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CAMHS won't see you now

How GPs can help with urgent care: the application of logic and reason

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David Cameron appeared on BBC breakfast the other week, in support of the Government’s £500m bailout for under-performing emergency departments (EDs).  The move has angered some ED consultants, who decry financial reward for failing standards.  So what’s all this got to do with the far-flung land of general practice?

Well.  Cameron went on to say (and, forgive me Dave, I paraphrase) that longer-term, hospitals have to work better with GPs, so that frail elderly patients stop bouncing in and out of hospital and clogging up corridors.  Indeed.

Forgive my paranoia, but hasn’t Dave just taken the scenic route to arrive at the rather spurious conclusion that EDs are failing because of GPs?  I know we earn far too much and we’re the fortuitous beneficiaries of an over-generous 2004 contract etc etc, but come on.  We’re all going insane chasing GPPAQs and briefly intervening; surely we can’t be blamed for the staggering increase in four-hour breaches (which, quite coincidentally, no longer carry a financial inducement)?  Let’s follow Dave’s thought process through, using an imaginary example, to see if it’s at all possible that he has made a few assumptions on his pootle through La La Land.

It’s 6.31pm on a Friday evening.  The local surgery has just closed for the evening, but the out-of-hours team are chomping at the bit.  At Bullingdon Residential Home, Ethel has had a fall.  She was only trying to stand from sitting, but the zimmer wobbled, and down she went.  There were no chest pain or dizziness, just a gentle mechanical fall, or a frame malfunction.  One of the support workers spots Ethel, helpless on the soup-stained carpet and gets her back on her feet, fully and painlessly weight bearing. In the absence of a senior (she’s popped out for a fag), 111 is bypassed and a paramedic is summoned.  No-one saw the zimmer wobbling, Ethel’s a bit shaken up, and suddenly she’s had a ‘collapse ?cause’. Off to A&E then. 

In the ED, a well-meaning but nervous FY2 greets Ethel, who’s clutching a dossett box of age-related medications.  So you’ve had a collapse Ethel?  Well, actually… she protests.  Her explanation (that it really was a wobble, not a collapse), falls flat and fades away as Dr Killing-Fields rampages through his doctor-centric consultation, sites his first cannula and requests a truckload of investigations.  These take an eon to return and eventually show nil conclusive.  Some bright spark spots that the collapsed Ethel takes warfarin for her AF and before she can say ‘I had a quick fall at tea, get me out of here,’ she is passed through a CT scanner.  There is no bleed.  As more trolleys back up to the ambulance bays, Ethel takes her spot on CDU, where she will unwittingly bed-block until the post-take ward round hours later.

Now Ethel doesn’t actually exist.  But her story is nowhere near as fantastical as Cameron’s coded accusation.  Even in pre-hospital utopia, these patients would still come into A&E, time and again.  What is seriously lacking is common sense in care homes, ambulance trusts and EDs.  I don’t blame care workers, paramedics or hospital doctors either, but a crazy cocktail of protocols, target obsessions and fear of litigation.

Imagine that Ethel’s fall happened hours earlier, at 12.31.  The local GP is called out, offers a few words of sympathy, quickly excludes fragility fracture and checks her obs.  Moments later he pats her on the shoulder and lets her get back to her lunch.

The services are already there.  GPs visit the frail and fallen in out-of-hours cars across the country.  I’ve done a shift recently and the service is not overstretched.  Don’t blame GPs Dave, just get punters (or their carers) to dial 111 (it can work very well) and apply some GP logic to ‘emergency care.’  After all, what’s actually best for Ethel in all this? 

Tom Gillham is a GP in Hertfordshire and Specialty Doctor in A&E. You can follow him @tjgillham.


Readers' comments (21)

  • Anonymous | 23 August 2013 10:13am

    "A 'duty of care' does not extend to providing paperwork and reporting that is outside of our contract "

    With jobsworths like this, is it any wonder that doctors have lost the respect of the general public?

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  • I think many accept that this Governments change to the benefits system has been akin to a demolition ball crashing down upon a walnut. It has left those of us who cannot work feeling utterly useless and inadequate, regardless of how much we have put into the community, ‘above and beyond’ the call of their own previous professions. I for one fostered up to 3 children at one point, a 24/7 care that saved the County thousands (a week) on care homes and all the ‘extra-costs’ that come with children in care.
    That is not considered in these sweeping (demolition ball) changes. Long-term sickness and pain had its affect and I had to give up fostering after 15 years. I would also add I had freely counselled any who needed me and been active around the clock in freely helping people in crisis. We’re not all scroungers and ne'er-do-wells.
    When told of the changes and that I would live on £71 (for 10 months) I felt my world slip away. That is how I ‘felt’, it wasn’t a metaphor.
    Some Doctors were clearly not interested in helping me. “I don’t believe it’s the job of Doctors [fade}” said one GP. I got the feeling I was no longer supported by my GP’s. How could I gather all that information from Specialists etc to present a case? How could I use the terminology of the Medical profession? Where was the TRUST I had in my GP’s? Even my Specialists had become un-helpful. A gap had developed and I didn’t cause it, it wasn’t my fault.
    I began to feel an utter waste of ‘good skin’ as they say; a time-waster, a leach on Society, no longer productive, no more use to anyone. You will all have heard the rest many times before. I sunk into the ‘Darkness’ with the inevitable result looming over me….. what do you do with waste? Dispose of it.
    It was the love of good friends who brought me back from the edge and a GP worth her weight in gold.
    Think on this. When you give the, “No help” response, consider those whom you mostly affect, those whom you have sworn to do no harm. And if any person in the Medical Profession has entered and finally come through the bleakness of depression, then think on. This is the result your “No Help” will have on many vulnerable souls.
    I only wish there was a cure for me. Then I could join the happy throng of the productive people, who could look down Dickensian-like on the worthless souls beneath me and my busy, important, significant position and tell them I don’t have time for them . . . or would I?
    My Plea: Please hear the call of organisations willing to work with you for a solution through this. “No help” will not help.

    PS Alison, I'm sure a lot of thought has gone into your difficult decision. You are right, we are left with one less truly caring Doctor. If I could, I would recount the help of a GP who has given me hope and help. This GP sounds very much like you and not at all like many of the 'distant' GP's I have met. I wish you well, but I also wish you might change your mind.

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  • To comment Anon at 1:34pm. Please, that is not a kind or helpful thing to say to someone who has struggled in her profession to be all that she probably hoped to be when she first set out. WE the Nation have brought this on by not being more pro-active in the changes. But let's not shoot the wounded - please - it's not helpful

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  • I would like to add that I believe this is the wrong battle and will affect the wrong people. If all the other demands were curtailed, we would have time to actually help people again. At present, the total demands are simply impossible to meet and we need to focus on those tasks which benefit patients.

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  • Please now that you have had too retire because of us awkward disabled people. Just hope you do not get sick yourself or you may find yourself were we are today,

    To all GPs struggling with the workload read the above statement and think about it. People will continue asking for work which we are not responsible for and then not give a monkey's when we're on our knees. How telling.

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  • And there speaks the voice of reason and grace.

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  • Dear fight back for justice, i am sure you could help out in GP , could your organisation help in the counselling of our patients with depression, you sound so sympathetic . Unfortunately we cant pay you for this work , and i know you are not specifically trained in it, but i am sure it would be a great help.

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  • To the writer of "Anonymous | 23 August 2013 1:32pm"....very articulate and well expressed sentiment. I would encourage you to take your story to the wider media. You have a powerful story and a gift for communication.
    Peter (and author of Anonymous | 23 August 2013 11:17am)

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  • What I think the doctors involve don't realise (judging by the text they are using) is that the Tribunal Service will never, never request information or evidence. It's the responsibility of the parties to provide evidence supporting their side, so the person who has to obtain and submit evidence supporting the claimant is the claimant.

    With the legal aid system that used to pay for evidence changed, we have no way to pay for it. Now, I don't think that GPs should have to do work outside their contract without pay. I also don't think that benefit claimants bringing appeals should be unable to get evidence. The only way we're going to resolve that gap is by working together, not doctors washing their hands of it. Certainly not by sending people letters that are materially misleading by suggesting that the Tribunal Service will ask for the evidence!

    So yeah, you're in your rights to just say no, and it's up to your individual consciences whether that's right or not - I'm not going to try to dictate. But don't send vulnerable people letters that may cause them to neglect to support their own case and thus have an appeal that could succeed, fail.

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