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Fresh Looks, Thin Skin

Friday 25 November 2016

This week I have mainly been improving my mind, or at least refreshing my looks, at the annual GP-updating week at Musgrove. It's a great opportunity to catch up with GP colleagues and also bump into consultant friends in the corridors. The years march on, and there now appear to be tables in the Academy reserved for 12-year olds with NHS lanyards, whilst I've moved definitively into the grey cohort who shuffle round looking slightly bewildered whenever we have to leave the main lecture theatre to go somewhere else. Tony Wright does a fantastic job putting together the timetable, and the quality and relevance of the sessions improves every year.  We should also recognise Doreen’s fantastic work keeping the 4 days running smoothly. One constant is the brilliant beacon of Harry's hour when he tells us what's really going on, and what the LMC/he/me are trying to do about it. This year's "State of the Nation" was typically concise and insightful (save for the odd dodgy photo), and the single-minded focus with which he'd prepared was evidenced by an impressively bandaged thumb, which he'd apparently tried to hack off whilst getting the slides together.

We held our third Confederation meeting last week, with a small but perfectly-formed selection of knowledgeable and involved GPs and managers from around the county. We discussed the recently released Sustainability and Transformation Plan (STP), and also the "Improving Access" scheme. The overwhelming sense amongst those who'd waded through the STP was one of underwhelm- where was all the detail, that really contentious stuff that we'd got wind of that was going to get the MPs and patient groups manning the barricades? As more details begin to emerge and consultations start, the heat is bound to increase. There is, however, an elephant that has crept quietly and almost unseen into the room, and is now tiptoeing round the skirting boards- finance to support double-running.

We know that for any scheme that reduces bed occupancy (whether acute or community beds), there needs to be an effective alternative, available and fully-staffed, up and running in parallel in the community, something known in management-speak as double-running. The problem is that there is no extra cash sloshing around in the system to pay for this, money won't have been released from the acute sector, the Vanguard monies are due to finish soon, and HM Government have declined entreaties to have yet another look down the back of their sofa. The disinclination of Phillip Hammond to find extra money for the NHS in the Autumn statement, whilst the DoH was focusing yet again on the perils of health tourism (which implicates only 0.01% of the health budget) by suggesting we become passport officers, tells us all we need to know about the funding possibilities. So where might any new organisations find the money? The obvious and probably inevitable answer is through private investment, but this will be an anathema to many, and could cause considerable unease in many boardrooms across the county. The County Council couldn't run the waste services without Viridor, and we know that Virgin Health now have a foothold in the BANES area to our northeast border, and also in Devon. Is there any realistic alternative?

It was a surprise (an unwelcome one) to hear recently that Somerset was one of the first cohort of sites chosen by NHS England to provide Extended Access to all patients from April next year. For £6 per patient per year, the CCG has to procure a service providing an extra 30 mins/1000 patients/week on weekdays, as well as routine access to services on Saturdays and Sundays "as determined by local need". Hmm. That doesn't mean that practices need to provide it. There is no capacity or energy in Primary Care, but we know that these don't necessarily need to be GP appointments; they could be with nurses, a pharmacist or even on-line. We know that some funding associated with the GP Forward View, and also for coming years in the Primary Care Improvement Scheme (PCIS), was to provide additional access, and we are in discussions with the CCG about how best to take this forward, and how any investment might link with that in the PCIS.

The default mood setting at our County meetings, as in most groups of doctors trying to put a brave face on things, is best described as cynically jovial, or maybe jovially cynical. Occasionally things crop up to instantly puncture the mood, and at our last meeting it was ongoing problems with the OOH service. In addition to the critically low coverage on some shifts, and problems relating to support for registrars, we also learnt that a very senior and respected local GP had been summarily suspended from the service after an assessor had deemed his triaging to be unsatisfactory. The only reason that the NHS has survived, such that it has, into the 21st century is precisely because we triage the way we do. We work at speed, we take calculated risks, and get through far more work than any other professionals aided by algorithms will ever get close to. This is no way to treat a skilled workforce, and although we subsequently heard that the decision had been revoked (and an apology received by the doctor), the reputational damage to the system mounts.

The firearms certification remains a mess, despite more recent guidance from the BMA, a process triggered after some enquiries by a Coroner and subsequent legal opinion- never an encouraging start. Every month we have an informal and unminuted meeting with Mark Sanford-Wood, one of the four GPC executive members, who lives and works in Devon, and pops into the office for an hour or so before catching his train to London. Amongst much else we discussed last week how the guidance needs to be further tweaked. It doesn't help that the letters that go out from each force are different, and if you read ours through closely, nowhere does it ask for a reply if the GP is happy for a certificate to be issued. Not replying undoubtedly puts the GP at risk, and we know that the GPC are actively seeking to rip the whole thing up and start again. In the meantime the BMA has up to date guidance (updated 15/11) on its website. We're all aware by now of the sort of things in a patient's history that might trigger concern that they have immediate access to a shotgun. I was musing this week if there were any additional questions we might want to ask if the punter had access to something more- an anti-aircraft battery, a submarine, or (just imagine) the nuclear arsenal of the world's biggest superpower? My conclusion is that there is only one.

It's been two weeks now and we're all still here. I'll admit to a pang of alarm when awoken by a brilliant flash and a bang in the early hours of Sunday morning, but thankfully it presaged the arrival of Storm Angus, rather than the opening foreign policy gambit of King Donald (first time round my sloppy keyboard skills made that 'king Donald- perhaps I should have left it at that). I was needed back at the ranch on Wednesday and so missed the GMC-led session on Social Media at Fresh Looks. It wasn't that I missed hearing how to avoid getting into trouble on Facebook (I'm not on it), but rather how to wean myself off the @realDonaldTrump Twitter feed. Initially I was hooked by a morbid fascination and sense of curiosity, although since November 8th that has turned to one of abject terror. At least it provides a response to my one additional question: How thin is their skin? Answer: Very.

Just to prove I'd been listening this week I could bang on here about filaggrin and the stratum lucidum, but you're a bright lot and will know it all anyway. I suspect the President-elect has rather better access to dermatology than we do in Somerset, but on the off-chance he was to ask my professional advice, I'd suggest less steroid and more emollient. Everywhere.

But not before I'd written a note to his local firearms officer.


Nic'k Bray
November 25th 2016

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