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At the heart of general practice since 1960

Water torture

Three GPs share their approach to a practice dilemma

You are a salaried part-time doctor in a seven-partner practice. When you saw Mr B a few months ago he turned out to have prostate cancer. Since then he has seen every single doctor in the practice the partners manage advanced access by restricting pre-bookable appointments and patients have to ring in each morning to compete for the emergency appointments.

Mr B is now housebound and has recently has had visits from three partners, as well as telephone advice and visits from the out-of-hours service and Macmillan nurses.

You are doing visits today, and Mr B has a lot of problems poor pain control, oral thrush, constipation and anorexia. He shows you a drawer full of medication that has been tried and discarded. He tells you that he hates having to see so many doctors because they all say something different; he asks if you will be his regular doctor.

Dr Zoe Rogers

'The best remedy is to involve someone else'

I would aim to involve the Macmillan and district nurses at the earliest opportunity, and work with them to provide the care Mr B needs. As the Macmillan nurse has already been involved it seems strange that Mr B's symptoms are not controlled. Perhaps something such as hypercalcaemia has changed the situation quickly. I would speak to the Macmillan nurse and agree a course of action for symptom control.

It may well be worth doing some bloods to exclude a treatable cause for his symptoms. If symptom control proves difficult he may even benefit from an admission to the local hospice.

It is important at this stage in his illness that Mr B has the opportunity to ask about his illness and prognosis, but I would not push the issue.

It would be sensible for Mr B to have one or possibly two GPs involved in his care. One difficulty with being part-time is that problems may crop up on my day off, so the best remedy is probably to involve someone else.

I will need to discuss with the partners at the practice how things might be altered to prevent this scenario happening again with another patient. Perhaps terminally ill patients need a continuity of care that we can no longer offer everyone in the era of 48 hours access.

Zoe Rogers is a part-time salaried GP in Aylesbury, Buckinghamshire

Dr Alex Williams

'The problem is too many patients and not enough appointments'

On the one hand you have the immediate and real needs of the patient, who is likely to deteriorate and need more and more care, on the other hand the practice will have to address the issue of continuity of care. The fact that you are both salaried and part-time gives you a major headache in finding a solution.

You have a duty of care to the patient and need to resolve the immediate difficulties. Speak to the Macmillan team about rationalising his medication (he needs more analgesia and laxatives), possible admission to the local hospice or the use of an infusion pump. The district nursing team may be able to help with an enema for his constipation and additional support for the family and carer.

You may have to procrastinate on the issue of becoming his doctor before consulting the partners. As a short-term measure you could review him when you are next working. You should discuss this with the practice manager and/or the senior partner/chairman. It may be an issue for a partnership meeting (to which you would with luck be invited to express your point of view). Another useful forum would be a critical event analysis where all members of the primary health care team would be present. We have found these a very powerful mechanism for identifying problems and more importantly also finding solutions.

Your part-time status will hinder good continuity. Possibly you could 'buddy up' with one of the partners if visits are required in your absence. The patient seems to be approaching terminal care so access to the appointments system will no longer be an issue.

The answer to the problems of advanced access is an issue in our own practice. The basic problem is too many patients and not enough appointments. The concept of doing 'today's work today' does not seem to work and so we are actively reducing our list to 1,900 and hope we will be able to provide a better quality of care (and maximise QOF points), while offering more accessibility.

Alex Williams is a full-time GP in Exeter and lead trainer in the practice

Dr Joanne Harris

'The Macmillan nurses have many useful ideas about pain relief'

This situation is all too common with the advanced access rules. Patients are guaranteed to see a doctor, but often not the doctor of their choice, and continuity of care can become a real problem.

However, working myself as a part-timer in a seven-partner practice I have found that terminal care can be an exception to this rule. Visits can be allocated on a daily basis to the doctor that has most knowledge of the patient. While the number of visits would vary each day they should be easier and quicker as the GP already knows the patient. With part-timers, a partner could be responsible for covering absences so at most the patients get to know two doctors.

There is also scope for involving Mr B in this arrangement. Many of his problems are not necessarily urgent and if advised that you are a part-time doctor, he could try to request visits for the days that you are working. Similarly, he could be encouraged not to use the out-of-hours service except in an emergency. An arrangement could be made for a regular visit as his condition advanced so that he would know when to expect the doctor.

I would want to make contact with the Macmillan nurses at an early stage. It would be useful to do a joint visit, try to address all of Mr B's physical problems and check what he has been told about the prognosis. The Macmillan nurses have many useful ideas about pain relief and other symptom control and it may be possible to delegate a visit to them and provide a prescription.

With the above arrangements in place, I would most definitely agree to be Mr B's regular doctor!

Joanne Harris is a part-time partner at a practice in Ealing, West London

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