Peter English (1.52 pm) is correct- this will open the door to a similar expectation of expected / required Saturday cover in future Primary Care contracts...Also whilst CEOs of a number of hospital trusts have come out against the imposition of this new contract, Foundation trusts can offer their own / local contract in lieu of an imposed national contract. This may be better than the imposed one, but it might be worse- this will have effect of removing the national contractual standard.... maybe this was one of JH's intentions in the first place?
I agree figures quoted are confusing- are these average earnings overall or for a Full Time Equivalent? Be that as it may, by definition 'average earnings' means many will be earning (well) below average. Similar figures released in past years included a few extremely high earners which skews the 'average' upwards. In addition many high earners will be working up to 9 clinical sessions per week, which is far more than most partners I know feel is possible or realistic to work, given rising clinical & non clinical workloads, if one is to retain any semblance of a work life balance (even a so called part-time partner can easily work 60-70 hours per week as I have done).
As all GPs know, the work doesn't stop when the phones go over or the last patient leaves...As someone said earlier, it just halts new work til 8am the next day... so that we can work as late as it takes to complete the hours of outstanding work! I too have had to refrain myself from calling a patient at 10pm ...I don't want the solution to be fleeing to the private sector or abroad, I believe passionately in the NHS and value of primary care, but despair at all the competing agendas and unrealistic pressures/ expectations. GPs must be united to challenge ever increasing & unresourced work ...
Re partner 0.22 am- I agree, much missed 'prevalence' comes down to consistent & correct coding etc... even with a robust coding policy in-house there can be slippage, especially if there are lots of locum clinical staff (ie: it's not necessarily a reflection of poor clinical practice) . Optimising QOF targets involves 'cleaning' data entry & coding in a similar way... but someone has to do the work, and it takes time and money !
It's all been said, but I'll say it again- it is ludicrous to give priority access on demand, based solely on an age threshold. No practice has unlimited appointments capacity, and this proposal would mean reduced access for other younger iller patients. It makes no sense at all.
We are fortunate to be able to provide 'Wellbeing Prescriptions' to vulnerable, lonely, at risk patients. They contact a 'Voluntary Service Navigator', who can assess the patients and signpost them / assist them to access a range of services to address some of their unmet needs. We (and other health and social care professionals) can also refer vulnerable patients to a resource called SHINE-a one-stop referral - which taps into a range of initiatives such as Energy , Benefits & Falls reviews etc. I'm sure no-one would disagree that providing these services is a good thing, but to hinge the primary responsibility for this on the GP is absurd and at odds with the whole idea of fostering a culture of multiprofessional integrated care working. It needs planning, commissioning, resourcing and the involvement / input of all members of a health and social care team..
I am deeply disappointed that 48 hour access is a key part of Labour's Policy. . We ( like most other practices) always have some same day urgent slots ( and scope to see urgent extras following telephone triage) so people can see their GP based on need. This means we can continue to provide advance booking too. In the days where we had to offer automatic 48 hour access , it was much more difficult to manage access overall, and ensure continuity for patients with non acute problems. MANY problems do not require 48 hour access ( routine prescription reviews and long term condition checks to name just two) . Many patients want the choice of pre-booking to see their preferred doctor for non acute problems.
Why focus on the odd urgent home visits as the challenge here- a far wider problem is the difficulty of co-ordination and integration of care for people who live out of area & need in put from a range of health & social care professionals ( noting that integrated care is also high on the national political health agenda). Think of how tricky it can be to keep abreast of all the local pathways, services and contact details in ones own CCG ...and imagine replicating that over a number of other CCGs ...Initially there will be two types of people who want to register out of area- those already on our list who are moving out of area to a different CCG but need input from multiple services we'd need to liaise with- can we say no? The others are likely to be fit mobile commuters, but they'll get ill and / or old...of course some may then choose to register with a GP closer to home, but if not, then what? I cannot see any argument to justify this proposal overall.
I wonder if NHS England has thought to audit the actual work on the afternoon of Christmas Eve, and how many out of hours presentations were averted. We dutifully stayed open on Christmas Eve. There were 3 telephone calls and 3 people walked in ( & were seen given the fact that we were open, though none would have normally required an urgent appointment). None of these contacts would have been likely to have resulted in an out of hours contact.... hmmm. Still it gave me a chance to catch up on some admin work.... To be fair New Year's Eve was busier but the surgeries were only 50% filled.
I assume such data will be invaluable to private health companies(and whichever government is so interested) to help to ascertain the feasibility and cost of rolling out a model of health care predicated primarily on private health insurance ...... mmmm
I completely agree with the points raised in this letter. Please add my name.
Dr Imogen Bloor
Mitchison Road Surgery
London N1 3NG
I agree 100% with you Martin Kittel . I'd also like to know how a 'named clinician system' ( which we already use in our practice for vulnerable patients) can possibly be implemented along side these extended hours proposals that are antithetical to continuity of care.....
Aside from the huge matter of adequate funding , the issue of work life balance of doctors, practice nurses and their staff, and the premises constraints many of us are under, there are many many reasons why this is not the wonderful thing it is being sold as ( to the voting public) . To cover this sort of schedule means more sessional / shift working, and less parallel working alongside peers . Weekend and late evening access might suit patients who doesn't mind which doctor they see for their acute self limiting problem, contraception or whatever, but it is the beginning of the end for any semblance of continuity of care for the chronic sick who are most in need. It makes scheduling multi disciplinary / whole team meetings/ practice CPD a logistical nightmare.How will information and training be disseminated across practice teams effectively? ( More e-mails??!) Who will be available in the day to attend the ever escalating number of external meetings required to meet DES/ LES/ CCG requirements,. Doctors involved in CCG work will need to be available during the traditional working day, relegating the less experienced, more junior drs to work late and week-ends. What about trainers and their registrars? Who will provide contemporaneous support , mentoring , in house training etc to less experienced doctors, locums, nurses ? The working day doesn't stop when the last patient walks out of the door. Clinicians and reception staff will be in premises even later into the night than they are now, What about management support in these extended hours? Will CCG IT support staff work across week-ends and evenings too , to bail us out when EMIS crashes for the nth time.? This may be a feasible model for a minority of practices but the idea that all surgeries can do this is a total nonsense, let alone whether it is desirable. Where is the evidence that it will result in better care and improved health outcomes ?
I have read this debate with interest, and value the thoughtful contributions from most of the non doctors. I too am a caring GP who struggles with contractual versus ethical aspects of these issues, I also empathise with the drs who feel stretched to capacity ( as I often do), in the context that the volume of this kind of work has risen exponentially . ( I too am usually working at least 12-14 hrs per day) . One practical solution I employ is that if a patient consults ( face to face or by phone) asking for a report for an appeal, I use that consultation as an opportunity to review the patient's main health (and psycho-social) problems , and the limits of their functioning ie: what they feel they can and can't do ( and where relevant the impact on their mental health) . I may add a comment as to what extent their account concords with my objective knowledge of the patient, in so far as I can know it. I document that consultation as fully as I can at the time ( showing the patient what I have recorded) & at the end of the consultation print it off as part of a brief summary ( ie: with a list of significant active problems , medication etc), hoping that the up to date narrative pads out the usually rather uninformative list of diagnoses. I explain to the patient at that time that if a more formal report is required in a different format, then I will have to charge a fee ( but we try to keep such fees as low as possible). This is a bit of a fudge, and some will not agree that this is even part of our remit. However this way I feel the consultation actually serves a clinical purpose in bringing me up to date on that person's health issues (as well as being able to provide some medical evidence for them). It provides an opportunity to review & optimise the patient's management & direct them to self management programs etc to help manage their chronic health issues. Sometimes obvious gaps in support become evident. However this approach isn't feasible for everyone, and there is a limit to the detail one can provide bearing in mind that consultations are notionally only 10 minutes. I agree that the BMA and medical organisations should be working with patient groups to continue to challenge and change the systems ( though I'm pessimistic as I don't believe the present government has any will to do so, nor does it have a real understanding of the impact of the present system on genuinely vulnerable people in society, nor does it understand how primary care works and the pressures GPs are under)....
Patients we have spoken to like the single point of contact idea in principle, but I await the outcome of the roll out of 111 in our area with trepidation. Reports thus far suggest extensive delays .... I agree with H Blumenthal that effective triage needs to be done by experienced clinicians . Electronic communications which consist of streams of protocol verbage, from which it's very hard to sort out the wheat from the chaf, are at best unhelpful and at worst add to the risks..