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Independents' Day

GPs must start saying ‘no’ to extra work

It’s time to draw boundaries between the work GPs will and won’t do, because we can no longer pick up colleagues’ slack, says Dr Fiona Cornish

‘Does general practice have boundaries?’ I asked myself as I headed off to visit a 90-year-old woman at 11pm on an out-of-hours shift.

We had been asked to treat a housebound patient who had faecal impaction and severe pain.

Apparently paramedics had been, spent an hour or two, assessed and concluded there was nothing they could do. The district nurse team decided it was not their role (although surely this is typical work for a district nurse) so the verdict was that there would have to be a GP visit. My response was to turn this into an adventure for the trainee and student and I asked them to accompany me.

‘Hello, nurse,’ the patient’s husband greeted me, before telling us how long his wife had waited, how many health workers had visited, and how cross he was with us.

For the procedure, I pulled on two pairs of Marigold gloves and deployed liberal quantities of KY jelly. After a heady five minutes of junior doctor-style ‘getting on with it’, my mission was accomplished. It gave me some pleasure to record in the patient’s notes: ‘Faeces evacuated manually and heroically.’

The next day, I wondered when manual evacuation had ever been on my list of teamwork jobs as a GP. Perhaps my response to the request from the patient with faecal impaction should have been, ‘this is not my remit’. But this is still an uncomfortable line to take. Most GPs are still trying to retain the qualities of Mother Teresa while adopting those of Lord Sugar. But being saintly and ruthless is increasingly difficult in the current climate.

Every day, I hear non-GP colleagues say they can’t take an INR because the patient is not on their caseload, they haven’t been signed up to do flu jabs, that a job’s not part of their remit or they have stopped providing the service a patient needs.

Unfortunately, the reality is that all those shunned activities end up in GPs’ caseloads. And ‘work dump’ is getting worse all the time.

Multi-disciplinary support for GPs from paramedics, pharmacists, nurses and therapists is theoretically a way to rescue us from the unsustainable current model. But it can only work if each member of the team takes their share of demand, rather than passing cases back to us. Everyone’s workload has gone up and GPs can no longer pick up the slack.


For example, GP appointments are often exploited when patients have been told to ask for letters declaring them ‘fit to use gym equipment’ or ‘unfit to take exams’. I spend two to three hours a week on unnecessary paperwork like this. Even if I charge a patient the standard non-NHS fee for this, I resent the fact that they have kept me from treating someone who is actually ill.

So we need to demand support from the rest of the NHS. Teamwork must be the way forward, whether this involves paramedics and nurse practitioners running rapid-access clinics for urgent cases, or innovative schemes such as Medihome, which provides regular post-discharge visits to elderly patients.

I’d advise GPs to adopt three rules for refusing work. First, don’t accept something as your job just because no one else will do it. Second, don’t be reticent about explaining to patients that the NHS can’t cover everything. Finally, and most importantly, resist extra jobs unless funding comes with them.

GPC and RCGP leaders have begun campaigns calling for better support for GPs – and we must hope patient groups and the Government will listen.

But without boundaries indicating which tasks belong to which roles in primary care, GPs will continue to be overwhelmed. Rising demand is crippling our profession, but if colleagues refuse to share the load we don’t stand a chance.

The next time I am asked to deal with faecal impaction, I will tell them exactly where to stick it.

Dr Fiona Cornish is a GP in Cambridge and former chair of the Medical Women’s Federation.

Readers' comments (16)

  • Well said!

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  • I had a similar experience.

    The district nurses asked me to visit a dying man because he was having faecal leakage and they suspected he might need an enema.

    No, they hadn't done a pr, that was my job. So I added him to my many visits. When i saw him he was very uncomfortable and slipping my finger in, it was obvious he had an enormous stool sitting there. I looked at his face and realised I could not wait for the district nurse to organise an enema. I took a deep breath and did a manual evacuation.

    He looked much more comfortable when I left. He died the next day. I was so glad I could do him that small service, but I despair at what ancillary colleagues were not prepared to do. Since when did district nurses abrogate their role in patient's 'bowel management' ?

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  • Very well said, Fiona. One of my top survival tips for exiting trainees was learn to say no politely and repeatedly. Those that can't, will find themselves burnt out, stressed and possibly exiting the profession permanently. We can't wait for endorsement by central government who is planning our collapse- we need to take a united stand and the LMC/GPC need to be behind us.

    I try to avoid doing these stupid letters because, quite frankly, I would rather keep my 10 minutes than earn £8 after tax.

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  • Will GPs be supported by the BMA if they do so???

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  • Isn't it time that nursing homes that are paid to provide 'nursing care' were required to employ their own doctor?

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  • 26 June 3.36pm
    District Nurses -

    The same time they abrogated their role in " oral hygiene " and " basic nursing care." The " too posh to wash " / " degree in Nursing " brigade. I am generalizing but Nurses expanding role appears to be training " mini Doctors. ". Meanwhile nursing care is left to health care assistants. (Or whatever other fancy title they are given! ). Degree courses rule out less academic people who would make excellent Nurses. I am one, an RGN with 30 years experience. I feel frustrated when I hear the above and am glad to be nearing retirement. However I do not look forward to becoming elderly needing Medical / Nursing care!

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  • I am a District Nurse who does the manual evacuations, flu jabs, bloods etc but I know many are only too willing to duck such work if they are given half a chance and stifling policy is just that chance. I am fed up with the "district nursing must modernize and embrace new work" when our original work still exists. The problem is we are being over managed to the point of extinction. 150 years of a successful service being wiped out in just a few years. Please GP's demand a district nursing service and help save us from extinction.

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  • Una Coales

    Well written and advised Fiona! We caregiving GPs must learn to say NO and set boundaries or face burnout.

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  • Unfortunately our contract says we are responsible for "managing patients who are ill or perceive themselves to be ill including Patients with chronic illness". That's a catchall phrase for a dumping ground for Unresourced work. This will worsen with the named GP responsibility as we will now also have responsibility for social care problems as "care coordinator". We have in the past asked our lmc to clarify and define what work we are responsible for with them but this Came to nothing as nationally there is immense variations on what is a GPs role via custom and practice. The Gpc have also been reluctant to define work role and responsibility boundaries. So we are exploited as we have a block contract. So if you don't know where it fits and no one else wants to do it or be blamed if things go wrong, send it to the GP team. Maybe we should all just become soldiers of Fortune, dump partnerships and work in GP Chambers. Only alternative if you want to be in control of your working life. Don't harbor hope from the bma una. You are wasting your time. The bma bear is more important than us!

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  • This is totally beyond what a GP should be doing.
    Such a procedure is not without risk to the patient.
    The patient should have been admitted to hospital and the procedure performed there.

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