Last month, a review of the Liverpool Care Pathway recommended that GPs should, as ‘particularly good practice’, provide personal contact numbers to dying patients and their relatives to ensure they are reachable out-of-hours.
I feel passionately about improving the quality of end of life care for our patients, and GPs might want to offer their phone number to patients, but no-one must require them to do so.
Returning to the way GPs worked 30 years ago is not the answer. The demographics of the GP workforce have changed, with many experienced professionals reaching retirement age and replaced by part-time/sessional GPs who do not necessarily live in their practice area.
The population we care for is also changing, with a predicted 17% increase in the mortality rate by 2030, most dying of complex co-morbidity. End of life care is rewarding work, but challenging too, and a GP’s home/work balance must be sustainable and healthy.
It would be bad for both patients and GPs if we were compelled to give our personal numbers to all our dying patients. I feel we should have the right to do so if we choose, but a compulsion to do so could be damaging.
Most patients do not wish to end their lives in hospital and do not need to; it is also too expensive for the NHS to maintain the status quo. More deaths in future are likely to take place in the community under the care of GPs and many of which will not need to be under specialist palliative care.
We need to plan a system to deal with this that allows GPs to work smarter because I believe most of us cannot work harder and want to provide the best possible care to patients at the end of their lives.
Choice to decide when it’s important
I freely admit that I still do give my mobile phone number to some patients when I choose, most recently to the family of a young man with complex problems from prostate cancer that wished to die at home.
I am, however, cautious nowadays. I had a bad experience when caring for my own father who was dying at my home from pancreatic cancer about five years ago.
I had given out my number to a patient, but their family members demanded a personal visit from me one evening when I needed to stay with my dying father, and the patient suffered a delay in getting care as a result of this.
It was uncomfortable for me having to refuse to go.
Issues with childcare, whilst not currently a problem personally, can also cause similar distressing conflicting demands. Phone calls from distressed patients out of normal working hours could increase the already considerable stress many GPs experience in balancing work and home life. The intensity and complexity of modern GP work in my view means it would be unsafe if we returned to regular night work followed by full days in the surgery.
Power to commission a solution
Another aspect of modern general practice is the power we have now had since last April to commission services for our patients. Giving our personal numbers to patients may undermine the need to ensure that we as GPs commission a high quality 24-hour service for the population we care for. We need to support and develop GP out-of-hours services, and show our patients that we trust the quality of care that they provide.
We need modern solutions to deal with the recent high profile difficulties related to end of life care.
The King’s Fund has provided us with top tips on what to commission to improve end of life care:
– Services to support GPs deal with Rapid Hospital Discharge. We would then have no need to have to respond to crises such as hospital discharges on Friday afternoons.
– Rapid response palliative community services, to prevent the need for GPs to be called and reduce unnecessary 999 calls and avoidable hospital admissions.
– Co-ordinated care, ideally using electronic palliative care co-ordination systems (EPaCCs). Used effectively, this system will obviate the need for us to give out personal contact details to patients.
– 24/7 palliative care nursing services for patients we have identified and, through good advance care planning, know wish to have care at home.
End of life care affects us all.
As GPs we can make a significant difference to our patients’ lives by proactively caring for them as individuals, but by also commissioning a structure of care that is fit for our patients and our own families alike. I like to work hard but I need time off too, safe in the knowledge my phone won’t off when my own family needs me.
Dr Pete Nightingale is a GP in Lancaster and RCGP/Marie Curie clinical lead for end of life care. These views are personal and do not necessarily reflect those of the RCGP or Marie Curie Cancer Care.