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Choosing our battles wisely

Copperfield

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Don’t get me wrong. Just like any other sane GP, I love being paid properly and I loathe having workload dumped on me.

But I do think we have to know when the pendulum has swung too far.

Such as, to give a local and recent example, the suggestion from movers and shakers that we should refuse the occasional request from urology for long-term monitoring of men they’re discharging with borderline PSAs – unless this comes as a fully-fledged, enhanced and remunerated service.

After all, it’s not core, is it?

Nit-picking over trivial stuff risks making us look ridiculous – not only to secondary care, but also to potential new recruits

Hmmm. The problem with the ‘core’ argument is that it implies the definition of our fundamental job is frozen in time – but it’s not, it’s fluid and dynamic. There are ebbs and flows. As medicine and the organisations within it evolve, so will our job description and, to a reasonable degree, we have to accept that.

And, to really grow horns and a forked tail, I’d add this: if I was a health service manager, I’d point out that GPs can’t have it both ways. If we really want bolt-on money every time we reckon we’re put-upon, then the reverse should apply: now that I have a dementia intensive support team resolving crises, an acute visiting service sorting home visits and open access to IAPT rendering referral unnecessary then, for each, maybe I should have a Local Reduced Service sum subtracted.

So careful what you wish for. Maybe we should start trying to distinguish between reasonable resilience and sheer bloody-mindedness.

We should keep our powder dry and our energy up for the battles that really matter (think DMARDS not PSA). Besides, nit-picking over the likes of something as trivial as PSA monitoring risks making us look ridiculous, workshy and money-grubbing – not only to secondary care, but also to potential new recruits. And if we alienate them, it doesn’t matter how you define core – there won’t be anyone left to do it.

Dr Tony Copperfield is a GP in Essex

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Readers' comments (31)

  • I don't actually agree with you this time Copperfield, PSA monitoring can be a disaster and is much better kept with urology. PSA results come in with hundreds of others and they may be within the normal range so filed as normal but actually are creeping up within the normal range, significant to a urologist but missed by the GP practice amongst everything else. With a few hundred of these this is a significant amount of work and needs a really robust system so it's not a trivial thing as you suggest.

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  • I also disagree- think youre reading this one wrong old chap ! In some parts of NI we have a phlebotomy LES whereby the Urology Consultant send the actual blood forms direct to patient at their own predetermined intervals for follow up and results go straight back to Consultant therefore who actions them. Much more sensible, and recognises not only medicolegal risk but money used up in GP / Nurse / phlebotomy equipment.

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  • David Banner

    I’m with Copperfield on this one. If an OPD discharge letter suggests annual PSA with “refer if rising” instructions, then this is a perfectly reasonable request of any semi competent GP. The alternative is armies of elderly men queuing outside chaotic Urology clinics who are then unable to offer reliable urgent/2WW appointments. The numbers per practice are low, we are probably bleeding them annually for cholesterol, diabetes etc any way, this is simply good co-operation between primary and secondary care. The public would be totally unsympathetic if we decided to make our stand on a cancer issue.
    Copperfield has regularly seethed over the trivial crap dumped dumped on us by secondary care, this (as he says) is different.

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  • David Banner the problem is that a lot of PSA levels will be rising but are within the normal range so when a GP is filing 150 blood results the PSA is just filed as normal as it's not 'abnormal' but for that Patient it is abnormal. You need a proper system to be monitoring it which can be done but don't dismiss it as 'easy work' that's risky.

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  • Abby @ 3.19pm.

    May I, at the risk of offending some readers, make a radical suggestion which if adopted could also be applied to other part of a GPs work? Hows about reading the notes, to give the result some context? Is it not often the case that the urologists are interested when the PSA reaches a certain threshold, and this is typically above the normal range?

    I'm fully with Copperfield and David Banner on this; David Banner uses the term semi-competent and it would appear the attitude of some does not reach that which would be expected from this not overly high-set bar.

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  • So IDGAF - you're normal policy with every normal result that comes in, is to scrutinise every set of notes? I must be a negligent doctor then.

    I also find myself disagreeing with Coppers for the first time in years.

    The issue is workload creep arising from a poorly defined contract. The solution is to fundamemtally change our contract.

    Until we do, this will be one of the million work creeps impacting on our time.

    And my days are only getting longer, so I can't see how a reduced service payment is justified

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  • IDGAF yes obviously in an ideal world everyone would read the notes and go into the letters and read that the urologist wanted a referral back when the PSA increased to 3 having previously been 1.5 but in 100 blood results the is a chance this will be missed and filed as normal. It's just another opportunity for something to go wrong - you can mitigate the risk but it's not 'easy' or quick which is what is suggested.

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  • And I don't think I'm semi -competent for being concerned that men with prostate cancer might skip through the net of GP monitoring - it has happened with tragic results

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  • Hello webice. No need to read notes just click on the PSA or any other indice for that matter. Up pops on the right hand side all the previous results for said indice plus à natty little graph. Quit whinging.

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  • You got this wrong Copperfield
    Never thought I would ever say that
    We have a nice LCS for PSA
    Its not about the money its about good shared care and safe systems / guidelines
    Get a grip

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