Grumpy Old Hector
Thinking about the ten-fold rise in out-of-hours contacts in our practice since it ceased to be our responsibility, there would have to be strict controls to prevent the otherwise inevitable abuse.
As ever, GPs would be ‘best placed’ to decide on the appropriateness of a home visit and still be threatened when the patient is dissatisfied. That then results in a tendency to say yes, especially from the ‘bad’ (mainly over-stretched) practices and a slow but relentless, irreversible increase in home visiting. How would the increased costs be paid for? Probably by reducing GPs’ core income!
If any organisation other than GP practices were to triage requests, to 'cover themselves' most of those refused would be told they needed an immediate urgent appointment for their year-long ankle swelling, cough for a week etc.
Really there ought to be no home visits whatsoever except in exceptional circumstances and for the terminally ill. Long ago I worked for a year in a small deprived town in rural Canada and did 2 home visits. One was for my convenience (300 yards away and quicker than waiting for daughter to bring her) and the other due to a combination of clinical need, timing and my previous involvement in the case. Essentially there were no home visits at all and nobody suffered.
Currently the public seem to be under the impression that they can demand a home visit and are doing us a kindness if they then agree to attend the surgery. This view may have been exacerbated by recent media coverage about the contractual obligation of GPs to do home visits, when they never mention that visits are only where the GP feels it is clinically necessary.
If everyone were brave enough to just say NO to inappropriate requests, the problem would probably reduce significantly. Some alteration to the contract wording might be necessary to enable such a change without fear of litigation.
Rejection of referrals by 'multidisciplinary teams' hiding behind 'policies and protocols' is too easy and risk-free for those making the decision.
If rejections were approved by a doctor, who personally bore overall responsibility for the decision, things might be different. However, crown immunity for secondary care doctors probably reduces any feeling of vulnerability.
According to the third last paragraph, branded Prozac is available. Pharmacists can dispense that even if the prescription is generic. They always want it rewritten as a branded prescription in these cases but cannot insist and I'd only consider that for personally owned local pharmacies. They screw the system to their financial advantage all the time, taking advantage of the drug tariff price and buying in cheaper drugs from abroad, so no sympathy from me if they were to lose out though the DHSC could no doubt fix that if necessary. NOT our problem!
I wish Pulse would remember that non-GPs with no knowledge of our pensions system read these pages. When reporting about pensions it might be a good idea to be more detailed.
In the above article “..highest earning GPs pay 14.5% in contributions, but an annual allowance worth £40,000 limits the amount of money that can go into the pot each year without facing significant tax penalties” could be interpreted as meaning that affected GPs earn over £276,000 per year!
There is the (now) 20.6% employER’s contributions (which we pay ourselves) and, critically, the annual rise in value of the pension pot, irrespective of the contributions, all contributing to the £40,000.
It is NOT just the ‘highest earning’ GPs who are falling foul of this dreadful pensions tax system.
The 1961 Suicide Act is unique in making it a criminal offence to assist someone in doing something that is not itself a crime!
GPs in Scotland need not be legally concerned as the 1961 Suicide Act does not apply in Scotland where suicide was never a criminal offence. Assisting in a suicide to the extent that it could be regarded as culpable homicide or even murder would obviously be a very different matter.
Providing a report that might be given to Dignitas is clearly neither. There was even a case about 15 years ago where a GP in the south of Glasgow prescribed drugs at the request of a terminally ill patient so that she could take her own life, which she did. As a matter of principle he was very open about it, the GMC became agitated and wanted to strike him off on the basis of criminal activity, but no crime had been committed. From memory, he was about to retire and did so shortly afterwards. The GMC would otherwise have no doubt 'got' him on something.
Fortunately it seems that no further action was taken after the police investigation of Geoff Whaley's wife, though it must have been very distressing. No idea what the legal position would have been for her or others with a similar dilemma, if she had driven with him to Scotland, ostensibly for a final holiday, then booked the tickets and flown to Switzerland from there. A nonsense that anyone should have to consider doing so.
Even if the law were never to change, the inappropriately overenthusiastic desire by some to apply it needs to be formally stopped, not just the issuing of advice or guidance to prosecutors. One wonders if those who drafted to 1961 Act ever intended "assisting, aiding or abetting suicide" to be so broadly interpreted that it now includes booking an airline ticket. I strongly suspect not. Perhaps more precisely and narrowly defining this might be an acceptable initial compromise if the law were not to change, though change it must. Those opposed to assisted dying just need to see a friend or relative dying from MND and almost all would change their view.
It is no wonder that the UK has relatively poor cancer survival outcomes when only those patients with the most worrying set of symptoms receive timely investigation and treatment. Everyone else, even if referred urgently, are put to the back of the ever-lengthening queue, triaged by a 'health professional' who either cannot properly understand relevant details of the letter or is only looking for key points on the tick-box part of the form. Appropriate 'Urgent - suspicion of cancer' or '2WW' referrals are sometimes downgraded if one factor is absent even though there are other symptoms/findings which together are more important.
Scottish Ambulance Service:
'GPs request emergency and non-emergency ambulance responses....When an emergency response is requested it is given the same priority as a 999 call from the public.'
Really? Always? Since when?
Sometimes very quick.
Worse if patient is in the surgery when even a 999 call gets downgraded. About 18 months ago we had an old lady who was clearly having an MI in the surgery, just 1 mile from a major hospital. Despite 2 additional 999 phone calls, the first 15 minutes after the original emergency request, the ambulance took 45 minutes to arrive and patient died in the ambulance. Complained and got typical administrative response.
In 2000 the Journal of the American Medical Association published a study that showed a significantly greater CVD and CHD mortality risk and shorter life expectancy in young men with cholesterol levels of 6.21mmol/l or above compared with those whose cholesterol was 5.17 or less.
Three large cohorts of men aged 18 to 39 were screened between 1959 and 1975. Those with a cholesterol of 6.21 or above had CHD mortality 2.15-3.63 times higher, CVD mortality 2.10-2.87 times higher and a life expectancy 3.8-8.7 years shorter.
Seems sensible that young people with significantly raised cholesterols should at least be advised and offered treatment at a younger age rather than waiting until later when vascular damage has already developed.
Vinci Ho, love your Eagles 'Desperado' analogy. Even the title of the song seems apt!
What about the last 2 lines of 'Hotel California':
You can checkout any time you like,
But you can never leave!
Not clear who is expected to cause the customs delays. Presumably not the exporting EU countries, but UK customs! One would have thought that arrangements could easily be made for drugs from the EU to be treated exactly the same as at present or is it a matter of being caught up in general queues? Never heard about problems for drugs currently imported from non-EU countries.
As regards cool storage of insulin, vaccines etc, they are transported in refrigerated vehicles to maintain the cold chain and any delay, be it half an hour or a whole day, certainly ought not to be a problem. There are vaccines from India used in the UK, with the cold chain correctly maintained during transport.
Adding a dash of ‘health scare’ of course spices up the Brexit mix politically.
As Prof Gask suggests, it’s all about the numbers looking good. They are fiddled mainly by exclusions, ‘failure to engage’ (including an inability of patients to state what they expect to achieve from the service), a negative/disinterested attitude from some therapists to discourage further attendances and rigid, short treatment course lengths. Pre-treatment and particularly immediately post-treatment assessments often seem biased to indicate a treatment success which the individual does not experience – or certainly not a week or two later.
Psychological treatment can be very effective and I can think of many patients who have obtained longish-term benefit (a few even permanent benefit) from seeing a clinical psychologist. However, doing it on the cheap using lesser-trained staff and treatment protocols/algorithms rarely seems to do much good.
I suspect that an impartial study into the longer-term (even 3 months) benefit of such interventions would show them to be a politically motivated fallacy.
Cobblers at 4.36pm makes an interesting point about the potential legal liability of those allocating violent patients. Violent/'challenging' patient clinics seem to be closing, presumably for financial or staffing reasons. Perhaps prior to allocation such patients should all be assessed by a forensic psychiatrist regarding their current level of risk. Waiting time and cost might encourage reopening of the clinics!
GPs are (sometimes inappropriately) much more tolerant of such behaviour than hospitals where there is an increasing tendency to call the police for quite trivial reasons. Any new zero tolerance policy will no doubt be implemented vigorously in secondary care - carted off to the cells for looking at a nurse with a grumpy facial expression. However, as others have said, we need the right to refuse to see violent, aggressive or threatening people without fear of litigation or primary care will be no better off.
If the RCGP were arrogant enough, as they undoubtedly are, to take a (presumably) remain/2nd referendum stance on Brexit then I would hope that all members who voted to leave the EU also leave the RCGP.
When making such statements which may be grasped by the public and journalists,'Part-time' or 'less than 37.5 hours' are inappropriate, potentially misleading descriptions. As indeed suggested in the text above, those consulting and seeing patients for example on 7 notional half days per week will still generally be working more than 50 hours a week if administration in the evenings and on their half days, both in the surgery and at home are taken into account, as they must be.
To a clocking in and out public, the total duration of our toil should be the important main figure, with consulting hours being identified as part of that total.
"...and shared with the specialist heart failure MDT"
The RCGP just might recover a tiny bit of respect if they simply said NO, GPs and the primary care team are too overburdened as it is. The specialist heart failure MDT should do the reviews and share the information with the GPs. They should then start reviewing other NICE guidance too. Formal refusal by both the RCGP and BMA to accept some NICE guidance as appropriate would probably be legally protective.
Also, the danger of 'misuse' of NICE guidelines by lawyers could be reduced if NICE made it clear in each and every guideline that they were just suggested guidance and that alternative management may be equally appropriate. Although this is alluded to by NICE somewhere, putting it in large, heavy print at the start of every guideline would be helpful.
I wonder if he had a relative called Tony. Tony Hancock had a similar level of medical knowledge, particularly blood transfusions. (https://en.wikipedia.org/wiki/The_Blood_Donor)Sadly he killed himself in 1968 and the suicide note stated "Things just seemed to go too wrong too many times" - as Matt may eventually discover.
"...we would like to see significantly more practices benefitting from pharmacist and pharmacy technician time, which will allow GPs to free up time..."
That might be possible if the good ones could be cloned! The reality for many practices is that the pharmacy person spends hours doing very little of benefit to anyone then hands the GPs big lists of things to check, which can take hours even though much of it is trivial queries scraped from the bottom of the barrel to show how busy they have been. Seems to cynical me like a solution to the over-production of pharmacists.
Health minister Lord O’Shaughnessy said: ‘Patients rightly expect that, wherever they’re being treated in the NHS, doctors and nurses will have access to all the vital information they need.
I’m ok with that, provided that there are adequate controls and the opportunity to reliably opt out.
Sharing data with non-medical ‘care’ organisations/social work etc is however a rather different matter and should be resisted. Others have difficulty in grasping the fact that just because you find something out does not entitle you to use that information as you wish.
Two examples: Several years ago I referred a young man to the drugs problems service, which is (inappropriately) run by social work. The electronic referral was seen by his probation officer who came across it on the social work computer system. A condition of the man’s probation was staying off drugs (though of course they had done nothing to help in that matter) and were it not for the enormous fuss I made, the probation officer was planning to get him sent back to jail.
Similarly, a patient who was a social worker in another area lost her job. There was just vague circumstantial evidence of data misuse but it was the only realistic explanation for various trumped up accusations.
This might be an opportune moment for a long-overdue campaign from the BMA for all GPs to resign from that self-perpetuating oligarchy known as the RCGP. Decimate their funding and see them wither and die.
Doing the same for the GMC would be more difficult legally but an at least equally appealing concept.
PS: Meant to add that prevention of terrorism is also a factor to consider. 4 or 5 years ago we had a terrorist suspect registered under a false name and was found via NHS registration data. He had not been honest regarding his occupation on the new patient questionnaire! Jailed.