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All Tosh and Cogs

Friday 22 June 2018

Last Wednesday, in a pleasing boost to my acronym bingo score, I found myself at the second-ever CEC meeting, which is a sort of ‘son of COG’. You’ll be aware that CEC stands for Clinical Executive Committee, and it reports to the Governing Body of the CCG. The CCG Clinical Operations Group (COG) no longer exists, but there is of course still the Commissioning Operations Group COG which is a committee of NHS England (SW): we used to be part of COG North that met at South Plaza, but now go to COG South which is just north of Saltash (we’ve been through this before- do try to keep up at the back). CEC is where the GP Clinical leads now gather. The CCG is undergoing a transformation of its governance arrangements, and as such the terms of reference of the committee are undergoing regular review, but for now at least, the papers and matters discussed at the meeting are confidential. That’s a problem for me as I can’t fill a couple of paragraphs telling you about what happened, but also presents a challenge for the GP colleagues on the committee, who are used to reporting back to their localities. I’ve seen what the plans for the future entail, and as the CCG is still a membership organisation with the practices as its members, would expect practices to learn very soon about what those plans are, so please look out for upcoming locality events to hear more.

One thing I can report from CEC without fear of being shot was that by dint of some judicious name-place juggling, I got to sit next to my erstwhile travel buddy, Dr Chandler. Our French cog-shredding bike trips from the last two summers are a distant memory, and we’ve both been busy so hardly seen each other for months. We arranged to meet over a Pondicherry lamb and lager (low carb had the day off) so we could harangue eleven plucky Tunisians and firm up our plans for a Southern Hemisphere jaunt in November, a trip which I anticipate generating significant blogfodder.

Will and I were cycling under the impressive Millau viaduct almost exactly two years ago, on day 1 of the Brexit catastroshambles. I know you’ll be sharing my sense of relief and joy that some 728 days later, we have at last heard that the future of the NHS is secure, with a 3.4% investment for each of the next 5 years, thanks in part to the fabulous anticipated Brexit dividend, and maybe a teensy tax-rise or two. Hurray, obviously, as I was worried there for a moment that there might not be a cunning plan after all. Others seem less convinced, including Sarah Wollaston - the Tory ex-GP and now Chair of the Health and Social Care Select Committee, who labelled the prospect of a dividend as ‘tosh’. She’s hardly known as a rebellious firebrand, but few are openly disagreeing with her assessment, and even if it did materialise, the promised £20 billion would hardly turn the system around, and probably just disappear into the cracks. The NHS and government have to come up with a 10-year plan for the system - no doubt building on the glorious success of the STP plans developed in localities - which will demonstrate how the NHS will reduce waste and improve services. The plan is due to be published later in the year, so that’s all good.

North Petherton might be one of the more bijou local surgeries, but it’s handy that on Friday we have the LMC Chair, the LMC Medical Director, the chairman of the trustees of the Benevolent Fund, the minute-taker for the LMC meetings, the editor of the LMC newsletter, the Chairman of the Somerset GP Board, and the secretary to the Benevolent Fund all working next door to each other. Not only can we pick each other’s brains about dodgy rashes and iffy results, but it’s surprising how often we need to make a quick decision about an LMC-type problem that’s reared somewhere in the patch or discuss whether we need to tweak something for the weekly update that will land on your desktop at lunchtime.

I congratulated Barry on the newsletter that arrived with last week’s update, the first that he has edited. On the back page, so often a repository for wit and light-hearted repartee, Barry had republished a typical wisdom-infused article by Harry that had first appeared in 2002. It was entitled “Error, Negligence and Fault”, and showed that even if you are Dr Perfect, given the number of clinical decisions we all make annually, significant errors are statistically inevitable. He contrasted error with negligence, and how the individual is affected by such events and what we can do to keep things in perspective and carry on as best we can in our professional and private lives. At the top of the article, Barry wrote that he had found it comforting when it first appeared 16 years previously, and it was invaluable for me to be able to forward the link to a distraught younger colleague who had just received a solicitor’s letter for the first time that same day.

We discussed whether we should update the article. 16 years ago feels like an era of milk and honey compared to today; we had plentiful primary care and community staff with the obvious associated benefits, more manageable workloads and a less litigious society. Personally, I could have done with Harry’s oracle 16 years before it originally appeared, when I was sorely tempted to jack the whole thing in and become a Cornish hermit living on pasties and Doom Bar.

The story starts positively. On my first solo neonatal crash-call, I’d been fast-bleeped to an emergency Caesarean in the obstetric theatre, and it was apparent as I pushed through the doors and cranked up the resuscitaire that this was going to be grim. No banter, just anxious voices, and bowel-loosening phrases like oblique lie, type 2 dips, thick meconium. I was handed a limp blue baby with an Apgar of one (if assessed by an optimist). The training kicked in, the intubation was easy and after a little while I was able to hand a screaming baby back to the mum. We decided to admit the baby to SCBU for observation as there were some congenital abnormalities that had not been picked up antenatally, but I walked back to join the ward-round from which I’d been bleeped feeling ten feet tall. I’d saved a life, and to this day it probably remains one of the most dramatic, exciting and scary events I’ve had to deal with.

Nine months later, I arrived back at Musgrove to start my obstetric rotation, and stuffed in my pigeon-hole in the mess was a large buff envelope from Messrs. Grabbit, Slimeball and Bastid (solicitors) suing me and the obstetric team for negligence. The single mother had been encouraged to take action by a no-win, no-fee outfit in the hope that she might get a pay-out to help provide some additional care for her son. The letter was couched in terms that left me in no doubt I was the most despicable and careless person ever to masquerade as a doctor. I was barely three years into my career, and the effect was profound. I went to see the obstetrician named in the case, who showed me a large filing cabinet filled with similar letters. Sometime later, she told me the case had been dropped, although 32 years on, I still haven’t been officially informed, but lose less sleep over it these days. The effects on clinicians can be devastating, however, and having discussed our younger colleague’s case last week, where they have continued to look after the complainant as well as their family, it seems that many patients probably think there’s a magic money-pit for compensation claims, into which they’re entitled to dip if they feel they’ve been wronged.

It’s hard to feel the profession holds the moral high ground, however, when we get to hear the horrendous accounts from relatives of patients who died in Gosport War Memorial Hospital over the past few decades. The fact that nurses were raising concerns as far back as 1991 is startling enough in itself, and there appear to be serious questions about why more action wasn’t taken by the police or the GMC earlier given the concerns that had been raised. It seems inevitable that there will be increased scrutiny of medical cover at community hospitals, and serious questions raised about how we look after elderly and vulnerable patients in the future.

The NHS70 parkrun was a lot of fun. There is always a good turnout from Musgrove at the Taunton event, and enough of us from Primary Care turned out to make our presence felt. I was talking to Rosie Benneyworth beforehand when we were collared by the Gazette reporter. He wanted our titles to put under the photo: mine was easy enough, but Rosie started off “Director of strategic transformation and….”. After several minutes, the reporter had broken his pencil and I was worried we’d miss the start. In the event I trotted round with my urology mate, and we both agreed we’d make it a regular event, which will be fun, as long as I can get used to spending 25 minutes at the start of every weekend discussing suprapubic catheters and prostates, that is.

On Wednesday this week, we had our monthly GP Board meeting, and those who were free spent a few hours beforehand working to flesh out proposals for the use of transformation monies across the county. We’ve come up with what Harry calls a ‘level 2’ proposal, and if approved by the CCG will develop this further (level 3- so exciting) with more detailed costings. We always felt that the GP Board would start to gain traction once we had something meaty (and tosh-free) to get our teeth into, and now the cogs are starting to turn. The CCG is aiming to share the latest thinking with practices very soon, hopefully next week.

Don’t you hate it when the nights start drawing in?

Nick

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