What is best to do if you are drowning and miles from help or the shore? You could put all your effort into struggling valiantly, in the hope that some external source of rescue will come along before you are at the end of your strength, or allow yourself to drown and believe in re-incarnation.
Reincarnation is taking a hard look at what we actually do as GPs
That was the dilemma I felt my practice was in 16 months ago, and the place I had reached professionally. My practice is in Gosport and I have worked here as a partner for six years. The centre of Gosport reminds me of the industrial small towns in the North where I trained, and seems strangely out of place on the south coast. We serve a population that is older, sicker and poorer than the national average.
In a way, I knew what I was getting into when I joined: the ages of the incumbent partners were 60, 59, 58 and 57, but in 2010 I really had no idea of the impending retention and recruitment time-bomb. In the last six years we’ve lost seven doctors – three to planned retirement, two to better remuneration locally and two to Australia. When I joined, there were 20 applicants for my job. Now, we don’t even advertise for a GP vacancy, we learned several years ago not to waste our money.
So am I advocating shutting up shop and handing back the keys? Not at all. Reincarnation in this case becomes the best option on reaching the understanding that treading water and trying to continue to do what we have done before is futile. Reincarnation is taking a hard look at what we actually do as GPs – see, diagnose, treat, refer – and recognising that we are by no means the only people who can do these things, and then working to actively make a team of diverse but integrated professionals.
Making changes fast
We had to work very fast from a standing start when we lost another partner last year. We made the active decision not to try and replace this GP with ‘doctor time’ and considered the options to decide which professionals we could access and how much of their time we could afford for about the same price as a full-time GP. We recognised that now was not the time to try and get ‘cheap’ labour by getting inexperienced people – we needed fully-formed professionals to prove concept and not weaken further a team who were already over-stretched and demoralised. We came up with a community psychiatric nurse (CPN), senior pharmacist and physiotherapist.
We didn’t have time to advertise, I reckoned on six months maximum before the mounting pressure would result in another resignation. Fortunately, in Gosport we were also part of a vanguard project and as part of this the 11 practices locally were attending fortnightly meetings trying to find a way forward. We found our pharmacist there as she gave a presentation one week. She was freelance and we were able to employ her half-time (another local practice taking her up for the other half of her working week). She was in post within three months. She’s an independent prescriber and carries out medication reviews, handles queries relating to repeat prescribing and checks discharge summaries, liaises with community pharmacies and initiates and titrates blood pressure medication. We have only just begun to tap into her potential.
The vanguard project is having a substantial effect across the practices in Gosport. Partnering with Southern Health NHS Foundation Trust, we have been looking at the re-integration of community staff into general practice, and we have the advantage of very local physiotherapy in a community hospital in the town. We decided we did not need much physio, and we have no facilities for much in the way of physical treatment in our surgery, but we managed to second two sessions from the Trust. Essentially we rent the physios from them. They examine and refer into the service if necessary, but most people are managed with exercise instructions. Patients can be directed to the physios without seeing a GP, helping our musculoskeletal workload.
The CPN is also seconded from the Trust five days a week from 10am to 3pm. In a practice where more than 30% of consultations are for mental health problems, he has been an enormous asset. In his first year in post he has worked with all grades of mental illness. He is now a prescriber and after an initial struggle getting his referrals into the AMHT recognised, is more and more being treated as an autonomous professional.
So is this what reincarnation looks like? I think it is part of the answer, and my practice is still evolving. There are lots more changes to make and the progress we have made is so far only measurable by a personal reduction in stress, but it’s a start.
Dr Rachael Ross is a GP in Gosport
