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CAMHS won't see you now

GPs cannot contain the chaos much longer

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Do you ever feel that, as a GP, you’re dealing with a complex system whose behaviour is so unpredictable as to appear random? Good, because you are. That, after all, is the definition of chaos. And one of many things GPs are excellent at is creating, out of chaos, a sense of order. This applies to the chaos of political initiatives, patients and – especially nowadays – secondary care.

We cannot legislate for a system that is massive, complex and mad

By the time you read this, the furore over the winter implosion of hospital services will probably be wrapping cod and chips. Forgotten, or dissipated by shifting the blame away from politicians and, judging by the latest headlines, onto us lazy, feckless GPs.

We haven’t forgotten, though: the winter crisis is merely an acute-on-chronic exacerbation of hospital dysfunction. Some of my patients won’t have forgotten, either. Like the elderly man who should have been an ‘avoiding unplanned admissions’ exemplar but turned out to be my most risible DES fail yet. End-stage COPD, revolving door admissions, and the answer to the ‘Surprise’ question being, ‘Isn’t he already?’ So: liaison with respiratory consultant to confirm switch to palliation, tick; long chat with patient and family explaining and agreeing approach, tick; emails to others involved confirming change in management, tick; mobilisation of community services, tick.

What could possibly go wrong? This: within two hours of a home visit for a final discussion about our agreed approach – specifically, ‘no more hospital’ – he was back in hospital. To everyone’s bewilderment, an ambulance had turned up, sent by ambulatory care on the basis of an abnormal blood test picked up from an admission the previous week of which I knew nothing.

Just one example of how, no matter how hard we try, we cannot legislate for a system that is massive, complex, underfunded, stressed, protocol driven, and mad. GPs simply cannot sort out the aftermath for each and every patient, not when what was once a trickle is now a flood. Only this week I have spotted a horrendous drug error on a discharge letter, an overlooked internal referral and a significant missed scan abnormality which at least counterbalances all those over-investigated incidentalomas. And these are just the highlights among the run-of-the-mill dysfunction we sort out daily, like today’s arthritic man I’d sent for physiotherapy who, via the standard noctor/scan/onward referral pantomime, ended up seeing a consultant, who has suggested I refer him for physiotherapy.

It’s overwhelming. As the hospital situation becomes intolerable, so does our role as their patient liaison officers, sense co-ordinators and safety-netters.

It’s hard to know where we go from here. Especially as it looks like the Government, with chilling predictability, is pinning the blame on us GPs – portraying us as the cause of the problem when we’ve been busting our GI tracts to mitigate its effects. I’d suggest we look to the Greeks who, after all, knew a thing or two about medicine. Because, according to Greek mythology, what came after chaos? Darkness. Politicians, you’ve been warned.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield

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Readers' comments (18)

  • Tony, I have followed your column for many years.
    What has become increasingly apparent in the last couple of years is the steady erosion of the sense of humour and begrudging love of the wonderful job we signed up for that once underpinned your superb rants against all the ridiculous demands of General Practice. I now sense only a growing frustration and fury at its destruction. I share your disillusionment and hope you can find a way to survive. DLTBGYD

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  • As free thinking, risk bearing professionals, we now seem to have to take the risk and responsibility for the protocol driven pallid GP replacements. We get the blame when anything goes wrong with individuals or the entire organisation, shame only got less than 5 years to go!

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  • At least you lot can shut up shop in the afternoon and go off home, while the hospitals deal with relentless chaos day and night.

    Why can't you raise your genuine concerns without recourse to lazy, malicious hospital-bashing. The problem is not dysfunctional hospitals, it is systemic underfunding, too few beds, too few doctors and nurses, and no social service funding.

    I've visited several GP surgeries this week, watching a single patient in the waiting room, as well as working in the hospital, and it's pretty obvious where the pressure really is.

    You guys have absolutely no idea how bad it is here.

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  • Dear No one else,
    I know how hard it is in hospitals (difference is that all GPs have had some work experience of this)
    The only part I agree the rest of what you say is the systemic underfunding. GPs manage 90% of patient interactions on approaching 7% of an NHS budget which itself is scockingly poor as a GDP compared to other developed countries.
    The rest of what you say about GP is unfortunately just arrogant, ignorant and crap and adds little to fostering good relations.

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  • Dear No one else,
    Well maybe if hospital doctors worked harder then AE waiting rooms would be empty? I remember in my days of working in AE we worked so hard that many times the waiting room would end up being empty (that's because we worked hard and fast - unlike todays juniors)

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  • David Banner

    Gentlemen, gentlemen, starting a fist fight between hospital and GP doctors is hardly dignified, and plays into the hands of the REAL culprits at the DOH. I'm sure we can agree that ALL sectors are woefully underfunded, and squabbling amongst ourselves will achieve nought.

    I too am concerned about Copperfield's recent blogs. The black comedy has been trumped by bitter angst. I suppose we all feel that the mounting chaos is no longer something to laugh about, but I only hope TC's mental health is in good shape. Keep well, brother, we feel your pain.

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  • Copperfield has highlighted the biggest source of GP stress - managing risk generated elsewhere in the health service.

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  • Sorry hospital docs but Copperfield is right to point out that GP's are dealing with a huge increase in work that really we shouldn't be doing. Work that is caused by other nhs staff not communicating with each other or the patient, or not taking responsibility, or not doing their own work in terms of prescribing, sick certification, giving results of tests, arranging repeat tests etc. etc. This is often a consequence of the internal market and low morale in hospitals and the lack of personal contact between gp's and specialists.
    So go on Copperfield, as usual you are spot on.

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  • You should all watch this

    This is the reality of ED every day. Dr MSC wouldn't last five minutes if he thinks we are lazy.

    At least half of the patients could and should have been dealt with in primary care, if their own GP took a bit of responsibility and interest. We are drowning in work that you should be doing.

    Why is our on site urgent care centre rammed with 50 patients at 10 am on a Tuesday morning every week. Why can't their own practice see them in core hours, where we all agree they'd get better care. It's because you have the luxury of being able to say 'sorry, no appointments today. No local surgery is open 40 hours a week, no local GP works more than three days a week.

    My advice to all medical students is definitely pick general practice over hospital medicine if you want work life balance and proper remuneration and to wallow in the foolish notion that you are somehow more deserving martyrs than those hospital consultants.

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  • Lost Dr if it is so good out here why haven't you joined us there are lots of vacancies and chances to show us how good you are.Please come we are despairing.Within 10 years at the pace we are going the will be NO primary care to talk about and hospital department will be taking the full brunt of the public demands.Remember we have 90+% of the patient contact for 7-8% of the budget.We can't hide behind serum rhubarb a ct scan and a short term admission to an assent unit bed(going through the doors at A&E the hospital get the same as we do for a years care for one patient).We refer when we have tot the moment things a re so bad I have patient begging me not to send them to hospital.WE ARE ALL IN DIRE STRAIGHTS.WE DROWNING.AS we go down for the third time we are also fighting each other when we should be fighting the government.A sad state of affairs.

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder