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A day as an extensivist GP

Dr Margaret Lupton describes a day treating elderly patients as part of an extensive care service

Profile: Dr Margaret Lupton

Age 48

Role Extensivist GP for a service for older patients

Location Blackpool, Fylde & Wyre

Hours per week Two full days (9am-5pm) and two half days a week, with a half day every week for SPA (‘Supporting Professional Activity’ time).

8.10

I leave the house to go see a patient in her home. Before they come onto the extensive care service, all patients have an assessment at home by a well-being support worker followed by a 1.5 hour appointment in the clinic (45 minutes with their care co-ordinator followed by 45 minutes with me, the extensivist).

Our service started in June 2015 and I joined in January this year. The aim of the service is to provide holistic ‘wrap around’ care for patients over the age of 60 with complex needs. Extensive care was originally an American idea with hospital geriatricians providing the extensivist doctor role. In our service we have one consultant geriatrician, working with several GPs.

We aim to reduce the burden of this cohort of patients on the local health services (their GP, out of hours, A&E, the acute wards and outpatient departments) and improve their wellbeing. Patients are referred to the service by their GP and we take over all of their acute care, while the GP continues to provide routine QOF-related care and repeat prescribing.

We have four community based clinic bases that we refer to as ‘hubs’. Most of our hubs are in primary care centres, but we don’t have all of the facilities of a GP surgery.

9.00

I meet the care co-ordinator at the clinic base and we head to the patient’s home. Normally I’d see the patient in the clinic, but our first patient is totally housebound and can’t manage to get to clinic even with patient transport. One thing I love about home visits in this job is that they are part of the clinic, unlike in ordinary general practice where we squeeze them in as an afterthought.

We talk to the patient to try and build up a picture of her needs. Karen is in her mid-60s and hasn’t been out of her room for more than six months. She is overweight and has heart failure, chronic kidney disease, type 2 diabetes, atrial fibrillation, COPD, ischaemic heart disease and chronic anxiety. She has been in and out of hospital for the past few months and frequently phones the out of hours GP service. She has carers who come and make sure she eats and drinks, and one of them walks her dog. She’s quite happy with her life but says it would be nice to go outside.

10.30

The next two patients are also new and I see them back at the clinic base, going through their problems in a similar way to Karen. 

12.00

We discuss the patients we’ve seen this morning in a post-clinic ‘huddle’, a face-to-face discussion between the team. For each patient we decide on an extensivist plan.

Karen is fairly typical of the patients we look after: over the next few months her wellbeing support worker will address her social isolation, her care co-ordinator will try to improve her mobility and I, along with the pharmacy members of the team, will optimise her medication and address her polypharmacy. We will also explore contingency planning, long-term planning and end of life decision making while she is on the service.

Like most doctors, I work through my lunch so I can go home on time.

13.00

I have four review patients in this afternoon clinic.

Patients attend routinely every three months for a 45 minute extensivist review. I look back at the patient’s initial assessment and systematically go through the plan made at that time to see where we’re up to and make sure things have been dealt with.

For one patient it’s their nine month review so I also look at their previous doctor review appointments and the results of blood tests we’ve done. We can access the whole GP record and hospital record too. Sometimes at the three month review I’ve picked up a chest infection, urine infection or new symptoms suggestive of cancer. It’s like detective work and similar to ordinary general practice apart from the fact that you are actively looking for problems.

16.00

The clinic finishes. We don’t have a post-review clinic face-to-face huddle, so I have an hour after clinic to write up the notes.

17.00

I leave the clinic and head home.

The big difference between our appointments compared with ordinary general practice is that we aren’t responding to a patient’s presenting complaint but instead we’re looking for problems that we can do something about. I was worried when I decided to do this job that I would be bored, but it’s quite the opposite – it is the most challenging and rewarding work I have ever done as a GP.

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Readers' comments (18)

  • But does this actually reduce GP consultation rates, AE attendance or admissions?

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  • Dear All,
    Sorry to be a bit critical but seeing 7 patients a day, and am i wrong to suspect that despite all the intensive input from the well being advisors that the person who is overweight, has heart failure, chronic kidney disease, type 2 diabetes, atrial fibrillation, COPD, ischaemic heart disease and chronic anxiety. Has been in and out of hospital for the past few months and frequently phones the out of hours GP service. Has carers who come and make sure she eats and drinks and that walks her dog and who is quite happy with her life, that person will still be in exactly the same situation in 6 months time? This is 30 years of experience talking.
    Unless this service can demonstrate real long term financial return then i think we'd be better of investing in adequate supplies of incontinence pads.
    Regards
    Paul C

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  • This comment has been removed by the moderator

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  • How about we all sign up to work and see only 7 patinets a day?

    Lucky for some who do this, the appraisals, the chuffy regulating others roles, and leave the rest of us to carry the spilling-over can of workload.

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  • Patients shouldn't be seeing their own GP at all whilst they're under the Extensive Care Team - if this has happened it is usually just when they first come under our care and haven't grasped how the system works.
    Anecdotally yes it definitely reduces A&E attendances and admissions but we're still in the process of gathering all the data to prove this. Our cohort of patients are very high risk for admission so some of them are going to still need admissions, but the aim is for any admissions to be short with a quick turn-around when possible.

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  • I have 20 years of experience as a GP myself, and this is not easy work - it's challenging. Anyone who wishes to come and shadow me for a day feel free.

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  • If you analyse a typical cohort of patients who are picked up by services due to high service usage it will almost always fall in the next 12 months due to reversion to mean or death. This intensive services such as the above will show a cost 'benefit' in the absence of a control group.

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  • Bob Hodges

    A GP not looking down the throats of 18 year olds or doing URGENT med3s and paracetamol scripts?? It'll NEVER catch on.

    Who'll declare that ear wax needs softening and syringing?

    Who'll issue more emollients for children with mild eczema??

    Who'll 'expedite' the routine hospital appointment that's been given for 5 weeks time??

    Who'll spend their evenings changing the brand of bread that coeliacs get on FP10??

    We should be told.

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  • I remember last time we were asked by CCG to feed back on reducing unplanned admissions DES, all GPs in Practice commented that we have no control over unplanned activity.
    Fully care-planned and supported patients were righteously calling 999 because their toes slightly changed color or they forgot where they had put their medication. On one occasion a pizza delivery man called 999 after a COPD patient got a bit breathless arguing with them about the toppings they had or had not ordered. And on another occasion patient called 111 on weekend to ask where they could go to buy some ibuprofen and ambulance was dully dispatched. I can go on.
    I am sorry, but the problem is not multi-morbidity but public's attitude to FATPOA service. And this scheme is just another expensive waste of taxpayers money.

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  • kind of agree with anon @1.11pm
    very difficult to prove services such as this show cost (or other benefit) to health economy.

    The elderly complex multimorbid have genuine healthcare needs hence will of course be resource intensive - adding another layer of service might save the odd "unplanned activity" for trivia but unlikely to make difference to much else.

    Efforts to reduce demand really need to be directed towards those (generally younger) patients who are worried well/accessing inappropriate services etc - but also a difficult cohort to control in view of FATPOA and complaints culture

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