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Let Them Eat Cake

Friday 12 April 2019

This week’s joint LMC/Training Hub study day at the racecourse seems to have hit the spot. The aim was to build on the Transformation event last November, with the focus this time being on the new GP contract, networks and neighbourhoods. The day was superbly marshalled by Martyn Hughes, and the presentations kept short and punchy to allow maximum time for interaction- in the panel sessions, afternoon workshops, and perhaps most valuably when mingling during the breaks. It is now established LMC policy not to have individual delegate badges- partly to save money (my car is full of them), but also to encourage delegates to find out more about each other. I’ll just put the ‘other side’ of the coin- that it can be tricky for us greyer folk when confronted with somebody we’ve been talking to at similar events for the past 20 years, then to find that their name has slipped out of graspable mental reach. A special thanks as ever to Jill, Sarah, Claire and Carol for organising everything, and in particular for finding a couple of non-pharma sponsors, whose stands supplied bars of Cadbury’s chocolate and a glass of champagne to supplement the fine racecourse cuisine.

There is some astonishing stuff already going on around the county, much of it down to the enthusiasm of committed and driven individuals. We have some serious talent around, and it was encouraging to hear some of our younger colleagues talking enthusiastically about becoming Clinical Directors. At the end of the day we held a closing panel session, and a quick and dirty poll from the audience showed that the overwhelming majority felt positive about networks and neighbourhoods, with a couple not sure, and nobody saying they felt negative. That was probably a better result than any of us had honestly hoped for and a little unusual for anything going out under the auspices of the LMC: as a rule we tend to be cautious and guarded about any developments as big as these. Somebody pointed out that the survivors left at the end were more likely to be enthusiasts- which may be true- but our intention was always to present the concept of networks and the development of Clinical Directors, mandated in the contract and so not much of a choice anyway, as a positive thing that would be well-supported by the entire local system. We see the group of new Clinical Directors forming the backbone of a strong GP provider voice for Somerset, and it seems the message got across.

At yesterday’s South West Regional LMC’s meeting (the third visit to the sunlit uplands of the racecourse in a week for me) we were able to compare notes with our neighbours, and generally we sound to be further advanced and in a better position, with fewer areas of real concern, than most. We’re not complacent though, and are aiming to develop a regional resource so we can share best practice and useful information between the LMCs.

It was disappointing that I had to dash back to North Petherton as soon as we’d drawn the study day to a close, but somebody had to play duty doctor and we’d failed to secure cover due to the shortage of locums, or at least of anybody prepared to be on-call. Talking to colleagues from elsewhere, this has become a common theme, but it’s also a barometer of the situation across the patch. North Petherton hasn’t previously ever had a problem- we look after our locums well and fill them with tea and cake. Barry and I have had to stand in for four extra sessions this week alone, and it’s not as if life is exactly quiet on the LMC front to allow us to do this. It’s a busy time of year, even without the new national contract generating lots of extra work; we are still trying to finalise the local Enhanced Services agreement as well as carrying on with all the ‘business as usual’ stuff. We’re all starting to look and feel rather frayed.

Last week marked the 30th anniversary of my arrival in North Petherton. I was initially there as a long-term locum before becoming a partner the following year (on April Fool’s day, naturally). Apart from a six-month period when Mrs Chair and I ran off to the northern tip of New Zealand to run a small hospital and provide GP services to the surrounding area, I’ve been there ever since. It’s little wonder that I tend to ‘see red’ whenever thinking about any new GP contract, but that’s because I sat perusing the 1990 GP contract in the shade of a spectacular pohutakawa tree (with brilliant red flowers/stamens) on a beach in Matauri Bay, deciding whether or not to take up my partnership. Decisions, decisions, decisions.

I was touched that all the off-duty surgery staff came in at lunchtime last Tuesday for a celebratory glass of fizz, and I was presented with a magnificent cake that had been commissioned from one of the patients (photo on LMC Twitter feed). It was an incredible effort, complete with all sorts of medical paraphernalia including a stethoscope, a packet of diagonal blue pills (yes- these were definitely sugar) and a perfectly reproduced handwritten dummy prescription dated September 2006. Everything was edible, except for the prescribed item- a clotrimazole pessary. I’m still trying to work that one out (so to speak). Two days later, we left a skeleton staff at base and took everybody else to ‘Lady’s Day’ at the racecourse. Best frocks and fascinators were to the fore, although Bazza was granted a technical exemption from the latter for obvious reasons.

It was the sort of cake that takes a lot of eating, so I shared it around wherever I went, including last week’s meeting of the Southwest Commissioning Operations Group (COG) meeting at the NHS headquarters in Saltash. It was noteworthy that only a few days before, Devon and Somerset CCGs had taken over full delegation of Primary (medical) services from NHSE, which had gone more or less smoothly, as far as everybody was aware. In addition, the two CCGs in Devon were merging into one body at the same time. What could possibly go wrong?

My anniversary earned a round of applause from the gathered throng- which was nice- until my Devon counterpart queried when my Mental Health assessment was coming through. These meetings happen every two months, but the February gathering was cancelled due to snow and there were several items carried through from the December meeting. For one reason or another, I was the only Somerset representative on this occasion.

Had she been there, Jill would have shuddered at the prospect of a prolonged ‘deep dive’ into the Public Health section of the agenda. We had updates on the switch to HPV testing to replace cervical cytology as the standard test (Somerset is the last county in the region to move to HPV testing). There will be a single lab covering the whole of the southwest by December 2019 and will aim to turn around 95% of samples in 14 days. We also heard about the roll-out of Faecal Immunochemical Test (FIT) screening to replace the standard guaiac testing for colorectal cancer. The cake had been going down well until this point. You won’t be surprised to hear that there is an apparent disconnect between these screening changes being introduced, and the planning guidance for CCGs to put in place subsequent tests such as colposcopy and colonoscopy. The FIT test is a single sample test and so should have a greater acceptance and hence uptake by patients (no need to store previous samples next to the butter), but because it only detects human haemoglobin and not steak tartare, is much more specific. Overall, however, it is anticipated that there will be a small but significant increase in referrals for colonoscopy.

We hope to hear about resolution to a problem with Child immunisation payments soon, and registered our strong displeasure at how some practices had been treated with respect to their Dispensing Practices Quality Scheme payments. We are also hoping that we might be moving towards a solution on data-extraction problems related to Child Health Information- something that our practice manager colleagues are more likely to be sighted on than clinicians. It revolves around the withdrawal of support for the Miquest system, which is likely to be derailed soon anyway with the switch to the SNOMED codes, and it will come as no surprise that there doesn’t appear to be any rush to develop a national solution, although some of the larger GPIT companies are waking up to the problem (including EMIS. There are definite advantages to having all the Somerset practices on a single system).

It was interesting to get a pharmacy colleague’s take on the new GP contract and the effect it might have on the wider pharmacy picture. We hear that the workforce developments mentioned in our new contract over the next five years reflect the national figures for recruitment and development- although on reflection, these might be the same people who were tasked with getting us 5000 extra GPs by 2021. The situation on the ground doesn’t sound any brighter for pharmacists. There is estimated to be a shortfall of at least 400 pharmacists across the south west at present, and the pre-registration training posts have a 60-70% vacancy rate in some areas. Some years ago, we heard from our Somerset LPC Chair that he was hoping to import hordes of enthusiastic pharmacists from his home stamping-ground in Northern Ireland, but it seems that they have now seen a better future the other side of the border. More of a concern to our colleague was that Primary Care in some areas are offering such high salaries that it was drawing pharmacists out of the hospital trusts, where some pharmacy services are now at serious risk of collapse.

The ‘nomenclature unit’ at NHS England seems to be busy these days. The same people who decided that we can no longer call Urgent Treatment Centres ‘Urgent Treatment Centres’ have now decreed that our ‘Brexit’ standing agenda item for the COG meetings must hereafter be referred to as ‘EU Exit’. Brilliant- but why didn’t any of us think of that? Thanks to masterful negotiations by the PM, we now get to enjoy another six months watching 27 countries trying to consciously uncouple from the UK. He’s a tricky cove, Johnny European. If it was up to me, I’d suggest they eat cake, but I’ve only got crumbs and memories left now.

Tomorrow evening, my lovely sister has invited us round for evening nosh with a small group that includes my MP. I can’t think what we’ll find to talk about, but Kate knows that I’ll behave myself (at least for the first bottle).

Tally Ho,

Nick

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