Peter is an Associate Director and Master Trainer for 4Mental Health Ltd and Connecting with People , delivering suicide prevention, self harm and workplace training programmes across the UK and internationally.
He had been a GP Principal for over 25 years and was in later years singlehanded, then forming a partnership before stepping down. He is now registered as a GP locum though not actively working as a GP.
He has worked with a PCT and on a CCG board for 8 years as a clinical lead in Wandsworth
He had led on the Wandsworth Self Management Service and promoting good health programmes in developing strategy and as a tutor.
He had contributed to a complex MH placements panel and was the clinical lead for personalisation and personal health budgets also in Wandsworth
He has been a clinical consultant for the digital mental health online community, Big White Wall Ltd, almost from its creation and latterly as their Caldicott Guardian
He has a passion for people's lives...
Complaints are a part of the system
In the vast majority of cases I suspect the public, a patient, a family, a loved one is seeking two things....
Clarity and understanding as to why something has happened
An assurance, if fault is found, that this should not happen to someone else - that we have learned.
The problem is that for a medic, a GP, the emotional impact and the fact that we too often turn this into a painful, punitive and punishing process is at fault here... we do not learn best from being punished, blamed and beaten. Using Clare’s word we are at risk of being “killed” by the process.
Clearly doctors have lost their lives but in so many ways:
Addictions and self-harm
And so much more...
Often never the same again
This is not to diminish the pain and anguish that may be suffered by complainants but it is vital that the process itself does not destroy life and where support for EVERYONE is needed it should ALWAYS be available. The process should always be about facts, fairness and resolution wherever possible.
When a tree has fallen in a forest the whole forest must not be burned down and left to die.
Let’s hope that as the process is reflected on, as all medics are asked to do in their own learning, that loss of a life, to add to the pain of a complaint, is removed as a risk. We all also need to prepare for the emotional and physical impact of these almost inevitable events.
When I mentioned highest attendances to AandE I meant WITH Self-Harm as the presenting contact...
Just some observations
There a few points to make here one in response to the article and the other is to the comments so far.
Thank you for an excellent article.
It truly does highlight many of the key issues associated with Suicide and Self-Harm and the powerful association between both. The UK has one of the highest attendances to AandE departments in EUROPE and we also have 3 times as many suicides as there are deaths on the road due to MVTAs. There is a 50-100 times multiplier of risk I believe of suicide if someone is self harming in that year...
So where some of us, may feel that these behaviours are attention seeking, they are indeed not.
They are connection seeking AND a warning of a highly significant risk of suicide and a marker of the enormous emotional distress and pain experienced by that person.
We know also I believe that about 70% of younger people who are self-harming have thought about suicide and that more that 60% of people under the age of 20 who take their lives by suicide were self harming
So I would only add/highlight 3 things in this great article
1. is that all people who present with self harming should also be assessed for suicide and at least asked the question each time - this actually is highlighted within the piece which is so important
2. Co-produced safety plans plays a huge part in mitigating risk both for suicide and self-harm
3. We need to understand that demographic evidence risk factors are based on the lifetime of a population - important but that needs to be considered and we must always look for individual personalised risks and triggers - an absence of evidence -based risk factors is not an absence of risk.
In relation to calling 999. This is a matter of the level of response required at any point in time. It is vital that GPs have the tools in place to make those response decisions commensurate with the needs of the individual. One also needs to mitigate against deterioration/elevation of risk when a patient is no longer in the room... this varies markedly over time and can shift quite rapidly and unpredictably.
Final comment is that of course it would be better still if the provision of DBT and MBT were more widely accessible for those with Emotionally Unstable personality disorder...
Thank you again to the authors and I only wish more of us picked up on this article with commentary...
Can I echo and multiply the words of so many comments here. I was very much touched by the words of Lydia Wood, Locum GP 29 Mar as well...
I had the pleasure of meeting you twice and I remember well having a discussion with you regarding the content of Pulse and whether it would be good to shift the balance towards "Good News" stories. I remember well you looking me in the eye saying something like (and I am too old to remember word for word)
"I have to be real to the stories and commentary that crosses my desk and in doing that transfer this to the magazine as fairly, honestly and as closely representative to the original as is possible - and so it is what it is."
In doing this, Nigel, you have represented the passion and the facts, allowing the good the bad and the downright ugly be voiced in Pulse.
In doing this also I know that you have reduced the isolation and helplessness that many have been feeling over the years and that this has improved and "saved" lives.
For this and more I say thank you
Best of luck
... you helped us stay awake...
My comments hold less sway as I speak from the position of having stepped out of general practice a few years ago but relevant as I had literally sat on the precipice several times... but on reflection though workload was an issue it was complexity that was the "demon"
Whatever changes are made following the BMAs proposal they must establish a system that supports Primary Care to return to a place where compassion, hope, care and support is paramount - where these elements are in place for Primary Care itself.
NO system should be established that simply makes the situation worse with increased exposure to litigation risk, a widening rift between doctor and patient and a worsening of the well-being of the workforce AND increased complexity...
IT might be that these proposed measures are the single greatest changes that could be put in place for general practice for a decade or more but then something else might have to give and a suggestion would be to put QoF on hold for a period of 3- 5 years while new patterns of working are established - in parallel a new more meaningful framework could be developed ready for release in 2023...
BUT the saviour of general practice may simply be to simplify...
Patients, their needs and the lives they bring have become more complex so the solution is never to make the framework to deliver care more complex - it needs simplification and flexibility with a freer autonomy. General practice was always designed to deal with complexity but not to be hampered by additional complexity.
Clearly if you simplify payment and quality systems some in the public, commmissioners, contract holders and government will suspect that primary care will "gameplay" and cheat the system but I believe history shows that there is more gameplaying within complex systems as people try to survive ... Primary Care wants to do the right thing for the population it serves why then voluntarily do GPs see more than an average of 40 patients a day... When they could have said no a long time ago?
So as confusing a response as this is it would be interesting to hear what others think..
Please ALL do take care - your lives are vital to you, your families, your friends and colleagues and those you serve... There is always hope and always reach out to those colleagues who you see suffering..
It's like the story of the man who phoned 999 only to be told that it wasn't an urgent problem so they should call
On doing this they were told it WAS urgent and should call
999... who promptly sign posted them back to 111.
This went on for a while... UNTIL
It emerged that the man's chest pain was anxiety, relating to a gambling problem and as a result he was told to contact 888 (.com)
Problem solved... laid a large sum on a single bet and now very wealthy.
Chest pain gone
Able to buy private health insurance
Thank you 999 and thank you 111
At least Jeremy Hunt IS concerned about the outcome of the recent GMC hearing case - as he should be...it overlaps with the sircumstances of overwork and the risks associated with it...
The realisation of the effect of this is surely:
A reduced number wanting to join the profession
A number much more rapidly leaving the profession in the UK
A reduced number working into goodwill
An increased number working to rule
A reduced number documenting reflective practice
An increased number practising defensive medicine
An increased number reporting failings in workplace and conditions BUT not holding out much hope for change...
Whilst Brexit reduces visa freedoms of overseas doctors
With the undercurrent of fear that all healthcare professionals are at risk of manslaughter charges
Not the best state of affairs for retention and recruitment really
But I might have misread the situation... is there an action plan anywhere to address this which is not simply about ... let’s put more money into the NHS
So much of this is hearts and minds stuff where compassion, support, hope, much more good sense and a feeling that you are not alone is vital...
Such a deeply sad situation for ALL involved and concerned... feel saddened end to end...
Prevention better than incident:
Partial extract from Duty of Candour (GMC guidance) - excuse the context but
"The guidance also builds on advice in Raising and acting on concerns about patient safety which clearly sets out managers’ responsibility to ensure there are systems in place to allow concerns to be raised and incidents investigated, and that staff who raise a concern are protected from unfair criticism or action.
There is a list of all the paragraphs in GMP and explanatory guidance which are related to this guidance in Appendix 1.
The guidance says that doctors, nurses and midwives should:
speak to a patient, or those close to them, as soon as possible after they realise something has gone wrong with their care
apologise to the patient, explaining what happened, what can be done if they have suffered harm and what will be done to prevent someone else being harmed in the future
report errors at an early stage so that lessons can be learned quickly, and patients are protected from harm in the future."
All really important... though
It seems that the way forward is for every clinician and manager in ALL situations to be able to freely and openly report ALL failings in systems and workplace environment that MAY contribnute to increased patient risk rapidly and PRIOR to any incident.
Maybe a dedicated email address and hotline direct to all these vital organsiations and people which is activated simultaenesouly... Let's see feet on the ground doing their bit to prevent
Then everyone can arrive and roll their sleeves up together in an effort to prevent an incident.
How else to more completely ensure that everyone is protected BEFORE an incident might occur..?
So much to say... Pulse Editor...
First and foremost I have a concern and I hope Pulse have a mechanism.
So many conversations I read here and attached to other articles are a descriptor of extreme distress and the symptoms and signs of this are all too evident.
I do hope that PULSE and the individuals who write comments here are aware of this and signpost or self signpost to get help.
PLEASE PLEASE get help... whatever that might be
Second. Jonathan.... thank you. I come from a self management skills training background and your words resonate strongly with me. You can alter your populations illness behaviour and your speed/balance and joy in your work is a reflection of how that can function - I am sure you apply many other skills. These are the transferrable and teachable skills I was alluding to but we have as an NHS community only touched the surface as the personalisation and self management agenda has never been taken to a scale where you see wholesale shifts in societal behaviour - patient activation. It can be done but requires a sustained national initiative over 10-20 years plus which is left untouched to see the fruit of the labours... takes courage to make this commitment. But courage is what we need.
Finally I also agree that patients self select and that this is a challenge and also a reality (where personal lists don’t exist). I have long said that, crudely speaking, there are two types of GP. One that generally thrives on and excels in acute rapid turnaround consultations and others who thrive/excel on complexity... the consultation length, approach and management is very different. Clearly there are some who do both just fine. In our complex world we need to accept we need to not see the consultation as a fixed 8.2 minute format and that we should match consultations between the patient type/need and the particular style of GP. We should also accept this working alongside our different colleagues.
But again I say to those suffering out there who feel like running away... make sure the first thing you do is run to get help, support and care. Don’t suffer in silence... Start to put your Safety Plan together now.. I have had mine for a long while now
Could this be Carillon all over again?
Some of the signs might be there if looked for hard enough
It’s a question...
... and meanwhile the profession continues to suffer
The CQC would not give an NHS organisation 2 years to get its act together!?
You clearly have a formula that works.
If these are transferable skills then you should be sharing them with those who are struggling, suffering, resigning or worse.
You would be a saviour to many. Resilience and resourcefulness can be taught and your formula might in fact be a significant approach...
Think about setting up training programmes as lot of GPs are not doing so well out there?
The reality is that only a fraction of the solutions lie within primary care itself. Creating more appointments, more doctors, more clinics, more budgets, more resources only addresses one side of the equation. Society, as a whole, has changed significantly and insidiously over time.
So many factors lie in complexity, expectation, capitalism, consumerism, passivity and repeated system change. The other side of the equation, with the control and ability to develop the change in behaviour required, lies with the public, nationwide societal influencers and the political system. Primary care has tried over decades to alter illness behaviour at scale but at best has probably contributed to a shift in the behaviours of a small number of their patients.... however the rest is beyond us.
In fact we have a political and regulatory system that has continued to push patients through every door and this has been akin to squeezing a balloon which is half filled. However now the balloon is full and can be squeezed no more for fear of it bursting.
The public is in a difficult position because they have, through various sources local, national and international, become more expectant and informed about potential treatments, illnesses and pathology, which is good, but in doing so have a heightened sense of anxiety and concern which in turn without certain personal capabilities and additional confidence and knowledge, takes them through the door of health care more - and so they come, often to the point of lowest resistance such as AandE. This is not blame, this is survival.
Alongside this people have become, to some degree, more emotionally fragile and mental unhealthy. GPs know this as they see higher numbers of people anxious, depressed and mentally unwell with a host of social challenges that in itself is another factor....
Last, but not least, if the NHS was a patient it would be diagnosed with depression. Of course this is not true for the whole system but a highly significant proportion of it... and Primary Care as we know is under unacceptable levels of pressure and stress and the evidence of the effect of this is all too evident. This article is yet another descriptor of this situation as there there is only a limited amount that tired, depersonalised, desensitised and demoralised GPs can do to parts of the system that they simply can’t change.
And so it is time to look to an entirely new approach to managing demand which would be highly complex, challenging and courage-requiring but must be done.
The complete solutions are therefore not simply in more appointments, more doctors, more clinics, more budgets and more resources
...... 24 hour 7 day a week general practice...
Need I say more.
Excellent piece of work...
now also look at the net benefit of immigration on the NHS when you look at the balance between utilisation and supply of services
Why are some people so stuck on myths that simply aren’t true but sadly these are some of the guys who control policy at the same time!!??
An unofficial often quoted statement by Noam Chomsky may explain
the current state of the NHS
And also the reason for Mr Hunt’s reappointment
“That’s the standard technique of privatization: defund, make sure things don’t work, people get angry, you hand it over to private capital."
Mr Hunt might still be there as the level of defunding, assurance that things are not working, generation of anger and the moment to truly hand things over have not all been reached yet... work in progress!
I wish you all the best in your treatments and recovery…
GP at Hand but will they treat feet as well?
This is disruptive technology and implementation at work.
Disruptive has its positives and its negatives.
The negatives have been discussed at length...
Are there positives? Time will tell.
There are so many dependencies and players here with economics, quality, choice meaning choice, sutainability and feasibility, sector destabilisation and so on at work it is so hard to predict - bit like BREXIT really!!
The world is changing in so many arenas and the end points are just not as clear as they used to be....
There are so many layers to this story...
What is interesting is that if this story emerged 4-5 yrs ago many of the comments would be much more antagonistic but due to the stretch that the nhs is feeling and GPs themselves it is starting to feel ok.
As so many have said private services have always existed... most of our out of hours services are private for starters to include 111
The question is how a patient gets to these services and how a patient’s complications are managed after they have used these services
The onous should continue to be on the private provider marketing as hard as they like but not depending on GPs to “signpost or recommend” these services. The private provider needs to market direct to the public ... however there might be a sniff of duty of care where a patient would benefit from quicker treatment etc... and then it might be that if we are aware that there is a quicker route then we should be signposting people to that OPTION... then it is patient choice all the way.
The other challenge is complications. Ideally what is private stays private until the whole episode is complete. However we all know that W pati4n has a right to come to an nhs GP at any time for almost anything and be seen, assessed and managed.. that is the nature of registration - almost 100% of UK residents have the right to GP registration and treatment - this includes complications at the hands of a NHS secondary care service or a private services.
The darker side is more a public health and moral issue. This will widen inequalities. Those who have will get more easily and this who don’t will lag behind. Even though speed to treatment is not the only quality factor this might skew outcomes for the select few... that feels uncomfortable.
Anyway it is worth relooking at the first page of the NHS Charter in 1948 when Aneurin Bevan launched the NHS in Manchester. Even on the first page of the first charter there was a whiff of “you might have to pay for some items”. Although I don’t think he was thinking of private services nevertheless the sense was there still...
Just some thoughts which may indeed be in wrong trees
Oh and to add...
Isn’t the solution a new form of dual registration?
This answers one of the elements in the motion about loss of income and would address the need for locality and face to face hands on consultation where required...
I wonder where this will go?
Jonathan Pywell 7:22 morning has hit the nail on the head
If they have been awarded a standard GMS contract then clearly most other GMS providers will be up in arms.
The thing about traditional general practice is two things
1. It is almost limitless in what it can “Manage” - almost...
2. Registration has next to know limitations which meets the rights of almost all residents of the UK to have a registered GP - almost
The Babylon Service is, with its commissioners, establishing a disruptive technology into the mix which is, while providing a Primary Care type service, clearly saying that significant elements of general practice can be delivered differently.
The key elements are:
To manage patients using remote technologies has limitations and to register patients under a standard GMS contract would I suspect, but I don’t know, challenge the service when it came to complexity, blended physical, mental and social morbidity, housebound and the very young and those whose presentation behaviours are bound into complex personalities. Thus any service like this in mitigating the risk would have to have mecnahnisms in place pre/at registration or at the point of clinical contact to manage these types of patient.
Most people have been saying that something needs to change in general practice and the thing is to at least embrace the possibility that a disruptive technology might be part of the solution.
The question remains is whether a traditional GMS contract is fair and the right framework. Maybe the only safe way to run such a service IS to filter patients at registration or have a mechanism to rapidly connect complexity and cases unmanageable online to a face to face service. There then remains the question as to whether certain patients can be managed by doctors way out of their area, knowledge zone. And finally, does it heighten inequalities where the new inequality divide is whether you are tech savvy (Happy) or not.
So many questions that deserve answers... this comes at a time where there are so many sensitivities and challenges for the future of general practice in the UK..... difficult.
Not being cognisant of all the details behind the placement of this new service I simply make some observations...
I love Catherine Welch’s reminder to us about queuing theory
This all boils done to which street corner you want the queue to be on
The queue does not go away ... they simply line up somewhere else
Centrally they can only cope with moving a queue rather than truly understanding WHY the queue exists.
A child says “I don’t want the queue here... I want it there”
And adult says “ the queue might be in the wrong place but let’s really understand why first”
The psychodynamics of why people attend AandE is a highly complex and multifaceted equation and when you deeply look at the cause and effect you see the truth behind AandE activity. Some you will recognise and some will surprise you, some you can tackle and others are utterly unreachable.
And finally if you imagine the game of chess. You don’t simply move a piece to another square because you can. You wait and explore many many moves ahead - cause and effect.
TimeToWakeUp oh... and grow up.