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Being There

Friday 30 August 2019

Ideas surge into conscious thought at the most inopportune of times. Sudden inspiration can hinge me upright at 3am, or distract me half way through a complex consultation. My superannuated synapses have a tenuous enough grip on reality as it is, and struggle to snag any fleeting gobbets of innovative thought; I try to record any cerebral flash as a ’Note’ on my iPhone before it vanishes in a hazy puff, forgotten forever. For better or worse, my phone is almost always within easy reach, which is why my latest sparking was inconvenient, as at the time I was skimming the German countryside at 100 feet in Guy Gibson’s Lancaster, and closing in on our primary target, the Möhne dam.

I was standing just behind the skipper’s right shoulder, braced against the airframe and with a perfect view of the instrument panels and the silhouettes of farm buildings as they flashed by below. An urgent cry of ‘trees!’ from the bomb-aimer caused Gibson to pull up sharply, the four Merlin engines howling with effort as the fuselage skimmed the topmost branches before we settled back down onto our planned track. Forty seconds later we were turning over water and could pick out the twin towers on the dam as we edged still lower to our final bombing height, the target illuminated by the full May moon, but also now by streams of tracer lacing up to us from the wakened ground defences. ’Bomb gone!’ came the call over the radio as……

Whoa. I sense growing alarm from colleagues reading that last paragraph. I admitted last time I was sleep-deprived, and had heaps going on. You might be worried I’ve started swigging the Steradent. Is this a fit and proper person to be representing Primary Care at the toppest of top tables in the local Health and Care system, you ask? Well, that’s exactly what my sudden whizz-bang thought was all about.

We still hear mutterings in the system that Primary Care doesn’t have an effective voice at the highest level. This is frustrating- it’s exactly the reason that we formed the Somerset GP Board (SGPB) in the first place, and we undoubtedly have more potential presence now, with invitations to the Leadership Board, the Fit for my Future (strategy review) Programme Board and also the Professional Executive Group (PEG), where most of the significant decisions are made. It’s only in the past month or so that the GP Board has had a seat on the PEG, but the meetings are usually on Mondays, never the easiest of days for GP attendance. A few weeks ago, I’d rushed to Yeovil for an afternoon meeting to find an empty car-park and bemused receptionist at the CCG. I hadn’t heard the meeting had been cancelled, but at least could make myself useful helping load some bulky equipment into a manager’s car. It transpired that I was on the circulation list to receive the agendas and papers for meetings, but intriguingly not on the ‘update list’ used to circulate news of cancellations. That was frustrating.

There are often other GPs at these meetings, and although wearing different hats (in the colours of the CCG and the Fit for my Future programme, for example), we all know the harsh realities of Primary Care, particularly if we’ve just rushed straight from a heaving surgery to get there. But what’s our main role in these meetings? Unlike the Trust Chief Executives, we don’t have thousands of staff under our direct command. It can be hard enough to corral our own practice colleagues, never mind trying to get 65 other private businesses marching in the same direction. Sure, we can build relationships and bang on about how hard we’re all working to keep the show on the road, but there must be a better way to inform and educate the wide range of colleagues we work with as to what it’s really like on the front line these days?

I’ve had several opportunities to meet with consultant colleagues recently, and our discussions invariably emphasise how counterproductive the divisions that, whether intentionally or not, have been allowed to divide the profession have been. Last week, Barry and I met with one of the gynaecologists at the LMC to discuss potential new pathways. We know that across the county Trusts have been told that they need to reduce the number of outpatient appointments by 39,000 each year, and so the current system will need to change in some way.

As ever, there are misconceptions on both sides. We heard how inadequate detail in the referral can hinder appropriate triage by their teams, whilst we were able to tease out what is realistic and practical for a busy lone-working GP to do before admitting a gynaecological emergency late in the day.

Tackling thorny stuff in a spirit of cooperation is a better option than not having a say, and then needing to kick off later when something completely unrealistic arrives unsanctioned on our desktops (it happens). I also spent time- more than initially planned- driving back from Devon with a neurology colleague last week. We chewed a lot of cud and had put most of the world to rights, before I hit a misplaced boulder and burst a tyre. He’d changed a wheel of his own recently (presumably the registrar had a day off) and generously offered ‘clinical supervision’ as I got down and dirty. We’d travelled only a couple of hundred yards more before realising that the front wheel on the same side was also flat, with a gash in the inner wall. Whilst I was prepared for repeat action, the car wasn’t as VW inexplicably only provide one spare wheel. Luckily, Mrs. Neurologist was free and so summoned to drive out from Taunton in their VW and deliver yet another wheel. Fun for all the family, and a dodgy and unbalanced trip back over the Blackdowns for me.

Despite knowing m’colleague for years, and the circumstances of our roadside sojourn, it was still good to catch up and put ourselves in each other’s shoes for a bit, but maybe we can go further, and that’s where ‘Virtual Reality’ comes in.

Even now, somebody somewhere will be developing a high-definition headset and vibrating vest, enabling the wearer to be in Jack Leach’s shoes as Ben Stokes at the other end hammers the Australian bowlers to all parts to save the Ashes, but last week, I was the one rigged up to experience what it would have been like (sort of) to be beside a proper English hero, Guy Gibson, on the ‘Dambusters’ raid’.

The Medical Director and I were on another of our pilgrimages, this time to the RAF museum at Hendon. Entrance is free, and so the cafe, which shelters under the giant wing of a Sunderland flying boat, was awash with mums trying to keep their children entertained during the summer holiday. After lunch, I found myself in the ‘Dambusters’ section, and paid a tenner for ten minutes in a curtained-off room, completely bare apart from a basic plywood frame, and strapped into their virtual reality equipment. The audiovisual effects are brilliant, and the vibrating vest gives added depth to the experience.

I’m certain that ‘pour empathiser les autres’ we could rig up something similar to mimic the effects of being on our front line. I can see the vest might need a little modification, with a cervical extension to maximise discomfort in the neck region for any number of situations we encounter on a daily basis, and perhaps another attachment at the sacrococcygeal level for those of us dealing with the knottier bits of our increasingly convoluted professional lives. Anyway, you get the gist. I think this one might have legs.

Sceptical? Virtual Reality is already a thing in healthcare and used as ‘distraction therapy’ in some NHS pain management clinics. In a trial organised by the University Hospital of Wales for mum’s labouring in its maternity unit in Cardiff, women are given VR headsets to ease their pain during labour, which I hear can sometimes smart a bit. The options available include being whisked to a white sandy beach, watching the Northern Lights, wandering among penguins or roving on Mars. Although the VR experience lasts for seven and a half minutes, the pain-relieving effects apparently last for up to 45 minutes, so I reckon you’d need about 8 years’ worth for a whole NHS career.

On Wednesday, one of our favourite cardiologists came to the practice to discuss extending his ‘remote’ cardiology clinic already up and running in a few of the larger local practices. The patients are virtual, their cases presented, and care discussed by the GPs and consultant in a Skype-based meeting. The aspiration now is to expand it so that multiple practices can join in the fun at the same time. Everybody wins- the consultant reports that it’s the most enjoyable aspect of his week, the GPs get a chance to discuss things with colleagues and educate themselves/each other, and the patients avoid a fleecing by Q-Park at Musgrove. It’s the future, as long as the technology co-operates.

Exciting new technology also got a mention at our GP Board meeting last week. We’d invited representatives from Modality to talk to us about their experiences of providing primary and intermediate services at scale to more than 450,000 patients, initially in the Midlands, but now also in other areas including Hull, Yorkshire, Surrey and Sussex. They are certainly innovative in their approach, using social media but also Artificial Intelligence (AI) to help plan future services including population health management and risk stratification. After their presentation we discussed what elements of Modality’s acknowledged expertise we might wish to tap into: contracting and subcontracting, with their attendant complications might be a useful place to start.

The other significant discussion at the meeting was, as ever, the representation of Primary Care in the system, and development of the ‘umbrella’ organisation. We’ve arranged a further meeting with the Clinical Directors on September 24th to take this a stage further and make the proposed structures a reality, possibly virtual, definitely virtuous.

Enjoy your weekend,

Nick

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