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At the heart of general practice since 1960

Hospitals are driving patients into a care cul-de-sac

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How did I get here, Talking Heads asked around 1981. They probably didn’t realise their question would apply to general practice 33 years later. It does, though, in so many ways. And this month’s examples of utter, furious, GP bewilderment are brought to you via the blinkered, one-dimensional thinking of hospital departments apparently hell-bent on screwing up patients and driving us to goggle-eyed distraction.

Three cases against the accused:

1 I refer an elderly diamond geezer with new-onset dyspepsia and weight loss to the upper GI team, as you do. He’s seen within the statutory two weeks, and has the requisite scopes and scans. So far so good. His tests turn up some suspicious lesions in lungs and liver, and a nasty-looking probable primary in his bladder. So after the obligatory multidisciplinary team humming and hawing, he’s referred to the urologist – and if you think you can hear the gears of the merry-go-round cranking up, you’re right.

He has his cystoscopy and, amazingly, it’s normal. The bladder finding was artefactual. So he hops off the carousel and finds he’s back where he started, with me, because the urologist has referred him back to the GP for further management. Still dyspeptic, still losing weight and still with unexplained lesions in lungs and liver. Thanks, chaps.

2 I refer another patient to the medical assessment unit. A 62-year-old rare attender, he has a mysteriously swollen, painful leg which he can barely walk on, plus he feels hot and unwell. It’s definitely a something, but not obviously anything: too feverish for a DVT, too swollen for cellulitis, too ill for trauma. I explain to the medical SHO that he needs a proper overhaul, deliberately avoiding the diagnostic cul-de-sac of the DVT pathway. So, obviously, they direct him straight down the diagnostic cul-de-sac of the DVT pathway. That’s why my next contact with him is at 5.45pm on a Friday, just after he hears from the DVT nurse that he doesn’t have a DVT, but that, because he is still ill, leg-swollen and unable to bear weight, he should phone his GP for further advice.

3 I get a letter from the psychiatric unit. My patient, a chronic schizophrenic with multiple previous admissions for psychotic episodes, has DNA’d for the outpatient clinic. So, ‘as per trust policy’, they’re discharging him ‘to my care’. Because, obviously, the failure of a chronic schizophrenic to show up is nothing to do with the social chaos of the mentally ill, or the amnesic effects of industrial-strength psychotropics, or the addling result of worsening psychosis – no, it’s wilful wastefulness on the part of the patient. And that, clearly, is now my problem.

Voilà. Care that is consistently unidirectional, relentlessly dysfunctional and distressingly mononeuronal. This is what happens when you deconstruct illness and its management, and run the NHS by pathway and protocol. It’s getting worse and, to be honest, it’s a bit depressing. Care pathway? More like a road to nowhere.

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


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Readers' comments (8)

  • I was discussing with my partners that hospital incompetence is my biggest stress.
    1. I print off a c and b referral for a patient.
    Patient contacts hospital for appt.
    Patient told 'if you do not hear within 4 weeks go back to your GP and get re-referred'.
    In God's name, why?
    2. I do the same for another patient.
    Patient later sent letter they failed to attend, which is not true, and to go back to GP to get re-referred.
    Cue rude letter from me to send the appt I asked for in the first place and to stop all these admin errors from incompetent staff.
    3. I need an urgent discussion with a specialist, it could be any specialist, for an urgent review.
    All the secretaries at the hospital have been sacked to save money so no one answers the phone, or the one secretary left is on leave and the answerphone is on.
    I spend 45 minutes on the phone trying to find a registrar or consultant to talk to which totally f***s up my morning.
    4. Multiple hospital letters referring to patients with serious conditions I admitted, having the briefest admission for a few hours only and:
    'GP to chase up vaginal swab, physio, renal function, anaemia, chest nodule and new onset AF'
    5. I refer a pt with hip and knee arthritis.
    Patient needs knee replacement, but 'go and see GP to be re-referred for your hip replacement'.
    In God's name, why?
    The list goes on and on, there will be further examples in this morning's surgery which starts in....6 minutes

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  • This is like reading a review of my own surgery, any day of the week. It is increasingly common that we are picking up the pieces from neglectful, incomplete or failed hospital care.

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  • Copperfield's usual wonderful insight into the trials of general practice. Thank goodness I'm retired.

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  • Chand, obviously we are doing well. Peverly and Copperfield are outliers, obviously unconnected to GP land. Not true, they are spot on.
    Chand and GPC, please listen to these writers - GP land is getting untenable. We are Independent Contractors, but we are getting stuffed at pay and pensions.
    Dont believe me - what has happened to Judges pay and pensions? What about MPs. Do I hear 11% pay rises, while we get pay cuts.
    GPC, if you cannot cut the mustard, while people like Pev leave, please resign. I am sure there are folks out there with a little bit more spine than you.

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  • Very depressing. However as things are going with hospital services being cut/transferred/privatised things will resolve themselves. Healthcare will be for the wealthy who can pay for what they need. The rest of us will either struggle on or die, thus relieving the government of having to pay the pensions we contributed into all our working lives.

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  • I have had a nurse on the admissions ward phone to ask for a copy of the referral letter or the operation is cancelled. 'hospital did not receive it' - well the chap had already seen a dermatologist, was passed to the plastic surgeon and had been given a surgery date so methinks my referral letter arrived.
    Last week, I was trying to transfer a terminal patient from his house to a palliative care bed. After many calls to and from hospice/nursing home/family and district nurse service, a bed was found for that evening. Great - sorted, or so I thought. At 5.30pm, I was informed by the district nursing service that the continuing health care nurse had blocked the bed until she had it in writing from me that I was willing to accept responsibility for the possibility he might dies in the ambulance en route to the nursing home. And yes, she had finished at 5pm without having the courtesy of phoning me directly with this information.
    I recognise with depressing familiarity Dr Copperfield's entire column and anon@7.55am

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  • These pop-themed articles should be a regular feature.

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  • Only today I had a letter from anticoagulant clinic to say a lady with multiple PEs had dared to DNA clinic so she was being discharged " as per hospital policy " .
    The local chemo nurse rang to say that a young man with learning difficulties and testicular cancer had failed to turn up for chemo and would I care to pop round and check his temperature . Before I could tell her where to go she rang off leaving me to imagine the scenario where I have to explain to the judge why I didn't visit someone where the possible diagnosis of neutropenic sepsis was raised but I chose not to do anything about it .
    The last one made me laugh out loud.the usual "GP to follow up" letter asked me to monitor a patient on venlafaxine for long QT syndrome. How exactly ? Apart from wiring him up to a ECG machine for ever more until one of us drops down dead !!!!

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From: Copperfield

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