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Hopes and Fears

Friday 5 January 2018

I had intended this to be a warm, mellow and comforting piece to ease us into the New Year. We waved the solstice off just before Christmas, and two days ago the earth swung past the perihelion, so the planet is now hurtling back towards the bit of the orbit that gives us our spring and summer. Can you feel the days drawing out? Admittedly only by about 90 seconds a day at the moment but hey, it’s a start.

It goes without saying that it’s extremely busy at the moment. Jill asked practices for information about patient demand and internal escalation procedures earlier this week, and the activity figures are extraordinary. One practice recorded 760 phone calls in one day, and everywhere reports very high demand for appointments and home visits. We’re grateful to all the managers who’ve taken time to collate and report this information which has been useful to share across the rest of the system.

There is genuine distress in many parts of the NHS, and no shortage of front-line staff prepared to say so publically either on main-stream or social media, despite the efforts of NHS England to control the communications. I had a text on Wednesday from the Clinical Director at Musgrove asking if we could have a phone-call to discuss what the system could collectively do, if anything, to help with the pressures. As it happened, I was 25 yards away with another GP/STP colleague having a post-festive catch-up, so joined him and the MPH Chief Operating Officer for an impromptu meeting. Musgrove had just got through its busiest day ever, with patients stacked and secreted in every nook and cranny. They had probably coped better than most trusts, and there was evidence that the closer working between social care and the health system over the past year or so had reaped significant benefits, with only 5 patients on the DTOC (delayed transfer of care) list, compared with over 90 this time last year. That’s quite an achievement, although not surprisingly, social care was running out of capacity. We discussed the limited ability of Primary Care, already heaving, to do anything unless released from other contractual commitments by NHSE, but also how improved availability of consultants for GP advice might help. More on this anon.

I was keen to hear their take on the announcement from NHS England of the deferment of routine surgery and outpatients until the end of January. We know better than anybody that demand never goes away- it just gets shunted to another part of the system, and any postponements inevitably increase our workloads, as well as pain and inconvenience for patients. I don’t understand how cancelling routine outpatients in many specialities is going to help ease the pressure, a view evidently shared to a large extent by the management at Musgrove, who feel that for now at least, they are more or less on top of things, and are asking patients to attend routine appointments unless they hear otherwise.

Somewhere amidst the festive carnage, word came through that our local A and E consultant and past President of the Royal College of Emergency Medicine, Cliff Mann, had been awarded an OBE in the New Year’s Honours list. Cliff and I overlapped for a time on the Somerset GP training scheme in the 80’s, when the tallest and most modern clinical building on the Musgrove site was the Special Care Bay Unit. ‘Playschool’ was on a Friday afternoon and followed a suitably stodgy lunch in the Musgrove Postgraduate centre. The entire consultant staff could (and often did) sit comfortably round two large tables, and were often joined by local GPs who would come to listen to the lunchtime clinical lecture, including one colleague (now dead, and from a practice that no longer exists) who was famous for dozing in the front row, rousing intermittently to ask searching and pertinent questions. Even then it was clear that Cliff had a brain the size of a planet, and it was a great loss to Primary Care when he went off to follow a different light. He has, of course, achieved great things, and I’ve bumped into him several times on the 19:03 from Paddington when we’ve both been coming back from meetings, me from something mundane at the BMA, and he from briefings with Government Ministers or Heads of State (probably). The last time I saw him was a week or so before Christmas, when he was escorting a formation of drips, tubes and beeping machines surrounding a bed, and possibly a patient, into a ward from A and E. His recognition is thoroughly deserved, and I sent him a congratulatory tweet. His reply was typically generous: Delighted and proud to be part of Somerset doctors- thanks Nick.

And that’s the point. We are one system, everybody doing the best they can in increasingly difficult circumstances. There was a time when fingers were pointed from one sector to another, but now there is widespread recognition that everybody is working flat out, in a woefully underfunded system, with too few beds, too few staff, increasingly sick and complex patients, with a steadfast refusal by the politicians to recognise the reality and engage in a genuine discussion about the future of the NHS. I know I’m sounding like a stuck record, but maybe, just maybe, the crisis in the service (and yes- it is a crisis) will be the spark to ignite that debate in a meaningful way.

As an opening gambit, may I respectfully suggest we start by cancelling Christmas? The build-up now starts in late October, with the franticmeter ramping up steadily until the big festive shut-down of non-emergency services just when we need them most. I’ve banned festive music in our place (at least when I’m there) as there’s only so many times you hear Johnny Matthis or ‘Mistletoe and Wine’ before you need to insert a jolly snowman somewhere, and for a large number of people sitting with us in our surgeries, it isn’t a happy time of year. On the Saturday morning before Christmas, I found myself driving around pharmacies trying to secure stocks of syringe-driver medication for a terminal care patient who lived in straightened circumstances. He needed larger doses than anticipated, the family situation was already difficult, and there was real concern that the local pharmacies wouldn’t get the necessary stocks of midazolam and levomepromazine in their final deliveries before they shut at midday for the holiday. Whilst we’ve had long holiday breaks before, the shortage of commonly used medications has added another dimension to the problem. Some of the ordered supplies didn’t arrive, and I ended up raiding our dispensary stock to make up the shortfall, but was fortunate to be in a position to do so.

2018 is going to be a big year for anniversaries: the hundredth anniversary of the end of the First World War, the formation of the RAF and Spanish flu, 75 years since the Dambusters, 60 years since the Munich disaster, and on the 5th of July, it will be 70 years since the formation of the NHS. There’s bound to be some schmaltzy official events to mark this landmark, and rightly so as there is much to celebrate. What will the service look like for its 75th anniversary, I wonder?

My feelings for C*apita know no bounds. I received a nice letter from the coroner a week ago asking for a medical report on a patient who had died suddenly some weeks earlier. The post-mortem was inconclusive, but with a hint that there might have been some relevant occupational factors. For him, this would have been in the 1960s, and not in the computerised record. The paper notes had already been returned by our super-efficient staff, and so we requested them be sent back (as we often have to). Our manager was asked to justify, in some detail and by several emails, why they should be returned, with the implication that they would have refused to supply them if not satisfied by our response. Maybe they’re inundated with GPs short of bedtime reading, or looking for something to occupy their lazy days, by browsing old notes and reminiscing about the good times with their favourite patients?

Another ‘Playschool’ contemporary of Cliff and me* retired this week, having left General Practice after 2 years, eventually becoming a Public Health consultant in Devon. We went to her retirement do at Dartington on Wednesday evening. I’m not sure that discussing the great cryptosporidiosis outbreak of 1995 in unnecessary detail with a load of Public Health specialists is a great way to enjoy a meal.

I met a GP for the first time at a racecourse event a few months ago, who told me that she missed my fortnightly rants about President Tango. I was finding it increasingly difficult to be outraged by his erratic behaviour, and that, of course, is precisely the danger- to start accepting what is clearly outrageous, as ‘normal’. Well, here we are five days into 2018, and we seem to be heading for a new pinnacle of the idiocrasy. Perhaps emboldened by his access to 280 Tweeted characters at a time, rather than the previous 140, during the last few days he has insulted Pakistan, threatened withdrawal of funds from the Palestinians, claimed credit for the ‘zero deaths’ in commercial air traffic during 2017, slated his chief strategist, and engaged in some gentle ‘who’s got the biggest nuclear button’ braggadocio with the notably stable and restrained North Korean leadership. I suppose any knob on his desk would look large in his tiny hands. Anyway, he’s banging on like somebody who knows that he might not have much longer left in the Oval Office- I hope because he’s either indicted or Congress decides to invoke the 25th Amendment on the basis of lack of mental capacity, rather than because he’s plunged us into nuclear winter.

LMC elections are coming up in the next few months. We did discuss whether to do this electronically, but fearful of Russian interference have decided to do it in a more traditional way, so look out for information coming soon on our distinctive golden paper.

Happy New Year to all,

We’ll get through this.


*apologies to those who’d prefer ‘myself’ or ‘I’ here. I bow to current grammatical thinking, albeit reluctantly!

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