Memories of a great teacher

This week General Practice mourns the loss of Professor Sir Michael Drury, former RCGP president, professor and teacher at Birmingham University.

He was part of a 'double-act' with Dr Hull that provided most medical students at Birmingham a first glimpse of medicine, patients and future career options from a GP perspective. They were known affectionately as 'Dreary and Dull', although the teaching style was far much more progressive and challenging than ward based traditional methods.

From those early encounters I learned the important cornerstones to clinical practice of 'active listening' and the very special relationship between a patient and a trusted clinician. They have been important to me throughout the 30 years of my clinical practice.

But how do these principles fare in an era when we are moving towards more digital interaction, remote access, patient empowerment and control?

Well the evidence on uptake of digital Primary Care services is very biased towards clinical initiation and support being the key enabler. So where doctors, nurses and clerical teams take the lead, patients are far more likely to engage, use services and gain benefit. My own experience is that there is little expressed demand for 'control' where a relationship of mutual trust and involvement exists, but there is an increasing interest in using new technology to get information such as results and linked advice quickly and conveniently. Perhaps this is the 'control' I should be working on?

So we are working on registering as many patient as possible to have an opportunity to digitally interact, and we want to record patient communication preferences so that we can start to use the technology to keep patients informed, updated and able to safely self-care. As an increasing proportion choose a digital channel as the default first contact, we have new opportunities to educate, sign-post and support without further demands on Primary Care staff that are delivering beyond a safe and sustainable capacity.

There are risks and challenges, as outlined in MDDUS pointers this week in a GP medical publication, but without clinical leadership and development in partnership with patients, the temptation for political and strategy interests to dictate and micro (mis)manage will be irresistible.

Disruptive technology through electronic interaction between citizens and care providers is here to stay, and will increasingly change the way we expect to work and manage health. But I believe we need to maintain and enhance relationships between clinicians and patients, and not to give up ‘active listening’ in favour of computer algorithms!

PRDS

12/06/2014

Slow progress & New targets

Well General Practice has begun to settle into a new year of shifting targets, altered priorities and 'initiatives' to change the service for the better!
Sadly for front-line service, no-one seems to have altered the increasingly dependant culture in society to seek advice for any potential ill, woe, grievance or disappointment that does not resolve within minutes.
My own medical degree, 6 years post graduate training and regular updating is no longer the main underpinning of front-line practice. It would probably have been beneficial to more presenting patients had I done a combined Dentistry and Social Work degree!

But for all patients registered with my Practice aged over 75, help is at hand with new requirements in the GP contract - being allocated a nominated and accountable GP. (By June 2014 - so Record Access relegated AGAIN as a priority.)

As one of my trusted colleagues put it to me this week - "I do think sometimes politician’s think a bit of spin will solve the world. What do they think GPs have been doing for 50 years but providing personal care to their patients. As if a “nominated accountable GP” will suddenly make everyone well!"

For an average practice like my own this causes unexpected challenges. As the longest serving partner but with a part-time commitment, I have a proportionally larger share of patient for whom I am recorded as the 'usual GP'. In fact to achieve an equitable (and manageable) share I will have to inform 149 patients that 'another' GP is allocated as responsible and accountable for them. Perhaps not a way to enhance my reputation and build long term relationships - but without this sharing of responsibility a large slice of my clinical availability will be swallowed by this worthy initiative.

But perhaps I am 'old-fashioned' - I have always felt professionally responsible and accountable for patients on my practice list - and paid Medical Defence fees accordingly. New directives do not improve capacity for my Practice, in fact they tend to restrict our freedom to prioritise attention on those in greatest need (there are some very fit, well and independent over 75's!).

The law of unintended consequences revealed again?

Peter S.

Difficult times….

No Blog entries for months - has he lost interest, faith, his password or retired?

Well sometimes when things go quiet it is because lots is happening, and sometimes there is just so much confusion no-one has a clue what is going on.

In the front-line world of General Practice the 'demand' for service continues to increase at a frightening rate. EVERYONE is queueing up to land more work at the door, mailbox or 'e-inbox' of General practice. These are daunting, fraught and dangerous times, with no clear end in sight.

The press remains schizophrenic in attitude to NHS services, on one hand 'blasting' the publicised high profile failings, then on the other hand fiercely defending a National Treasure. Clearly part of the long run up to a General Election next year where Health will be a political battle ground.

So what is happening in a 'real' GP surgery, trying to find solutions on a daily basis and deliver a sustainable service? Well we have far too much on to spend any meaningful time to develop on-line services. Even basic transaction support becomes questionable when we have no spare capacity, so harsh but practical decision are made to support any service we feel helps capacity and safety, but to abandon those who do not seem to us to help or at least prove resource neutral.
Our decision:
Transactions actively supported for online medication requesting and appointment reminders
Transactions retained for appointment booking and cancellation
No active support (or withdrawal) for patient access to records

If we are in the vanguard of 'early adopters' for Record Access, what does this type of decision indicate for other practices? Well, we suspect that few will actively promote online activity that costs time, effort and money. We are well aware of the claims and reports by 'enthusiasts' over efficiency to the business, but we have NO capacity or resource to get that far - even if we believed these claims were realisable outside enthusiast practices. Transactions for appointment booking seem to have little value to patients giving 24/7 access when we have 10 days to wait for a free appointment! SO the point is that online interaction we currently have does not add to capacity, and some fear it may fuel unrealistic expectation.

For those who are sceptical of the claims from General Practice I can only report my real-world experience of the last Friday and Monday in GP land. Both were days 'on-call', triaging and seeing those with perceived urgent problems (medical, surgical, dental, social, financial, administrative etc etc), both lasted from 8am to beyond 7pm. No coffee breaks or lunch, and an intense run of 'decision taking' and 'risk assessing'. Having been 'dusted' around by cleaners on Monday evening at 7:20 pm I gave up, to complete paperwork the following day in the early morning before 'work'. Not sustainable or safe.

So the new GP contract from april 2014 promises to incentivise/require GP practices to interact in more modern online ways. But as a service we are close to breaking point in a way none of us long serving providers have seen before. If GP service collapses so does the rest of the NHS. Forcing Online interaction will not be the final straw, but perhaps there are other greater priorities?

Difficult times…..