MD Soundbites!
24th November 2023
Sharing the learning…. Is the pace at which you are working stopping you from learning from others? At the practice this week we rekindled our SEA programme and it was fantastic. An opportunity to establish some sensible ground rules, discuss some interesting cases, and walk away feeling that everyone had benefitted. It made me reflect on how practices can develop and share their learning and evidence quality improvement for CQC. If this is a process that you would like to develop further then perhaps have a look at these links
CQC GP mythbuster 3: Significant event analysis (SEA)
RCGP Reporting and learning from patient safety incidents in general practice A practical guide
Medical Appraisal Scotland Domain 2: Review of Significant Events
The guidance on Good Practice for Team-Based SEA Meeting is worth a look.
Best wishes
Justin
17th November 2023
Please be flexible!!! Why is it that some practices can retain their workforce and others struggle… there are a significant number of factors but one that is overlooked is how flexible the employer can be. Flexible working: raising the standards for the NHS as published in 2022 and is worth a look.
NHS defines flexible working as ‘an arrangement which supports an individual to have greater choice in when, where and how they work’ and combines three organisational themes: patient/service upset and staff experience, service delivery and work-life balance of colleagues. Perhaps time for us all to give this some renewed thought. NHSE provides some useful links here.
Best wishes
Justin
10th November 2023
ADHD …. Got me in a spin!
‘Thanks for the call doc, I have been without my ADHD meds for the last 3 weeks as they are out of stock – I am going to lose my job if you cannot help’.
Alternative, ah… where is that guidance I started to think. Rescued by Catherine – fellow MD who is more organised with filing than me, I was able to work through the problem to help. If you are faced with similar challenge this week this guidance may help.
This guidance from Avon and Wiltshire is useful also.
Justin
2nd November 2023
Being inspired… an e-mail landed in my tray this week and it immediately inspired me.
‘Kindness Respect Teamwork
Everyone Every Day’
Almost every day I meet someone who inspires me. Whether that is a patient who shares their story, a colleague who delivers excellent care or just someone who makes the world a better place in some small way. This particular quote was shared by a GP after they raised concerns about how a patient in their practice was managed. However, rather than rant they shared this quote!
Need to be inspired? Consider the podcast ‘Inspiring doctors’ - it is worth a listen.
Justin
27th October 2023
State of Care
CQCs State of Care 2022/23 report is a very challenging read. Almost every aspect of this report shows that our health system is in difficultly. It is the health and care workforce section that I wanted to bring to your attention.The NHS workforce sickness absence rates have increased. Working conditions are more stressful. Over the last 2 years NHS staff have generally been more than twice as likely to record ‘anxiety/stress/depression’ as the cause of their absence than any other reason. This accounts for 20 to 28% of staff sickness absence. With the challenges being so real it is hard at times to see a way forward but retention of staff has to be key. We know that our practices are adapting with many now employing an array of health professionals to support. Reflecting on conversations with colleagues this week perhaps the only way we can ‘survive and thrive’ is to firstly take a look at our culture and make the time at work as positive as it can – for me that is making time for each other and getting the simple things right. Working in healthcare remains an absolute privilege but working within the right team makes that a reality! ‘Workforce and Wellbeing’ is part of QoF 2023/24 but the one aspect that sticks out for me in the Overview of the QI module is improving staff wellbeing!!
Take care everyone.
Justin
20th October 2023
World Menopause Day….. this was the 18th October this week for those that are not aware. Almost every week a full time GP will have a consultation with a patient who is going through the menopause. We focus and aim to provide the best possible care to our patients. However, are we doing everything to help our colleagues in the work place? We have real workforce problems and need everyone at work but are we tackling this issue?
Women between the ages of 45 and 54 alone make up a fifth of all NHS employees, and so up to a fifth of our workforce could be experiencing menopausal symptoms. Many of our services in general practice are led and delivered by women, therefore we must create a safe environment for menopause to be discussed in the workplace. Some links to help think about how we can help our colleagues going through the menopause, I hope you find useful.
- BMA Advice and Support
- ACAS also provides some helpful guidance
- I found the BMA menopause survey discussion really informative
- Supporting or NHS People through menopause
For those on half term next week enjoy some family time.
13th October 2023
General Practice Improvement Programme
The modern model of general practice….. needs to be able to manage on need not wants. I have written before about the safe working and managing workload but I do want to promote again the national General Practice Improvement Programme (GPIP).
Every day many practices in Somerset are being overwhelmed by the numbers facing you in the waiting room or the number of calls that need to be made. We all know you can only see one patient at a time. This GPIP needs to be tackled in a step by step manner. If we want to stem the flow and provide safe effective care and have a more meaningful day this programme needs to be seriously considered.
Perhaps designate this to a clinical lead and give them time to consider how this could work for you…
Happy reading.
Justin
6th October 2023
Cancer diagnosis is always tricky …. ‘if you have not heard in 2 weeks please call the surgery’. I have been saying this for years but the guidance has changed and to help us manage our patients' expectations and call backs to the surgery we need to know the changes.
From 1st October the 10 existing guidelines are streamlined into 3 – these are:
- Faster Diagnosis Standard: a diagnosis or ruling out of cancer within 28 days of referral (set at 75%)
- 31-day treatment standard: commence treatment within 31 days of a decision to treat for all cancer patients (set at 96%)
- 62-day treatment standard: commence treatment within 62 days of being referred or consultant upgrade (set at 85%)
So perhaps we need to change our safety net advice… but critically it does not alter the way we refer.
Further information on the background of this can be found here and here.
Justin
29th September 2023
Good Medical Practice… 1995 and beyond. In 1995 (when I was at medical school) the first edition of this document was published and I clearly recall the seriousness that the medical school attached to this publication – it has always stayed with me. Move on almost 30 years and there is a new edition that will apply to doctors in 2024.
The standards focus on behaviours and values which support good team work, make everyone feel safe to speak up, and empower doctors to provide quality care
Five key themes:
- create respectful, fair and compassionate workplaces for colleagues and patients
- promote patient centred care
- tackle discrimination
- champion fair and inclusive leadership
- support continuity of care and safe delegation
It can only be a good thing to discuss this important document and be fully aware of what is expected - don’t forget the footnotes!
Happy reading and sharing.
Justin
22nd September 2023
Being the team you want to be… one of my colleagues this week conveyed their frustrations as they gave an account of getting a complaint when they believed that they had done nothing wrong. What struck me was how comfortable they felt about discussing the issue being new to the team.
Being able to discuss problems that arise, develop better ways of working and supporting one another is so important. But why do some teams function and others not…. Part of my week has been about looking at organisation culture and why some organisations and teams support one another better than others. I was reminded about the five dysfunctions by Lencioni which are…
- Absence of trust
- Fear of conflict
- Lack of commitment
- Avoidance of team accountability
- Inattention to team objectives
There is no doubt that together we are better.
Best wishes
Justin
15th September 2023
Meeting great people…this week we had the LMC educational event of ‘What does good look like? Taking back control of General Practice’ and if you weren't there you missed a valuable day (but you can catch up with the presentation slides here). There were some inspiring speakers.
Do you remember when you were a medical student or a junior doctor and you had been taught a technique but when under pressure it falls to a bag of bits – this happened to me in taking arterial blood gases once! Those gases are important because clinical decisions are based upon them. Scott McKenzie, from Scott McKenzie Consultancy, described many things including the importance of culture. Well consider how important the culture of your organisation is, how welcoming, supportive and facilitatory it is. However, what is it like when it is stressed? Is it still so welcoming? Successful organisations have great people and great cultures – taking time to build it matters.
Heard of Allyship? Emma Symonds, from NHS Somerset gave an inspiring talk on developing and looking after your team. Do have a look! Guide to Allyship.
We heard from many people wanting to take back control and build a better general practice for Somerset – we are lucky to have great people but we must work hard to keep them.
Have a good weekend.
Justin
8th September 2023
Leadership… Most of us are not that interested in ‘medico-politics’ but we definitely need GP leaders who are. This week I was sighted on a feature article in the BMJ that filled me with hope - Better and safer: an new ambition for GPs in England. In this article Dr Katie Bramall-Stainer, the new Chair of BMA’s GP Committee (GPC) Chair in England, as of the 3 August, sets out her vision.
Bramall-Stainer believes wholeheartedly in the partnership model with continuity of care as its heart, but says that this has been undermined by politicians of all parties, with some suggesting that it could be replaced with a totally salaried GP workforce. “That would cost billions. And where is the evidence that it’s going to bring efficiencies?”
It seems that we have a leader that really understands our pressures.
I expect that the temperature in the negotiating room is going to start to mirror the heat we are facing at the coal face!
Have a good weekend.
Justin
1st September 2023
12th September … there is only one place to be! Well not quite, but I did want to bring to your attention the LMC / STH Study Day at the Taunton Racecourse on the 12th September where one clinician and one non-clinical lead can attend. We hope the day will be useful in helping us all reflect on what ‘Good’ looks like and taking a little bit of control back in our working lives as we face the winter. It is not too late to get involved, click here for the agenda and if interested book here.
Taking control but being kind in the process seems key to me. Yesterday, I had completed a telephone consultation and the lady on the phone suddenly said ‘That’s great doctor – here is my husband’. Having already spent 15minutes on the phone I was slightly taken aback and without me catching breath, he proceeded to ask me about his blood results and tests at some pace. After a few minutes I politely asked if he could keep his scheduled appointment to address his concerns which he kindly accepted. One small example of the constant demand for more of our time. For most of our clinical days it can seem that we are running a race… a race against the clock to complete the list of clinical questions in a set time. We do not have time for those extras and having multiple extra tasks or queries can make the day overwhelming. It makes it doubly hard to always give your very best and be kind when stressed. The BMA this week talks about ‘Why be kind?’ It seems so obvious, but as we battle to meet our patients needs it is a very good reminder that being kind not only helps our patients but helps us. Worth a look over coffee. However, to always be kind we need time to think at work. That requires time for us to think and change how we work.
Our study day may not change the NHS but may in a small part help us share ideas for Somerset general practice to continually be ‘good’, learn some new skills to take some control back to deliver the care and kindness that we are proud of.
Justin
10th August 2023
Sharing is caring…
For the experienced GPs out there, I am sure you will agree that you have seen most of the problems you are encountering many times. You rely on those experiences and knowledge to provide the best care possible. However, how do you cope when you are not so certain? I was reflecting for my appraisal this week and reading through an entry that I wrote some time ago where I was uncertain about how to manage a patient who was end of life. The circumstances were complex. I had some concerns and took a few minutes to collect my thoughts asking myself ‘who is the best person to ask ‘. I needed to sense check my thoughts and know that I was on the right path. I spoke with a very experienced palliative care nurse and that 20 minute conversation helped me know that the care I was planning was ok, I was right. I had confidence that the patient was receiving appropriate care and my anxiety reduced. Working in our world seems to becoming more complex and more time pressured. A close colleague said to me this week ‘it's like we are meant to be consultants rather than generalists in all specialities these days’. It made me think…. we cannot know everything so work within your competences and do not be afraid to make time to ask – team work is related to performance.
Take care everyone and enjoy the sun… they tell me it is coming. More soundbites in a few weeks ?
Justin
28th July 2023
Thinking Cancer
Cases that make you think!! I know you may be thinking what a daft thing to say as every patient and every important diagnosis makes you think. But there are those cases that stick with you, that hit at your soul. The first time I really experienced this was when I was SHO doing oncology and I met a young man who was in his late 20s (as I was at the time) and he was dying of bowel cancer. The day he died on the ward I felt he took a part of me with him, probably because at the time his wife was expecting their first child, my wife was too and he never saw his unborn son. I recall him saying that because he was so young no one at the time considered he had cancer. We have all had such cases and in our privileged position we have to try and diagnose cancer early. It is often far from easy. However, often there are resources out there that are so close to home that we miss them. Have a look at the bundles of information in the SWAG (Somerset, Wiltshire, Avon and Gloucestershire) Cancer Alliance and GPs Talk Cancer that has just started! There is also a free set of courses on cancer that look promising (have to say I have registered but not started them yet) but perhaps worth a look too.
Happy holidays!
Justin
21st July 2023
Collaboration is the name of the game… you would have to be living under a rock to not be aware of junior doctors strikes, consultant strikes, GP surgeries stressed and in Wales reports that unless urgent action is taken the service is at risk! BMA NEWS
Here in Somerset there are overwhelming pressures but within our county there are leaders, GPs and practice teams driving change. The landscape at the moment is difficult but listening to a collective group of providers, patient representatives, voluntary sector providers at the Western Somerset Access to Health Care event this week in Dunster gave me hope. One service that you may wish to look at to help your patients, colleagues and friends is Open Mental Health.
There is some inspiration stuff in here and having seen the benefit that a male patient has had from this, it makes a difference.
Tough times mean tough choices but as Christopher Reeves said ‘Once you choose hope, anything is possible’ . For me this is about sharing our struggles and making time to discuss them.
For those about to have your summer hols with family and friends enjoy!
14th July 2023
Workforce – we all agree we need more of us… For those that have not had a chance to look at it the NHS workforce plan is out there and it is ambitious. There is some fantastic stuff in it at least on paper – the number of GP training places to increase by 50%, GP trainees to spend the full three years of training in primary care, experienced doctors to work in primary care (under the supervision of a fully qualified GP), all foundation doctors to spend 4 months in general practice and so the list goes on. Surely this must help …. I was left hoping so after listening to an elderly patient this week who needed to tell me at length that access to doctors was unacceptable and we must put the care of patients at the heart of everything - I could not disagree but we all know the pressures. However, the reality is that to provide the care that is needed we need more of us, for me the NHS workforce plan provides hope and perhaps a platform that we can use to turn the tide and inspire as many doctors as possible to be JUST A GP in Somerset. See Just a GP campaign and A behind the scenes look at life inside and outside the the surgery in Somerset.
Best wishes
Justin
30th June 2023
Just sometimes I think things will change… can you imagine a GP land where there is the time to see patients, have the resources to make meaningful change in our practices, time to reflect and learn and the removal of meaningless bureaucracy. Well that is the vision for the BMA as negotiations start for the 2024 GP contract. The BMA ‘Call to action for General Practice' hits the mark and filled me with hope. Have a look, because the BMA in due course will want to hear your views.
22nd June 2023
Professionalism…. we know how important this is but there are times when it is tested to the limit. In discussion with colleagues this week I was reminded (and experienced first-hand) the abuse that patients can give doctors and our staff. Some of this is nothing other than shocking and unacceptable, an article from The Guardian this week indicates that abuse of doctors in the UK is not going away. My reflections this week in speaking with colleagues is how hard our role can be but the importance of maintaining a level of professionalism at all times cannot be undervalued and the importance of sharing your experiences with colleagues.
The Medical Protection Society have historically produced some excellent guidance and the GMC is clear of the importance of professionalism in action.
Taking this seriously at all times will help keep us and our patients safe in tough times…
16th June 2023
E-mails that make you stop and think…. it is almost impossible to read everything but I was sighted on the fatal accident inquiry in 2001 of Emma Frame who died of adrenal insufficiency following communication from the ICB Medicines Management Team. The full report can be seen here and the lessons from the inquiry. While this case happened over 20 years ago it is still very relevant to our practice today. The array of medications that we are expected to consider in practice today is vast and perhaps one simple lesson for us all is just double check the dose before clicking and issuing!
9th June 2023
Planning normally helps…conversations about end of life care can be challenging and normally require dedicated time, space and considerable thought. We all know that it normally helps if you know the patient well and the family. Sometimes there is a need to have the conversation over a few consultations. It can be difficult and requires time, the latter being something we often have little of. The letter in the BMJ this week ‘Helping people plan end of life care’ just triggered me to reflect on some recent clinical encounters out of hours where I have met patients and families where the planning has been done exceptionally well and in other encounters where further documentation in EMIS or on the TEP would have helped. As GPs managing end of life care we have the opportunity to make a huge difference to those facing death and their families. The organisation Compassion in Dying may help some patients have the conversation and for us to remember these conversations can really help others be in control of their end of life wishes. They also help the doctor make the right decisions when they may have to visit at the weekend and overnight!
1st June 2023
Ethical challenges…. Sometimes these can be tough and having a framework can help. Often there is a relevant law or regulatory framework that we can rely on but there are occasions when things may be less clear cut. I found myself in such a scenario recently when asked to review someone who had rapidly deteriorated following a short illness. I found myself asking myself questions of ‘is this right’, ‘should I do this’. Simply if we are asking if something is ‘right’ or ‘wrong’ we are asking an ethical question.
The BMA have released a useful framework.
- Recognise that you are facing an ethical question - if so STOP and think!
- Identify the ethical components… what are the views of the patient.
- When necessary seek additional information… if the patient cannot give you the information then seek ways of obtaining their wishes, feelings and beliefs.
- Identify relevant legal or professional guidance… remember the law and GMC guidance is binding. While guidance may not be law a decision made in line with professional guidance is less likely to be challenged.
- Critically analyse the question… just think is your decision reasonable and defensible in the circumstances. Record how you reached your decision!
- Support the decision with sound arguments. Discussion with other doctors without breaching confidentiality can help but YOU need to make the decision and do so in conjunction with the patient as much as possible.
Try it out….
Have a good weekend.
Justin
26th May 2023
Share a story…. As GPs we do great things every week. Chest pain is one of those conditions which can be barn door in making a diagnosis but at other times it can very much be shades of grey. Mrs X was in her late 70s and over the weekend developed achy pains over her chest, she had called 111 and it was thought that it could be musculoskeletal but to seek advice from her GP! She did just this on a Monday morning. The lady had a very unremarkable past medical history with little risk factors. However, the GP took a detailed hx, undertook an ECG that showed small Q waves in the inferior leads only. The GP felt that despite the vague symptoms she needed hospital care and arranged an admission. Several days later is awaiting a triple bypass as an inpatient.
Many of us have had encounters like this, but it made me take stock and remember to trust your intuition and that ‘gut feel’. Some consultations just need a little more time and discussion with a colleague to get our thoughts together….
I have previously shared details of safe working in general practice – if you have not had a look dive in here because only by working safely can we take the time to provide the care we all want to give. Access to us is another issue, but we have provided an update this week and much more on that is to come.
Enjoy the long weekend …
Justin
19th May 2023
That person’s been on a course…. I am sure you know what I mean when someone at the practice has been on a course and the inspiration speakers that they have been with give them the belief that things can change. Along with some colleagues this week I had one of those days learning about the ‘Outward Mindset’. I was going to share the details in a few weeks but my discussion with some GPs on a team’s call from another LMC has spurred me to do so sooner. They were fundamentally angry that their local services were failing and that their general practices were being pushed to do more. They shared that the problems in their system were not really being honestly addressed. The call however, made me reflect on how we can only make successful change if we work together and how having an ‘Outward Mindset’ can help. Listen to how the Ford Motor Company turned around a 17 billion dollar deficit and a further brief video on what an ‘Outward Mindset’ is about.
Have fun...
12th May 2023
Contract changes…. Changes to GMS regulations on access come into effect from Monday the 15th May and the LMC has received a number of contacts from concerned practices. Within the update this week the Somerset LMC have been clear that this is essentially business as usual and only if capacity is exceeded should patients may be redirected to alternative services. Somerset GPs are leading by example and trying to deliver the best service they can, as a collective body within a responsible system. This week at the LMC we have poured over the primary care strategy, talked to ICB colleagues and considered how we can support practice resilience and generate data that can measure this. Embedding quality in primary is complex but it fundamentally does require an agreed strategy, a willingness to work together with appropriate funding.
Our primary care strategy is exciting and there will be engagement events arranged in the near future that will be an opportunity to share, challenge and shape this... watch this space.
Keep the faith everyone.
Justin
5th May 2023
System support… how often do you think that systems and processes are clunky in the NHS? Hardly a surgery goes by for me when I either cannot find the right form, have to question a referral process, have some IT issue or have to chase an administrative issue. The core medicine seems to be the easy bit! The daily administrative tasks can be a burden that add to our daily pressures. In our health systems we just see this on a larger scale. At the LMC we have been battling with the myriad of meetings that seem to appear based on local and national priorities and like LMCs over the country we often question why there seems to be a new hot topic that suddenly gains momentum to solve a crisis. The reality is that these are challenging times and the solutions are definitely not simple but I take solace from speaking to younger GPs this week who are starting to lead change and local GP leaders who constantly champion for a better general practice for tomorrow. We need our practices to be the best they can be and that is why at the Somerset LMC we are focusing on workforce, our resilience, services that support our patients and relationships. The editorial in the BMJ this week ‘Tackling the crisis in general practice’ is worth a read over coffee.
Until after the coronation ….
Justin
27th April 2023
A trust-based system... discussions this week were constructive between the LMC and the ICB on how contracts could potentially be amended to be less prescriptive. The Hewitt Review that was published earlier this month was an independent review of Integrated Care Systems. In brief it recommends that local leaders can focus on improving outcomes in their populations and how less national targets could help. A focus on treatment of illness rather than prevention is welcomed but will it be heard? If you feel like a peek see here.
Also a shout out for World and European Immunisation Week that has taken place this week from the 24-28th April. We know in our practices how hard it can be to promote vaccinations but the following links regarding measles may help some get vaccinated.
MMR vaccination, it’s not just for children
Think measles, it’s not just a kids’ problem
For those that have the weekend off, enjoy, recharge and catch up next week.
Justin
21st April 2023
GPC are on it….. at the LMC South West regional meeting this week I had the pleasure to listen to Richard Van Mellaerts, Deputy Chair of the GPC, and what was abundantly clear is that they are working exceptionally hard to get the best deal they can for general practice. Negotiating the final year of a five year deal was always going to be a challenge but imposed contract changes were not on the cards. The GPC asks were simple and clear: reduce bureaucracy, support the spiralling costs of running practices, move the PCN and ARRS funds into the global sum, remove the GP pay reporting requirements and have a phased roll out for the access to records, to name some of the most salient points. I think we would all struggle to find a working GP in Somerset who would not think that there was anything here that was anything other than very reasonable, but despite this the profession’s asks were not listened to. Representatives from the SW LMCs were aligned with the Deputy Chair, accepting that the government continue to refuse changes and are not supporting the profession at a time of crisis. The question is what next? We await details of the emergency GPCE meetings with the government later this month that will guide on next steps. While the national picture may be bleak I cannot imagine our health care system without GPs at the centre and the question I have is, ‘what do you want to see in the contract for 2024’? Please give it some thought, link through your LMC locality representative and make your opinion heard. We want to hear what you think and with our ICB, GP provider board colleagues and the leadership from all of you, make general practice in Somerset an even better place to be. I assure you I am not deluded, I genuinely believe that with our collective will we can and will survive in Somerset however, the status quo has to change. The plea from the Deputy Chair is join the BMA… For those that want to know more about the GPC plans have a look at here.
Happy Friday everyone.
Justin
14th April 2023
Reconsidering the value of the front door….. at the LMC we know it has been a tough week for many - especially for those practices that have had to cope without their junior doctors. I was fortunate enough this week to visit some local practices and I came away thinking how inspirational so many of our Somerset GPs are. Like all of us these practices have been battling with rising demand and workforce challenges but they have responded by addressing their front door and improving their triage capacity. They know that every appointment is exceptionally precious and as a team they have reflected on what is safe practice (see BMA Safe Working in General Practice Guide), re-evaluated what is urgent, created clarity through protocols, galvanised the team and driven organisation development. Just this week the BMA have updated their triage tools that many may find useful… have a look here.
Justin
5th April 2023
Had a few days off last week but back again with the MD soundbites….
This week has seen me reach out to some colleagues for support and it was greatly received. I saw an elderly gentlemen with a rather large mass, I have seen lumps before but this was rather unusual and I had that nagging thought of was I right in my differential. A niggling feeling of doubt came over me as I formulated the management plan. Having asked the patient to get some bloods, I then knocked on my colleagues door. ‘ Hi Charlie (not real name), can you give me a minute? I would really like your thoughts on the chap I have just seen, can you give me your thoughts ?’ ‘No problem Justin ‘. It felt great to share the plan and between us we addressed the issue and the patient was pleased. However, equally pleasing for me was the ability to be able to ask and know that despite over 20 years of being a GP every day is a learning day! Easter for many signifies new beginnings but regardless of your religious or otherwise beliefs perhaps we can take stock and recognise that each and every one of us needs support at times. As we move through the funding challenges, workforce difficulties, managing workload and thriving we must above all look after ourselves and create that culture of support. There are links in the update this week on safe working, take them seriously is my advice and above all make time for one another. Compassion for our patients is key but also for one another, a moving account of working in an ICU can be found in ‘ Life in the balance’ by Dr Jim Down. While general practice is not an ICU we frequently manage complex cases, often manage immense uncertainly, almost daily negotiate complex health issues and to do all of that we must help one another.
Happy Easter everyone
Justin
24th March 2023
Would you like a seat at the BMA table to negotiate with the government… I am not certain I would albeit that I would very much like to hear the debate. Or do you think it would be like the Tower of Babel which Mierles refers to as a ‘tower of incomprehension’, got me thinking this week when I had an inspirational discussion with a colleague.
The BMA have this week shared the letter that they have written to the Secretary of State – very good letter I might add. The BMA warns that ‘doctors are ready to act’ and is calling for the Department of Health to suspend plans to impose terms on GPs in England from the 1st April. This short video is worth a watch. At the LMC we have concerns that the contract focuses on access which we feel may be unachievable, we need reduced bureaucracy to facilitate direct patient care and support practices to cover rising inflationary costs. Hear more through the webinars.
While the debate lingers we have to thrive and I was inspired this week by some practice managers who I met. They talked of organisation culture and how they are trying to develop their place of work – impressive eh! We will be discussing this further at the LMC study day on the 12th Sept – date for the diary.
“A student of management and organisation theory could only be stunned by how little the efforts to improve quality [in health care] have learnt from current thinking in management and from the experience of other industries.” Christian Koeck BMJ 1998;317:1267–8.
Goodness we know the weeks are exceptionally challenging but I was hearted when I heard a patient leave a colleagues room this week and say ‘Thank you doctor – that was incredibly helpful’ to which the doctor replied ‘no problem at all, we are here to help’. If you have items that we can help you with get in touch somersetlmc.office@nhs.net.
Have a good weekend …
17th March 2023
Had one of those weeks… I expect some of you will reflect my sentiments of being rather battle weary as we approach the weekend but perhaps some of you may also have a feeling of success of a job well done. The junior doctor strikes have come and gone (albeit maybe more to come), the BMA are asking GPs to join national webinars about the contract and the outcome from the budget this week is that there has been meaningful change to allow us to work on … A useful update on the pension can be found here.
So, with pension fixed (well step in the right direction) the government hope that more of us will continue working – let’s hope so. However, with the national contract going to be asking for more around access targets (update sent last week on the 2023/4 contract) the LMC has started a programme to consider how we can address our workload. How do we evidence our value? Much like a clinical encounter - if it is not recorded it did not happen, we need data! Data that evidences our value and why we must ‘shout out’ about what we do. At a practice visit this week I evidenced first-hand how every clinical encounter is recorded – impressive. Have you ever been stung by a solicitor’s bill when they charge you for every minute! I am not suggesting that but I am saying we need to record what we do and therefore what we can stop doing…..
The LMC committee this week supported the use of EMIS enterprise and a programme for the LMC to work with practices to develop data sets that we can use to make meaningful change. Fundamentally, while we await national guidance on the Primary Care Access Recovery Plan we must consider what measures can we collect that will help? How do we get our practices in the best shape? What measures would help? Most of us would agree that direct investment in general practice is the best way for this government to improve primary care but if that is not coming how can activity be moved away from us? It is going to have to be before next winter and our models of care need to reflect this. No mean task. Your LMC committee are serious about change.
Just as our practices cannot manage every ask we as doctors cannot either. In the LMC update today Dr Catherine Ievers (MD) has shared some great links of setting limits in a limitless system. Thank you Dr I – great job, inspirational stuff.
Until next time
Justin
9th March 2023
Do we make a difference ….. well in a word YES (and a significant one). As GPs we really do some fantastic work but we absolutely do need the headspace. There have been a couple of clinical encounters with colleagues that have really hit home for me this week. A GP was talking to me this week about a patient who had been to A+E several weeks ago and had been very comprehensively investigated. Over a month later she had similar symptoms, passed through several hands and needed a GP to look at it again with new lenses and think! The symptoms had altered, the pain had changed, they were less well and needed specialist investigations – the conclusion was reached because the GP had had time to think and take the necessary action. Another colleague had reflected on how through a series of consultations managed to identify (facilitate via a translator) the real cause of a patient’s problem. This had resulted in an early diagnosis of a cancer and probably a life saved. However, if we do not make time to think and process we cannot manage these complexities. As GPs we are experts in managing complexity and steering a clinical course for our patients but we need time – I know in short supply! This concept of time has me pondering as I head back from listening to some inspirational speakers at the LMC Medical Secretaries Conference this week. We can no longer do it all. Yet many of us are still trying and burning out! Did you know that burnout increases the risk of clinical errors – perhaps by as much as 63%. While our national leaders are lobbying hard with government and developing strategies for our pressures to be heard and actioned we need local solutions. The Somerset LMC sent an update this week on the proposed national contract and while we await further developments (there is talk of industrial action) we must develop our strategy. What do you think about GPs taking industrial action? Please help us by being a part of this debate. Details of the webinars can be found here.
Our ambition in the Somerset LMC is to continue to attract high quality GPs, support practices to work safely and thrive. We can do it. However, our voices have to be heard and we do have choices! Choices was something that resonated when I heard Dr Rachel Morris speak today. Find out more here. More about this in the weeks to come.
In future my fellow MD Dr Catherine Ievers will be joining me with these soundbites so you be getting a double act ?. Let us know at somersetlmc.office@nhs.net what you are thinking.
2nd March 2023
Communication always seems to help…. I expect there are very few of us that have not experienced the incredible frustration of saying to a patient that you will refer them only to find that the referral may be blocked or there is such a delay that we have concerns as to how we will manage their care. I am unfortunately old enough to recall a world where I had met or knew the consultant colleague that I was often referring too - a system where I would collate together the results, history, and imaging so that my consultant colleague had the information that they needed. However, with our colleagues being able to access EMIS it seems rather odd that we need to be writing anything as all the details are on EMIS! This week I had the good fortune to be asked to meet with two ‘wise owls’ from general practice and secondary care to discuss how virtual clinics could help us manage our patients more effectively. This is being addressed in a small number of practices where a consultant cardiologist meets virtually with GPs to discuss patients and share the management challenges. Feedback has been very positive. GPs are reporting that they can obtain answers to clinical questions, it can prevent patients having to travel, improves timeliness of care and may I say helps us communicate and share uncertainty. The relationship between primary and secondary care has been much debated – an interesting article on this can be found here …. https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-016-0442-y. Would you like to see more of these types of arrangements? What specialities would work for you? If we are going to improve we really must consider how we collaborate and learn best from one another. Do share your thoughts justin.geddes2@nhs.net.
Somerset Medical Examiner System… at the moment as of the 1st April GPs will not be able to certify deaths without going through a Medical Examiner. This date will fast approach and is critical that everyone is aware of the process to prevent distress and delays in arranging certification. The relevant documents have been uploaded to our website. Do take a few minutes to be familiar with the process.
Until next time
Justin
23rd February 2023
Work to live of live to work…. unfortunately it is easy for us as GPs to feel compelled to serve our patients at all costs, and to lose our perspective on reality! The vast majority of us need to be working much smarter. Dr Andrew Tressider reminded me last week of the Yerkes-Dobson Performance -Stress Curve (p36)
Perhaps more of us need to not just hear this advice but start to listen and act on making change. This concept of change was a theme at the GPPB this week. We started to consider how as a board we can create meaningful action that enact realistic change. Workforce, Safety and Quality were key themes. The fundamental issue we face is that there is a significant mismatch between what we are expected to deliver and the resource that we have to deliver it! We all recognise this, we discuss it and we attempt to address it, but we struggle because like tomatoes on the supermarket shelves at the moment GPs are in rare supply! However, while we await details on national contract negotiations (no developments yet) the need for us to address what is within out control could not be greater. We all want to work in an environment where we ENJOY what we do – sound idealistic but we have to make it happen (at least most of the time). The battle to retain GPs: why practice culture is critical makes an interesting read! I was reminded of this this week when I reflected on how some clinical colleagues are adapting their role with their piers to create flexible working, working on areas of interest, having the lead GP for the morning working with staff and making time to talk and support. GPs will move to our county (they are) and our practices when we do a better job at taking time to set safe limits in our days, recognising that every GP is not the same, sharing our pressures and creating a culture where Somerset General Practice is the best place to be! The LMC continue to drive General Practice to be that Great Place, Great Potential – Transforming your work-life balance - let’s all do our part to promote it ?
17th February 2023
Sometimes people are not well meaning… be aware of ‘Fraudulent GP Contacts’. I would like to thanks Dr Joanne Nicholl, Designated Doctor Safeguarding Children and a GP in Somerset for the following information. ‘Over the last week it has come to light that there have been several hoax contacts through GP Practice’s electronic consulting systems. The person concerned claims to be a child or mother with children who have serious mental health and safeguarding concerns, who are new to the area and so not registered. They also mention that they are fleeing or currently in a domestic abusive relationship. They cannot be found on the NHS spine and when there are attempts to gain further contact details, they stop engaging. This leaves the practice concerned that there may be children at risk whom they cannot contact. It appears that these may be down to one individual who is known to the police and health system for making repeated hoax claims. If you have a similar case in your practice and are not able to gain assurance that either the patient is safe or it is definitely a hoax consultation, then you should contact the police on 999 or 101. The Police can trace the source of the consultation using the IP address of the person’s email. Please ask the Police to advise you of the correct details for the patient so that you can contact their registered GP (traced through the NHS spine) and alert them about this call. The GP surgery caring for this particular patient is aware of the huge amount of time and stress this is causing to an already overstretched system’. So, if you have such concerns please contact the police.
Overstretched but surviving this Winter…. The pressure continues and as Winter moves to Spring I think we would all recognise that demand remains high. The GPAS data continues to show that General Practice remains at Opel 4. The ICB will be writing to practices this week to share the final details of the Winter Resilience Plans. It will finalise the position that there will be £1 per weighted patient and this will be paid in February. Importantly, there is also the recognition that the commissioned level of Enhanced Access (60 mins per 1000 patients) can move to core hours. The LMC has also received contacts from some practices about 111 direct booking and while practices are encouraged to maintain these slots they may be triage slots before being booked to a face to face appointment. These negotiations have not been easy as the ICB have been constrained by the national team but the additional level of funding equates to £616k for Somerset. All parties recognise that Winter planning for 2023 needs to start now!
Viewing a body after death… Previously HMC has allowed a body to be viewed via video. The government guidance however, states that if a body needs to be seen after death that this is in person and NOT by video. Therefore HMC would like all GPs to revert to seeing the deceased in person after death. We have received an apology that this has changed again but this is the government guidance.
Inspiration from others….When having a coffee this week I was speaking with a clinical pharmacist on the management of a patient whose HbA1c had dropped despite the patient not taking their metformin (due to being intolerant) but having unintendedly lost some weight. This led to questions about which medication to use next and how their work as a clinical pharmacist augmented the management of long term conditions. They were a fountain of knowledge and make me reflect just how fortunate the practice were to have this skill set on their armoury. See Employing clinical pharmacists in General Practice to find out more and here for a diabetes refresher.
Have a good weekend.
Justin
10th February 2023
Stand your ground …. there has been some debate this week about whether GPs should take up the prescribing for certain complex issues. One of the areas of debate has been the prescribing for patients with transgender issues. It was a rather hot topic when we spoke about this in the LMC this week. Our advice would be that no clinician should prescribe anything in an area of medicine that they do not have the appropriate expertise or are comfortable accepting the consequences of the medication prescribed. More information is on the LMC website, including a GP letter template for NHS or private. As generalists we know a huge amount but if there are areas of clinical practice that you do not feel confident in prescribing our advice is don’t and seek advice. For more detailed guidance you can check out the GMC guidance.
Being a busy bee is admirable but even bees need to rest! Yes, GPs and our staff and colleagues are busy but we need to find time to think. Previously I have highlighted the importance of safe working in general practice but as a practice and clinical team do you need to do more? Just because your work patterns have always been set in a particular way does not mean it has to stay that way. There is clear guidance from the BMA - perhaps dedicate some time to consider the implications for your practice. Everything flows from creating a change to the historic cultural shift of the self-destructive urge within some practices to continue to work harder and longer to meet patients’ needs. Set some limits to be safe!
This cultural shift was a focus at an LMC away day this week. More on that in the coming weeks but our vision is
‘To encourage and support General Practice to be safe and sustainable in order to thrive’.
Yes, safe and sustainable! Many of you will be aware that the Springmead practice will close later this month, we do not want any more. Just like many of you the LMC team are feeling the pressure and we have to change how we work. We could not be more committed to supporting you but we do recognise that we have to focus on what will have the biggest impact on making your working lives as good as possible. This is why we have been committed in obtaining Winter Resilience Funding and creating meaningful actions with the ICB. We have seen the final proposed position from the ICB which includes £1 per weighted patient but we are disappointed with the time that it has taken for the ICB to reach their conclusions. We do not believe that they are doing everything they can to support us. Fundamentally, we are still not in a position to clarify how EA slots can be moved to core hours or how available locum capacity will be shared. The ICB would like to release payments to practices as soon as possible, which we welcome - they will be writing directly to you all shortly about this.
If you are off next week due to half term have fun and for those that are not catch up next week.
Justin
3rd February 2023
Not all doom and gloom! Well we have made it through the first and in my opinion the bleakest month of the year so well done! It is hard when every day there is more doom and gloom about our health system – I am not going to list them you will be glad to know… I was reflecting on patients being able to self-refer to specialists and bypass GPs. At the practice this week over coffee we were discussing someone who had surgery 12 months ago and was passed between specialists for multiple tests and scans without taking a holistic look at the whole problem. As GPs we are experts at managing these types of problems and was therefore pleased to see that the BMA have spoken out about self-referral and some of the pitfalls that it may bring, see link. The health
