Friday 13 April 2018
This week marks the half-way point in my tenure as LMC Chair. To celebrate, I found a whole new COG meeting to go to, and it was actually rather good. In times of austerity, everything gets recycled, including the acronyms. I used to attend the CCG ‘Clinical Operations Group’ meetings as LMC observer when I was vice-chair, a duty I was delighted to relinquish to Karen. The ‘Commissioning Operations Group’ is an NHS Southwest meeting, attended by the local NHS team, CCGs from Cornwall, Devon and Somerset, Chairs and Chief Officers from the LMCs and also pharmacy representatives. NHS Southwest is divided into a North and South group, and historically we were always in the former. Harry was delegated to go up to Bristol to attend meetings in the soulless South Plaza NHS building, and never seemed overly enthused by either the surroundings, or the proceedings themselves.
Somerset has recently been annexed by the ‘peninsula’ (or did we annex them?), which feels a more comfortable fit; we have much more in common with Devon and Cornwall than inner-city Bristol. The meeting was in Saltash, and so necessitated a dawn start. It’s rare I head to Cornwall without bucket and spade, but at least I remembered my passport (burgundy and proud). We got to the border in record time, and the formalities crossing the Tamar were less rigorous than anticipated, so arrived at the rather bijou ‘Peninsula House’, the base for the NHS Devon, Cornwall and Isles of Scilly team, with an hour to spare. An unlikely-looking single storey building, slapped down in the middle of an industrial estate, it had the advantage of being in the shadow of the largest Waitrose store I’ve ever seen, a fab venue for a pre-meet with my Cornish counterpart, who joined us in the cafe. There’s something about the staff in Waitrose; our coffee and croissants were served by a delightful lady with a name that conjured great breeding (well, it didn’t begin with a ‘K’), and whose air and general demeanour suggested that she was probably a lady-in-waiting, resting between (royal) appointments.
The meeting itself was constructive and a chance to compare what’s happening around the region. The only other forum where we’ve had all organisations represented across the table are the quarterly Primary Care Joint Commissioning Committee meetings, but that only relates to Somerset. We started with updates about overseas GP recruitment (rightly, it’s a long and rigorous process), increased funding for local initiatives (Somerset is recognised as a real success story because of our GP Career Plus scheme), flu vaccine ordering for next year, and each county’s plans for Improved Access. There was a debrief from ‘Snowgate’, which caused varying degrees of carnage in all three counties, particularly in relation to communication. There was a discussion of the lessons learnt and how it related to practices, but also pharmacies, many of whom were especially vulnerable as they relied on locum pharmacists travelling long distances to get to work. Somerset CCG led a discussion on methods to identify and support practices at risk under a section headed ‘Deep Dive- System resilience and workforce’. We’ve banned ‘Deep Dive’ as a term in our LMC for a number of reasons, not least that some of us can’t stop sniggering about it, and Jill surprised the assembled throng by requesting that, to ensure decorum, ‘DD’ never appears on the agenda ever again. Otherwise, it was a positive and worthwhile experience, and I’m sure will prove a useful forum in the future. We finished in ample time to join the first M5 holiday jam of the season, marking the end of the Easter monsoon.
Time for reflection: Doctor Bray senior qualified from Birmingham in 1953 and started work immediately at a large teaching hospital in the city. As ‘housemen’, he and his colleagues did what it said on their tin- lived and worked in the ‘house’, and he was expected to be resident throughout the year, apart from two weeks annual leave. There wouldn’t have been much point in living outside the hospital in any case, as the 1-in-2 rota meant there were precious few hours in the week when he wasn’t expected to be around (my paediatric SHO post on the Taunton GP scheme, which included covering the Special Care Baby Unit, was a 1-in-2: the ‘good’ or easier week was 75 hours on duty, and the other, a less good 138 hours).
Despite the hours and the demands of the job, he recognised his good fortune. Had he been born a few years earlier, he could have been machine-gunned wading ashore in Normandy, had his corvette torpedoed negotiating the Arctic ice-floes en route to Murmansk, or been folded into the rear gun turret of a Lancaster, pinned in a searchlight beam 10,000 feet above the Ruhr with both port engines ablaze. Times felt good: powdered egg was no longer rationed, there had been the coronation, and Denis Compton had scored the winning runs to regain the Ashes. The Medical Defence Union caught the mood of optimism, and was offering lifetime membership for 25 guineas, with no talk then of run-off cover or transitional arrangements (for the benefit of our more callow colleagues, a guinea was 21 shillings, or for the most, £1.05). He didn’t take up the offer, which at the time he thought expensive, although many did subscribe; Mrs. Chair worked for an obstetrician at Musgrove in the 80’s who was still enjoying full value from his 25 guineas, much to the chagrin of his younger consultant colleagues. The nurses’ home next door to the doctor’s mess was teeming with attractive and amenable talent, all of whom were keen to help my father dent his annual salary of 350 guineas, and one of whom was scheduled to become Mrs. Bray.
I know historical context is a thing, but it’s worth bearing those figures in mind when I tell you that last week we received the heftiest locum bill, by some distance, that we’ve ever received for a single day’s cover. On the face of it, it didn’t sound particularly busy, certainly not by the standards of the Tuesday after the Easter holiday, which I’ll come to in a bit, if I can bring myself to revisit it. Anyway- had we been able to transfer the money we’re being asked to shell out back to 1953, it would have paid for two years (or 10,650 hours) of the elder Dr Bray as a houseman, and we’d still have change left over for three life-memberships of the MDU. I’m certainly not decrying the fact that locums should be free to make an honest crust, and it’s a competitive market, but the comparison is, well, interesting.
More interesting still is the concept of the Life membership, and something that, at the very least, might make you weigh the odds and question your own mortality. I called in at the Fleet Air-Arm museum at Yeovilton recently after a truncated meeting at the CCG. I had another meeting in the area later and so had an unexpected couple of hours to kill. It was going to cost £14 to have a peek inside, but sensing my hesitancy (mental, for now at least), the kindly lady at reception handed me an application form to become a ‘Friend of the Fleet Air Arm Museum’. For £12 a year and the cost of a stamp to the secretary in Weston, I could be a member of the Society of FFAAM, and entitled to as many visits as I like (and the quarterly ‘Jabberwock’ magazine). Better still, for £120, I could become a life-member. Wow- that sort of implies that after 10 years, you’ve hung on longer than they expected you might, either as a prescient being or regular attender, and you’re in bonus overtime territory. I started writing the cheque, but then spotted that if I was to hang on to this time next year, when I have a Very Big Birthday, my lifetime membership drops to only £60. I paused, and I’m still not sure how I feel about this. My brain is addled by months of damp and cold, but it’s hard to see this in terms other than that my life expectancy is half next year what it is this. If that’s the case, then I’ve probably only got two years to live, which is a shame, not least because I hoped there might be life after the LMC chairmanship.
Back, briefly, to the Tuesday after Easter. Predicting a riot, we had a locum booked to supplement the two of us who normally cover Tuesday. All slots were booked within a few minutes of opening the phone lines, and we seemed to be heading for a busy but manageable day. Unbeknownst to us, the locum was norovirused-up and there was an email nestling in the Practice Manager’s inbox saying that they wouldn’t be joining the fun. No choice but for the two of us to get stuck in and get through it, which we did on a wave of dark humour, caffeine and chocolate. Some questions popped up through the day. Firstly- where were all the GPs? We asked the locum agency whether there was any chance of another locum to be told they were still trying to fill 40 slots that week. Next, a clinical question that arose as a ‘while I’m here, doc- a quick one’: we know they never are, but this one was particularly foxy- what’s the cause of browny discolouration of the nail beds, but confined to all fingers on one hand only (no difference in pulses, nail morphology etc.)? Finally, the most crucial on the day: I’d woken with a wonky knee that I couldn’t stand on properly, and lurched around heroically until about 4pm when I found a stray naproxen tablet. I hadn’t had lunch, but what, I wondered, was the ‘after food’ equivalent for Cadbury’s ‘Bitsa Wispas’, a bag of which my lovely colleague had bought me earlier in the day? In the end I decided that an appropriate dose was 60g, or about half a bag, so lined my stomach with that and garnished it with 500mg naproxen. Do as I say, not as I do. Anyway, my knee got better and by the end of the day I was positively prancing, though on reflection that might have been the sugar rush.
So what’s going to be taxing us most in the coming months? The urgent care agenda is going to be absolutely critical in term of sustainability of the system, and with significant implications for how we run our in-hours services. We know that the system at the moment feels fragmented, and if we’re having trouble describing what happens with urgent care, then how are patients expected to make any sense of it all? If you haven’t looked at the item in the CCG GP bulletin from a week or so ago, please do, and have a go at the Survey Monkey attached. We’ve got some really meaty meetings coming up in the next few months, and there’s little time to waste.
By my estimates, I’ve got 730 days left, in every sense.