". Actually what they usually say is: "it's an emergency". It rarely is.

During the week, our patients can always get to see a doctor within 24 hours. They may have to wait longer if they wish to see the doctor of their choice but if something is urgent, then that's the maximum wait. It's usually less. Anybody phoning before 11 am and who says "it's urgent" will be seen that morning!! Routine appointments (which last longer) are usually in a couple of days time, and if you want an evening appointment, then it will be anything up to a week (but if you're fit enough to get to work, then maybe that's not as bad as it sounds?

The upshot is that the anxious, the worried well, the over-dramatic, the unscrupulous, and the irresponsible get to the front of the queue; whilst the sensible, the responsible, and the reticent wait until an appointment is available. It didn't seem fair then, and it still seems unfair now.

I have asked "the authorities" to define what constitutes "urgent" but they duck the issue saying it is a clinical judgement. Clearly they can't generate a list of ailments, but they could provide us with something like "an impact scale"; a description of the sort of impacts that are "emergency", "urgent" or "non-urgent". It could be similar to the categories assigned to IT problems where the severity is decided by the effect of the fault (inconvenient, etc) rather than a definition of it. We would probably end up seeing the patient but at least, if they were taking the mickey, we could then caution them about their unacceptable behaviour.

Until that happens, the usual suspects will arrive at the desk, demanding to see the doctor of their choice, because "it's an emergency".

Bureaucracy vs Reality

Just before closing time, the mother of a 14 year-old girl phones us and is very anxious about her daughter's "funny breathing" and chest pains that she had had all day at school. She is asked to bring daughter to surgery where GP examines the lass. As a result of the examination, the GP decides that there is no cause for alarm and that with the medication prescribed, she should soon be well again. However, if Mum is at all worried during the night, then she should not hesitate to call the out-of-hours service.

On the way home - GP is giving me a lift to the station - he says that he won't be at all surprised if Mum calls the OOH doctor although as far as he could tell, there was no cause for alarm. We then talked about the uncertainty inherent in many GP diagnoses and the "ninty-nine times in a hundred" they would be correct. Especially in today's medico-legal climate that leaves me worrying about the other "one in a hundred". I reflected on the two different approaches to such a dilemma: the doctor's versus the manager's.

The GP knows that if he or she refused to take probability into account, our hospitals and emergency services would be overwhelmed within a day. He/she takes responsibility for managing the flow of patients to the next stage of medical intervention be it hospital treatment, medication, or perhaps diagnostic testing. It doesn't get noticed because it isn't a tangible activity; but it is a real benefit of having a well-trained and well-motivated "gate keeper".

The manager is likely to try to remove all risk, if not from the system, at least from that part of it for which he is responsible. His approach will be: "if in doubt, refer". I have some sympathy. After all, he is the one that will have to deal with the "one in a hundred" should it result in a formal complaint.

I don't have a neat solution. Homo Sapiens rather inconveniently presents in an infinite variety of shapes, sizes and combination of physical and psychological variations, most of which are tucked away out of sight or reach.

The NHS only works because doctors assess probabilities and having done so, hope for the best. You may not like the sound of that, but in essence, this is what happens. We can rightly demand that this assessment is skilled, appropriate and that the evidence supports the conclusions that are then drawn. If the assessment is proven to be deficient, then let justice prevail. But, providing it is reasonable, our society and its legal processes should support such doctors and resist the demands of those seeking perfection. The costs to us all would be catastrophic.

I See No Ships

Dear Patsy,

Thank you so much for all your recent communications to us lowly people who look towards you as their leader. My word you have been busy but through this maelstrom of media engagement your new organisation has triumphed. I haven't actually seen the Powerpoint presentation as yet; our PCT's IT department is busy taking down the Christmas decorations at their shiny new offices in Marie Celeste House. Nevertheless I think I have the gist of what you had done. Perhaps you could confirm my understanding?

Your new communications team (the Strategic Press Information Network - "SPIN") have already scored some notable goals for the good guys. Clearly it helps to have a clear and unabiguous target (and what government has more impeccable credentials when it comes to targets?). Having said that, why not come out into the open and say exactly who you mean instead of hiding behind a code name of Greedy Pigs (or "GPs" as they are already known amongst the congoscenti). Let's name and shame. After all, these GP bastards have a lot to answer for.

There's that awful PFI or "Perpetual Financial Indebtedness". I was about to say that only GPs could have come up with so financially awful but then I remembered ENRON who did try the same thing. Still your solution is a master touch. "Put the Blame on Contractors" or "PBC" has solved the problem in one simple yet ever-so-stylish stroke. Of course, PBC only works when viewed against "PBR" (the "Public Sector Borrowing Requirement"). This clearly is no impediment since our almost Prime McMinister seems to have no problem in shuffling the numbers around with the leger de main of a Mancunian croupier.

As any good admiral, you are now reaping the benefit of having thought ahead and deployed your reserve troops ready to deal with the situation as it has unfolded. Operation "Blame" ("Bring in Lots And lots of Management Experts") is as much a triumph as Nelson's was at Trafalgar. Everyone expected you to cover up the mess made by these GPs but oh, no! You simply came right out and did it. "It's all the GPs fault. They have taken all the money."

Brilliant!

I can't wait for next week.


p.s. Just remind me - who were those GPs exactly?

An Appeal

Dear Patsy,

I am writing to say how sorry we are to have been the cause of so much inconveniece to you and your team at the Depratment of Health. How could we have been so inconsiderate? How could we have so exceeded your performance expectations and quality targets. Please, please calm yourself. The solution is at hand.

Our partners have cancelled all their sessions for this week in order to focus on re-establishing the "cost trajectories" that had been established in your original plan. In doing so they are helping in two ways: firstly, it will lower our quality indicators scores and start us on a firm trend towards the 777 points you assumed we "average" practices would achieve. Secondly, we will stop registering new patients which will lower our totals thus directly reducing our income. It has been most pleasing to help you achieve these most important objectives. Of course, we need to look to the longer term. God forbid that we should ever be accused of short-term thinking.

We will be issuing redundancy notices to the two health care assistants that we recruited to shoulder much of the administrative and routine monitoring tasks. Such actions have both good and bad outcomes with which we are
wrestling: we will achieve less and thus earn less which surely is a good thing? The trouble is we will spend less so we will still appear to be the same greedy money-grabbing bastards you have led with such grace, such aplomb since your appointment. Our nurse practitioner has now finished her nurse prescribing course and which for the past four months we have been trying desparately to get our PCT to authorise so she could use the knowledge she has worked so hard to learn. We didn't realise that their gross inefficiency is part of your master plan to reduce our prescribing spending. So, our pursuit of the appropriate signature will cease immediately.

Reducing our staff brings other benefits. We now have some spare equipment so if you know of anyone who wants two Celeron P2 PCs with less memory than the average Alzheimer victim, together with two HP 959c printers with worn print heads and wonky power lead sockets and who provided they can outbid our local museum, then they are theirs for the asking.

However, let's not be negative. There are some real win/wins on offer. We have decided only to refer patients if secondary care can be booked via your wonderful Choose and Book system. Thus you will soon be able to claim that everybody is using Choose and Book successfully and you never know, one day it might actually be true. What a day that will be. In the meantime, we continue to enjoy the built-in restrictions that slow down the whole process thus in turn reducing spending. We especially like the way you have camouflaged these sophisticated barriers as technical problems, slow connections and inexplicable log outs. Darned clever those computer boffins.

I'll need your help on the next one. Could you point me in the direction of another government-led organisation that has been too successful and resulted in over-generous incentive payments? I would like to have a "heads up" with your opposite number in whatever ministry they work to get the griff on how to claw back the money whilst maintaining morale and improving output. One will do, although two names would provide me with more depth of experience. No rush on this one.

Finally I do feel the need to confess that we may unwittingly provided ammunition to those who feel that your views on general practitioners may be anything but entirely well-informed and wholly accurate. So, with immediate effect, we are withdrawing our labours from our local out-of-hours service so that we cannot be accused of earning too much from private fees. I have to confess that we failed to opt out and reduce our income by the fifty-odd thousand quid our partners could have spent on you rather than on themselves but it's no use crying over spilt milk. I don't like a "blame culture" any more than you, but quite frankly, it wouldn't have been a problem if our local GP co-op wasn't so damned efficient. Then out-of-hours cover would have cost us the fortune it seems to cost in most other places. Still, I have now hit our co-op manager round the back of the head with a plank and let the air out of her tyres and this should do the trick.

Please find enclosed a cheque from the practice which represents a downpayment on the repayment of the scandalous Tsunami of cash that has come our way. More will follow I am sure. Perhaps we should send it direct to Accenture who nearly lost so much money on NPfIT? Didn't you used to work for them? Perhaps you could let me have the address of one of your colleagues?

Always here to help,

Bestest wishes