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Friday 31 January 2020

Yesterday we were at the racecourse for my last ever Southwest Regional LMCs meeting. It’s a quarterly get-together of experienced lags from six LMCs to discuss how we’re all doing, share concerns and decide what might benefit from a regional response or action. We speculated on what might be happening with the GPC negotiations relating to the rejected Primary Care Network DES specifications. We still haven’t had any news about the special LMC conference flagged for an unspecified date in March to discuss the profession’s response. It’s getting a bit late for colleagues to arrange locums to cover their attendance.

We also discussed a regional approach to reporting the activity levels in GP-land, using a colour-coded system developed by Devon colleagues. It’s based on an on-line questionnaire that will take practices approximately 10 seconds to complete and involves only ticking two boxes, which is then collated electronically by the LMC on a weekly basis. Practices are asked to rank themselves as either green, amber, red or black depending on a listed range of markers including appointment waiting times, staffing levels and sustainability, thus giving a much more nuanced sense of what’s really happening than just a single factor such as the waiting time for a routine appointment. The more information and evidence of the true state of practices that we have available when on ‘escalation calls’ with other providers, the better. More on this anon.

Obviously, if Coronavirus arrives with a bang, then activity levels could rocket. The next few weeks is traditionally the peak time of year for travellers arriving from China, and Somerset has a significant Chinese population, not least amongst the pupils of its private schools.

Those of us who regularly spend hours in meetings discussing the tortuous consultation and engagement processes relating to acute and community hospital bed numbers might have cocked an eyebrow at the news that the Chinese managed to build a new hospital for 1,000 patients from scratch in just over a week (and apparently staff it), with at least one more under construction. They learnt how to do that during a previous Coronavirus outbreak (SARS) in 2003, but alas not much else, as the conditions where such infections are thought to originate are still commonplace in their traditional markets, where animal to human transmission is facilitated by close proximity and poor hygiene. In most of China the Primary Care sector is so poor that patients who think themselves ill present straight to hospitals and the system is close to being overwhelmed, with a shortage of diagnostic kits and protective clothing. It’s almost certainly going to get worse over the coming weeks and months, how much we can’t speculate. I wouldn’t want to trivialise the situation in China, which has now been declared a global health emergency, but the public health hazard that ‘Corona’ represented to British youngsters of my generation was very different.

Every Thursday, a yellow lorry stacked high with fizzy pop pulled up outside our front gate and the cheery driver would lug a crate full of diabetogenic promise to our front door, in a dazzling array of colours and flavours (ciderapple, cream soda, cherryade, and dandelion and burdock amongst them). We drank more Corona than we did milk, and got 10p back on the empties to spend on sherbet lemons and Caramac.

What were our parents thinking? They were friends with the local dentist and presumably had some sort of pact to keep him ‘drilling and filling’, leaving us destined to lug round a mouthful of amalgam for the rest of our days, or until the glycosylated pegs fell out, one by one. By chance, our dentist daughter has recently embarked on a postgraduate degree in restorative dentistry and having read in the last blog that I’d broken a tooth was on the blower in a shot offering to refashion my bite with heroic amounts of metalwork and dental Polyfilla, so that she could include me in her portfolio.

Corona folded as a company in the 1990s, and now there’s only one lorry that regularly visits every household in the UK: the refuse collectors. We heard recently about a promising Somerset initiative that has come in large part from the collectors themselves. The new contractor, SUEZ, has committed to 12 of its staff becoming Dementia Awareness trainers, and in the first three months of the contract will make all of its 469 collection staff dementia aware. They already have a ‘duty of wellbeing’ and are keen to act as the eyes and ears of the vulnerable. There are 5000 customers in the county who have assisted collections, where they have help with putting out their rubbish and recycling. The cabs are fitted with the necessary technology so that any of these customers who ‘miss’ a collection will be reported automatically in real time and adult social care or the police contacted (they call it ‘zero tolerance’).

After nearly 31 years at the practice and with only a handful of clinical days left to work, I’ve been struck by a new and (hopefully) irrational anxiety that something is going to go terribly wrong before I hang up my stethoscope for the last time. My sleep is even worse than before, and I suspect it’s the GP equivalent of the ‘nervous nineties’ if you’re a batsman approaching your first test century. I gather it’s not unusual.

I know so because I talked about it when visiting my Alma Mater for a Medical Society reunion last week. I was seated at dinner between two Senior Fellows who had each relinquished more exalted roles than mine. One was a Professor of orthopaedics who had pioneered revision hip arthroplasty, and the other used to be the Archbishop of Canterbury. Having heard about my wobbly week, the former reassured me that in his experience this was quite normal and even to be expected in the closing stages of a career. He told me about one of his colleagues who had prepared a medicolegal report in his last few days at work that was subsequently ripped apart by the opposing legal team with such ferocity that he spent the first seven years of retirement trying to seek redress and restore his reputation. That helped.

It turned out that I needn’t have worried about whether or not something would arrive on my desk to ruin last Tuesday before it had even started. It did, with two examples of what frustrates us to the brink of madness.

The first was an update from our secretary about a patient who was being pinballed between departments in a couple of Trusts to the north of us. A CT performed by urology had revealed a potentially significant incidentaloma, and I had been requested to refer him urgently for a gastro opinion. The patient wanted to go back to the hospital where he was already being treated and they had the scan on their system, so that should have been easy enough. My (urgent) referral in mid -November was redirected two weeks later to upper GI surgery in the same hospital where it sat for a month before they rejected it saying that it would need to go to the BRI. Off it went, only to be bounced back saying he should be seen where I’d initially referred him two months previously. I’ve fed back on this lunacy to the CCG via the Datix system but really wanted to speak to someone on the provider side to let them know my thoughts. In the middle of a busy day it’s easier to let these things pass as evidence of a system in distress, and move onto the next heap of fun, but we shouldn’t accept poor behaviour when a patient has been put at risk. It took a bit of phoning round, but eventually I found a helpful real human secretary at the first Trust and told her all about my real human patient who had been left in the lurch. She promised to do what she could.

The second was a humdinger from a Speech Therapist about a child with neurobehavioral problems. She wrote saying that she’d discussed the child with a Community Paediatrician, who had recommended that I formally refer the patient to Community Paediatrics (!), but in the sure and certain knowledge that the referral would be rejected as the child didn’t fall into the current acceptance criteria. They’d already told the parents that my referral wouldn’t result in anything happening. Despite having never met the child myself, there was the hint that my referral would somehow add something to what they already knew, my concerns would be logged (where?) and that I could then look forward to referring them again at some unspecified time in the future. On behalf of our secretaries and myself, I declined to join in the game, but took an anonymised copy of the letter to a meeting the following day with the senior leadership of the appropriate Trust, who reacted in much the same way as I did, if with less swearing. As ever, it’s one thing hearing the right noises from the generals; the acid test is whether their strong words are reflected in what happens on the front line. At least it highlighted again the considerable sinkhole that has opened up in community paediatrics.

It’s finally happening. It was in my fourth blog that I first addressed the outcome of the Brexit vote. 95 blogs later, I’ve accepted- glumly- that we’ll be leaving the EU later today. Whilst you might be planning a weekend ramble through the promised ‘sunlit uplands’, I’m going to seek solace in chocolate.

As ever after Christmas, I have a large selection available, but which to choose? Keen mathematicians will have clocked that this is blog no. 99, and there can only be one choice to garnish the title line on this crumbliest and flakeist of days. I’ll mainly be in the bath, in soft focus.

Splish Splash


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