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Fudge Factor

Friday 16 August 2019

Can any of the panel suggest what’s happened to our greengage crop? It was all looking so promising just a few weeks back, the tree laden with ripening fruit. Apologies to anybody looking for nuanced medicopolitical commentary, but it’s August, traditionally the ‘silly season’ when nothing much happens; the punters are on holiday and we’re feeling chilled and relaxed. There’s not a lot to do between checking the phones are working, and peering expectantly into the surgery car-park hoping for some casual trade, so I thought perhaps instead we could go all ‘Gardeners’ Question Time’?

Or maybe not. Summer has proved increasingly stressful in recent years, even before last weekend’s tropical cyclone distributed our less substantial garden furniture around Taunton’s northerly suburbs. There’s plenty going on across the patch to keep the Exec team off the beaches, and there are never enough locums, certainly until the hordes of newly qualified GPs surge onto the scene in early August; has there been any sign of them yet? The one thing worse than being unable to get a locum is to have one booked, who then cancels their booking at a stage when there’s no realistic chance of securing a replacement. Frazzled and exhausted partners don’t want to begrudge colleagues their week or two away from the fun, but we’re only human. Add into the mix a squirt of extended sick-leave somewhere else in the team, and practices can very quickly find themselves in real bother. We rely increasingly on the goodwill and good humour of staff, with tolerance and understanding from patients to get us to the end of each day, but it takes its toll over time. We know of a large Somerset practice that, by virtue of retirements and sick leave, has been on average 14 sessions down each and every week this year.

The LMC makes no apology for banging the drum that Primary Care Networks are there primarily to shore up local Primary Care before they can even dream about heroically rescuing the rest of the system, but how do we envisage that actually happening? Developing closer relationships and trust between practices is a good start, but will only go so far, in much the same way as the ‘thoughts and prayers’ distributed by American politicians after mass-shootings. As yet there’s been little appetite for staff to work in each other’s practices. We know that some of the at-scale providers now managing practices will have a clause in their contracts that a staff-member (including GPs) might be required to move to work in another practice if the situation dictates, but what happens practically when all practices are running white-hot and on fumes? Few would cope with suddenly losing a significant member of the team to another practice, and certainly not without feeling a teensy bit aggrieved, unless there was something substantial coming the other way in mitigation. A large-scale provider might be in a position to parachute in a physiotherapist or mental health worker, but when staring down the barrel of an overflowing session, nothing can adequately replace a battle-hardened GP. Maybe they could lay on a fleet of minibuses to take the extras to a nearby Urgent Treatment Centre/MIU/soothsayer/gardening club of their choice?

I’ve seen a lot of 03:49 in recent weeks. Friends know that I’m not a great sleeper at the best of times, and these are not those. There’s a load of stuff bubbling and threatening to come to multiple heads like a complex abscessy sort of thing in the next month or so. Mrs. Chair came down in the early hours recently to find me absent-mindedly poking a Seroxat-logoed ballpoint into my eyeball, and being a perceptive soul suggested I jot down all the things that were troubling me.

I gave it a go, and she was surprised when I asked for extra paper, especially as there was nothing related to actually looking after patients until half way down the second page; that feels to be the easy bit at the moment. Being a GP partner should be a wonderful privilege, but carries extra responsibilities that make life complicated, from carrying the can when there’s no locum cover, tackling staffing or premises problems and wrestling with the CQC website, to wondering whether you dare explore a non-functioning U-bend.

I can still recite the rarer causes of pericarditis, name all the branches of the internal carotid artery, and explain how ACE inhibitors work, but put any of us outside our comfort zone and the stress levels rise. Having spent several hours this week poring over, and subtly tweaking, our practice ‘Statement of Purpose’ section on the CQC website (if you’re not the CQC registered manager in your practice, did you even know you had a ‘Statement of Purpose’, and that not keeping it up to date carries financial penalties?), I triumphantly pushed ‘submit’ to which the computer said: ’Sorry, you don’t have access to Notification of changes to your statement of purpose’.

Huh? I’m the foxtrotting Registered Manager! That’s all I’d been doing for the past few hours. To give the CQC their due, their customer service team are pleasant and professional, and appear to have more than a smattering of counselling ability (‘I can sense that you’re upset….’). It turns out that the CQC website quietly logs you off in the background after 20 minutes or so, although feels it best not to tell you what it’s done in case it spoils the fun later.

Or how about this question from a document relating to the proposed sale and lease of our practice premises: ‘If the transaction is the grant of a new lease at a premium, and you are entitled to do so and the Buyer asks you to, will you enter into a Capital Allowances Act 2001 section 183 election for the Buyer to be treated as the owner of the plant and machinery fixtures for capital allowances purposes?’. That wasn’t even in the section they recommend an accountant completes, and comes in as question 37.2, just in case the previous 37.1 haven’t pinged all your syllogistic rivets.

Nothing is simple any more. Last week I dutifully repeated a blood test as suggested by the lab and, also as suggested, included the lab reference number for the previous test, which involved 25 keystrokes. With the population of the earth somewhere near 8 billion, it would only take 10 keystrokes to assign every earthling an individual number, so what are the additional 15 characters for?

Mrs. Chair is a kindly soul, and prone to take in waifs and strays. This month’s lodgers in the west wing are a couple of junior doctors at Musgrove who needed a roof for a couple of weeks before their rented house became available. They’ve been supervising new F1 doctors, many of whom evidently find the adjustment to the express lane on the end of a bleep quite a shock. Any doctor is aware that the early weeks in August are best avoided should you decide to fall perilously ill, but at least the induction offered to juniors today is more comprehensive and friendly than many of us might have had (‘that’s your bleep, and you’re on call until next Tuesday’).

Where us oldies did take the points was in the ‘firm’ system. You worked for Mr. Slashalot as a medical student, he liked the cut of your jib and you did your best not to faint or sneeze into any of his open abdomens, and hence secured the job of your choice. Sure, statistically there was likely to be a psychopath somewhere in the hierarchy, but generally they were supportive structures, and there was nothing quite like following a patient from clerking on admission to their leaving hospital, whether horizontally or vertically. Few consultants today really know their juniors- certainly not well enough to lend them a car as one of mine did, and how often do we phone a ward and have trouble finding anybody who knows much about our patients? I heard Dame Sally Davies, the Chief Medical Officer, talking recently about the lack of pastoral care amongst the medical profession and especially junior hospital doctors today. One thing that would make a significant difference, she felt, would be the reintroduction of the firm system. What are the chances?

Did you also get the following recently? Dear NHS Email User, We regret to inform you that, NHS help desk service is urgently updating all NHS Account users as a result of virus description which has been sent across all NHS Extension. You are Urgently required to forward your login Email and Password to NHS Helpdesk Service ( for urgent update and reactivation of this Email Account now. to avoid losing access to your account kindly provide your email address and your correct password for your safety. I should bloody cocoa. Never mind the dodgy syntax and random capitalisation (maybe the same joker writes the EMIS drug labels?), the email itself appeared to have come from an Eileen, working in a hospital in Kent. It’s very kind of her, but I think I’ll pass- as I did yesterday to the same message from an HCA in Brighton. Do they take us for mugs? Well obviously, yes. It’s a fair bet that an NHS worker somewhere will fall for it and let them into the system. Closer to home we’re aware of a spate of walk-in burglaries in GP surgeries, and on at least one occasion a staff member, relieved to have heard from the ‘police’ that her wallet was recovered was persuaded to reveal her PIN number over the phone. Beware, people, there are vagabonds everywhere.

The answer to the greengage conundrum turned out to be Fudge, the only one of our recent litter of puppies still with us. He’s now nearly 14 weeks old and growing fast: by the time he leaves in another week or so, he’ll be the size of a small pony. The family who are having him are away until the end of August on a long-planned holiday to the Far East. Mrs. Chair was happy to offer puppy-hosting/foundation training services, and it’s much like it was for the first eight weeks, except that the damage is now at a higher level, in every sense. We were surprised when he turned his nose up at the puppy food, until discovering his mother jumping up to pick greengages for him to eat. We await the enterological effects with trepidation.

We generated kennel club names for each of litter- pedigree dog owners will know that in addition to their calling name, they have a longer handle that goes on the official pedigree certificate. Thus, Archie is ‘Archibald of Gables’, Max is ‘Bernard of Blackbook’, and Peggy, ‘Margaret of Parkfield’. Our younger daughter came up with two: ‘Duchess Boom-box’ is better known as Doris and now lives with her own housekeeper in Henley-on-Thames, and Fudge, arriving as he did on the same day as my pension, is ‘Lumpsum Dumpling’. Imagine trying to tell that to his new family, including the oriental matriarch, whilst keeping a straight face.

Nick (nope- I cracked up)

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