Political "Top-Trumps" and GP Record Access

No postings for more than 10 months - and no-one noticed…..

I have moved from GP partnership into the world of a 'Portfolio' GP, maintaining clinical practice at my former surgery, but working for HSCIC across a broader remit to link projects and programmes closer together, for patient and clinician benefit.

In England there has been consistent work going on 'behind the scenes' leading up to a flurry of activity in March to activate online interaction between citizens and General Practice. So with the publication of achievement figures today, there is a sense of surprise and amazement that the landscape of opportunity for citizens has changed so much.
Of course the sceptics will argue that 'only' around 5 million people are currently registered to use these types of service, and that very few yet go as far as to access the medical record elements.
While that is true, there are several markers of a 'step change' in attitude to the opportunity, approach and demand for digital interaction with Primary Healthcare services:

• General Practices themselves turned on the functionality - a positive attitude
• NHS England and GPSoC worked to educate and enable - facilitation NOT enforcement
• Improvements in Patient Facing Functionality - a market waking-up to opportunity
• BMA commitment to work with NHS England - constructive dialogue to expedite benefit
• Alignment with future strategy - Five year forward view

So I am very optimistic that General Practice IS leading the journey of discovery about how citizens and Health & Social Care services can effectively and safety interact in a virtual environment. We all need this to work, to mitigate the politically unpalatable reality of demand outstripping the resources we currently have, without radically new different ways of working.

Digital interaction, with supported self assessment and management, improved signposting and the effective delivery of a virtual service to support healthy choices and rehabilitation, is a major part of the ambition in the next 5 years. Without it the Health and Care services may well soon sink under the burden of 'wants' and 'promises'.

Health and Care services are there to deliver what citizens are assessed as needing, in a manner that is as acceptable and convenient to citizens as possible. Time to move on from Political 'Top-Trumps' to utilise digital interaction to improve the quality and safety of health and social care.

PS - Social Media Hermit…..

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…..

Continuity & Personal Service

No additions/comments/updates over the summer - pretty typical of the 'behaviour' in GP practices. With more staff on holiday, those who remain are busy with the routine work and NOT with making heroic plans to deal with the expected winter pressures, the next rush of central developments and demands, and the ongoing barrage of NHS criticism.

So what has been happening in our quiet attempts to improve the range of options for digital interaction with patients?

Firstly there is a slow, steady and sustained trickle of new registrations for Online service registration. No great demand for Record Access, but significant interest in appointment and repeat medication ordering. And we believe that some basic publicity has helped!

Second observation is the realisation that my system provider had failed to repair SMS appointment reminders to patients AND continues to report in the record that an SMS reminder has been sent!
Does not inspire confidence that future digital interaction (upon which we plan to increasingly rely), is yet robust enough?

But my most important reminder of priorities happened during a seemingly ordinary 10 minute consultation yesterday, and it has lifted my spirits at the end of the summer holiday.
The consultation in question was with a patient I have known for most of my 25 years as a GP. I was reminded that 22 years previously to the day, I had attended urgently at his home to discover a classical presentation of a 'heart attack'. At the time I carried a wide range of emergency drugs (before Paramedics existed in my area) including morphine (now rarely carried thanks to a former colleague in Hyde) which relieved the urgent situation before departure to hospital.  The intervening years have seen a range of interventions, surgical and pharmacological, but have probably all contributed to a long and active retirement.
I was thanked gracefully and politely, for myself and my surgery continuing to 'care' and provide a service that is appreciated daily.

So for me this is a reminder that care, compassion, responsibility and continuity of care have not started because of recent 'scandals' and 'painstaking reports', or arrived by computerised protocol. They have existed throughout my working life, in all care locations and from all members of the caring and support teams I have worked with. The failures remain the minority exceptions - often when the 'needs of the system' are allowed to override the judgement of those at the point of care.
I must remember that in ANY of my attempts to open up more digital communication and interaction opportunity, compassion is not delivered by a computer, or 'care' by an algorithm alone. It is those who run the systems that must introduce technology that supports rather than detracts from these qualities. Quite a challenge ahead!

Peter S.

Memories

Time flies - and medical students grow into doctors who (sometimes) grow into respectable senior members of the profession.

I look back with rose-tinted spectacles, as on this day 30 years ago, I am reminded that I stepped out onto the ward in a starched white hospital coat as a 'proper' junior doctor.

The unsuspecting patients in Birmingham were not warned or prepared as I assumed responsibility for decision making on a whole new level.There will clearly be differences with the new generation, who may start better prepared, better supervised, less tired and better trained to interact with fellow human beings, but I suspect much of the excitement and trepidation is undiminished.

The 'digital' junior doctor may well not be burdened with pockets full of reference material, may 'clock-off' without a 24 hour duty shift, but will still need to practice and refine what they have started to learn over 5 years about interaction with patients, relatives and colleagues in healthcare. No amount of 'virtual' practice can match real life in remaining a steep learning curve.

So my advice to them is to listen, and engage the brain and heart when dealing with people.

Technology is fun, and essential to use, but can only compliment the essential care, compassion and personal touches that nurses, doctors and all our colleagues provide.

Good luck, and learn quickly. I need you to be looking after me sooner than you think!

Peter S

Expectation v Capacity

It is very hard sometimes being part of such a negative, defensive, pessimistic and cautious profession - or so the 'media' currently paints us in General Practice.

For those with an interest, there is an additional thought provoking publication from the 'Medical Protection Society' over on-line interaction and relationships between doctors and patients - worth consideration.

MPS Guidance

In particular I am concerned of the mis-match between patient expectation on routine response to e-mail enquiries, and the attitudes and capacity in General Practice.

Simply put - more communication channels from the public to General Practice will add to demand and workload unless other work, communications and processes are discontinued. I believe most practices are currently working at or beyond safe capacity, so yes, we are cautious with good reason.

Peter S.