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Communication, Communication, Communication

Friday 2 March 2018

It’s rare that correspondence arrives in the LMC office that leaves the team speechless, but a Taunton colleague forwarded a letter last week that left our collective flabbers well and truly gasted. It was allegedly from the Home Office, although the composition and grammar suggested that they might have outsourced this particular operation to one of those best-beloved Nigerian princes who are forever getting stuck with vast sums of loot that need to be deposited for safe keeping, and without delay, in your NatWest account. Here is a verbatim quote from the letter, under the UK visas/immigration department heading:

“Also he’s stated that he’s suffer with vertigo and has suffered a heart in 06th December 2017 where he had a 3 stents put in him. He has including a number of medication that he takes.”

There are more ‘sics’ in there than you can shake a stic (sic) at. Best-beloved goes on:

“We intend that any decision on your patient’s asylum claim, but your patient does not have legal representative at the moment. We would rather issue a decision to yourselves than your patient. This will allow them to find legal advice in person via an interpreter along with the decision”

Hmm. The gist, I think, was that a refugee seeking a visa to stay in the UK, had declared mental health issues (understandable if you’ve fled after being shelled in Aleppo), amongst other medical problems. It’s hard to believe it’s genuine, but what the letter suggests, in its distinctive and elegant style, is that the chaps at the Home Office would be awfully grateful if, as we GPs have nothing better to do and are ideally placed etc. etc., we could break it to the poor terrified wretch sitting in front of us that we recognise he’s got mental health issues, but he’s got to go back to where he came from. For our part, we suggested the GP return the letter back to where it came from: deportation isn’t yet part of the core contract.

I need to tell you, or at least someone, about last Friday morning. It’s 345 days until my next appraisal, and it’s the sort of stuff I’d have de-chested to the Medical Director at our early Thursday Costa catch-ups, but he’s now gone, and hopefully enjoying something long and cool in the glow of a Sri Lankan sunset. Fridays aren’t usually too bad at our place: three astonishing GPs work with an excellent nurse practitioner and a lovely team of nurses, one of whom calls in at Tesco on the way to buy croissants. We make time to catch-up through the day, and our patients are generally well-trained and happy. I wasn’t duty doctor, and the perfect start to the day was the rising sun, luminescent blood orange, hanging an inch or so above the horizon between the houses as I headed down Greenway Road. What could possibly go wrong?

I start by plugging into the documents that have arrived overnight. I’d emailed my colleagues earlier in the week about a dodgy 111 pathways report where the fit young male patient complaining of right-sided chest pain, aggravated by using his arm, was disposed with ‘Emergency Ambulance Response for Acute Coronary Syndrome’. Here was another one, this time for an even younger woman, complaining of her shoulder and arm feeling ‘weak’. Same disposition: ‘Emergency Ambulance Response for Acute Coronary Syndrome’. Huh? I printed both reports out and put them side by side to compare. Same call handler? No. I scanned them both for, but failed to find, any explanatory, exonerating or mitigating factors. I tried to work systematically through the endless and distracting list of negatives: “There was no..., The main reason for the call was not..., there was no indication for..., The Individual was not....”. Hopeless, useless and dangerous. Look at any repetitive script for long enough and the effect can be like those Magic Eye illusion books that were so popular in the 1990s. The last thing I needed this early was a giant 3D penguin looming off the page, so I put them aside for action later. Another current (and recurrent) grump is hospital letters that arrive with just a name at the bottom, and no indication of title, rank, or responsibility.

Onto the results. There’s bad news immediately about a lady with alcoholic liver disease who’s now decompensating. I’d referred her urgently to hepatology a month ago; she couldn’t get an appointment in Taunton, but has a date in Yeovil for five days hence. Over the past two weeks, her bilirubin has quadrupled, her GGT and INR are climbing, whilst her albumin and sodium are heading south fast. I phone her and she says she feels OK, but I’m wondering if I should admit her now. Here’s a handy hint for learning patients’ NHS numbers: try using the Consultant Connect app, which necessitates entering the 10 digits manually every time you attempt to make contact, on a morning when nobody at the other end wants to play. I have successfully, if reluctantly and unintentionally, confined hers to memory. The problem at my age is that something else has had to slip its synaptic shackles to make space, although I’ve no idea what it was and whether it was important, and even if I did, I wouldn’t be able to remember it- obviously. I admit the patient later in the day after talking directly to a helpful medical registrar.

Next, an unexpected anaemia. It’s illogical and irritating that I can’t add a request for haematinics on-line, having made the original request that way, but have to use a fax or phone instead. Did you know that the NHS is the world’s largest purchaser of fax machines?

Nurse Croissant pops in to tell me about an ear-syringing course that our HCA is signed up for. It lasts for two days, and NC is to be her mentor. Naively, I assumed that ‘mentoring’ would mean putting together a packed lunch, waving her off at the school gates and encouraging her with homework, but no- the mentor has to go along for a whole day of the course. Heck. I don’t remember having any instruction in how to syringe ears. In my early days, it was one of the essential skills of being a rural GP, along with suturing farmers in grubby kitchens, hinging yourself upright and alert when the phone rang at 3am, and timing your run up the stairs of the Mary Stanley maternity unit to coincide with the screams of the baby, rather than the mother. We used one of those jumbo-syringes, unless a certain colleague had borrowed it to fill profiteroles. Admittedly, there were a few things that could go wrong; you’d only get the water temperature wrong once; collapsed patients and piles of vomit make the place look untidy, and titchy ossicles glistening in a kidney dish have a sort of “once seen, never forgotten” quality. There’s probably a middle road, but TWO DAYS?! The PDF file produced by the Primary Ear Care and Audiology Services of Rotherham (yes there really is, and they run the course) include a picture of ‘most’ of their team, 19 of them all lined up. Presumably the first day is taken up with introductions. (Just caught up with NC-tells me training was excellent, but our HCA now has to watch 10, then do 10 supervised before being able to fly solo…Really? It’s not like it’s an anterior resection. Do you ever feel that there are two speeds in the NHS, and that some bits move incredibly slowly, apparently oblivious to the frantic chaos elsewhere?)

The first patient on my list is a man in his early sixties. I’ve asked him to come with his wife for this review as we’ve identified her health problems as a factor in his depression. She has cardiomyopathy, and back in December I’d written to cardiology requesting a review as she was getting many more palpitations and dyspnoea. I’m surprised to hear she hasn’t been given an appointment date yet; she’s been told it will be August at the earliest but to try ringing again if she hasn’t heard in four weeks. I email the consultant and get a reply within 15 minutes (and he’ll see her next week). I rang him later to thank him, and to get his reaction to my two 111/ACS cases. He can trump me: a year or so ago, he’d put a pacemaker in a lady who lived in a remote spot on Exmoor. Two days after the procedure, she phoned 111 to ask what analgesia she could take. The air ambulance was dispatched (no kidding) and delivered her to Musgrove (double no kidding). Almost before the rotors had stopped spinning, she’d been prescribed some cocodamol, and told she’ll have to pay for a taxi back home.

(On Sunday, the car I was following and a cyclist had a fight over the same bit of road near St Albans. The car won, and over the next hour or two I acted as airway-guardian/drip stand/principal witness as the roundabout around about me filled with 9 assorted emergency vehicles, before the air ambulance arrived to join the party. It was fortuitous that nobody in the Home Counties had weak shoulders or niggling pacemaker sites at the time.)

My fifth patient had woken that morning to find he’d lost vision in his right eye. I phone the emergency eye person. No, they can’t give him an appointment- I have to send an e-referral. WHAT? The clerk I’m speaking to is adamant. This is nonsense, and I know the LMC has already raised this with the trust and the CCG. Our deputy medical director consulting across the hallway agrees, as does one of the MPH medical directors I email. There’s a block somewhere, and later I get a reply from one of the acute medicine managers saying that there is no work-around, and any faxed or handwritten referrals will be rejected. This is ridiculous, and a significant patient safety issue. Apart from anything else, we’ve already established above that they’ve got more than enough fax machines. I reply (having turned on the official LMC Chairman signature) that if that is their stance, then GPs across the county will have no choice other than to send all such emergencies to A and E, rather than using named specialty clinics. It goes quiet at the other end.

I’ve got one visit: a request from a DN to visit an elderly chap who has been in hospital for weeks after a fall, and discharged from Bridgwater yesterday on the Discharge to Assess scheme. He’s in pain, neither his wife (who has a broken arm), the physio or DN can get him up. Neither can I, nor find any obvious new medical problem. I phone the community hospital ward where he’s come from, assuming the bed has been held open? No- apparently, it’s been more than 24 hours (just). He ends up being readmitted, but to Musgrove. So that worked really well.

All of us consulting that morning will have faced the same problems and frustrations. Even with consultation rates climbing, and individual patients becoming more complex, the clinical bits still feel easy compared to trying to rescue patients from gaps in badly designed or implemented systems. It’s no surprise to anyone that patient satisfaction with GP services has declined, when we’re spending a disproportionate amount of our time, energy and enthusiasm trying to sort this stuff out. Please continue to let the office know of any particularly bizarre/irritating/easy-fix examples you come across.

Stay warm, take a shovel, and spare a thought for poor Harry in Sri Lanka.


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