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Sticks in the Sand

Friday 4 January 2019

Whisper this quietly but it seems that the system overall, at least using the parameters that the NHS likes to measure, such as A and E and 111 performance, ambulance handovers and bed occupancy, has coped significantly better this Christmas than it did the last. Not surprising, perhaps, given how dire things were last year and the milder weather we’ve had recently. But how was it for you, out in the real world?

Maybe it’s to be expected as I get older, but Christmas is more of a struggle now than it used to be. The calendrical gods were kind to me this year, wiping out two Tuesday duty days; the LMC office was closed for the week, and there were no meetings with the CCG, the Trusts or anything to do with the ongoing Health and Care Strategy Review. I still found myself hinged upright in the middle of several nights worrying about what was, or might be, going on out there, but generally it was quiet. Too damn quiet.

We all need structure. My faltering synapses are easily bamboozled these days, especially with fewer reference points around which to hang the week. Effectively ramming four weekends into a fortnight, most of it spent in the mid-winter permagloom, is going to play havoc with any unsuspecting circadian rhythm. Garnish that with double the normal calorie intake, perhaps an extra unit or six of the hard stuff, and it’s not hard to understand why January comes as a relief to body and soul alike.

I don’t much like the build-up either. I’ve always railed against Christmas music (especially Johnny Mathis) in the waiting room, not only to protect the sanity of the staff, but because Christmas is a difficult time for many of our patients. We always hold the surgery ‘Secret Santa’ thing in the local hostelry over the last workday lunchtime before the break, with a lone GP and receptionist running the afternoon show until closing. Nobody wants to see their doctor on Christmas Eve unless there’s something seriously amiss either above or below the tentorium, and usually it’s a quiet afternoon. On my last such session, I shared my Secret Santa novelty chocolates with the receptionist as we watched ‘Bedknobs and Broomsticks’ together, before pondering how to fill the last few hours until stumps.

I found a list of those who’d died during the year, and spent an hour or so phoning their partners to ask how they were getting on. It was draining emotionally, didn’t do anything for our QOF score, or anything to light up any performance monitoring dashboards in the CCG, but it felt to be one of the most important sessions of my year. That’s a problem for us: so much of our most valuable work just can’t be measured. Any idea how many patients you kept out of hospital last week? How often did your knowledge and ability or willingness to bear risk save your brood from unnecessary investigations or potentially harmful hospital admissions?

I thought about this again recently when reading a well-written article by Dr Phil Whitaker ( in which he describes the value that GPs bring to the system, built on their knowledge of the family and management of risk, and how continuity of care is so important to the system. He describes how the change in balance of partnership and salaried GPs could affect this, and his hopes for the outcome of Nigel Watson’s Partnership Review that should be reporting later this year.

There’s widespread acceptance now that a flourishing Primary Care is absolutely critical to the future of the system as a whole, and there’s an important meeting coming up at the end of the month where the CCG are inviting all the main players in the local health system to discuss what the provider landscape for Primary Care should look like in the future. Many practices will be perfectly happy to continue with their current arrangements, and become involved in the development of their local ‘neighbourhoods’, however that might occur. Others, for a variety of reasons, may be looking to integrate either with another practice or with one of the local Trusts. We have examples of each situation already in the county, but what happens if, say, one of the Trusts starts to dominate the provision of Primary care? What controls, if any, should there be to balance the landscape? Does it matter if we end up in a truly Integrated Care System? Practices are still private businesses at the end of the day, so what say, if any, should the CCG have in how they decide their future plans? How will this be affected, if and when the CCG becomes gets full delegation of Primary Care commissioning from NHS England? The LMC, the GP Board and Somerset Primary Health have all been invited (as you would expect), and we’ll be discussing what the LMC approach should be, and how we can adequately reflect the interests of all our constituents at our county meeting next week.

Having reliable reference points is more important than just getting an old lag like me through the festive season. As part of the ongoing Health and Care Strategy Review, I attend the Acute Settings of Care group, whose remit is to discuss which hospital services should be provided in the county, and at which sites. We have two relatively small acute Trusts, geographically separated and serving mixed but predominantly rural populations. You have to have some fixed points, or sticks in the sand, around which to build the rest of the system. There is a general expectation that there will be two Emergency Departments in the county, for example, around which other services such as acute medicine and critical care would need to sit. But it gets more complicated when you start to consider what’s happening over our boundaries. If Dorset are moving their acute stroke service to Bournemouth (historically part of Hampshire!), does it matter if the only one in Somerset is in Taunton, or should Somerset have one at all? Does the extra travel time get compensated by a 24/7 rota in fewer and more distant centres but with appropriate expertise? How do we take account of what’s happening across the borders in Dorchester, Bath, Weston or Exeter? It’s trickier than it looks, or maybe not.

There was carnage in the LMC office when I arrived yesterday morning: cabinets and cables scattered everywhere, and worryingly, the feet of a prostrated ex-Medical Director poking out from under a stray desk. Happily, that turned out to be ‘ex’ in terms of past role, rather than post mortem, and Harry, who’d popped in to clear some cupboards, had been ordered to get on the floor and sort some wiring out. The office is undergoing a New-Year revamp and expansion to reflect the increased workload of the team, with Jill and Barry moving to a neighbouring room. I’m not sure where I’m going to be sitting yet, but it’s essential that I’m still able to exchange sotto voce insults with the Medical Director.

I’m braced for another appraisal next month, and this year have a new appraiser, having worn the last one out. But what to put in my PDP now that I’m 59 and 9 months old? What really excites me or could enrich what remains of my working life? In recent years, the balance of my PDP has subtly shifted to become less clinical and more lifestyle-focused, appropriately so when the greatest problems I face at work are not so much what’s wrong with the patient in front of me, as why can’t I bend my knee, and why have I come down to reception- again? This week I’ve come up with an idea that will see me busy and interested, at least for a few months, and keep Mrs. Chair in smart shoes and fresh frocks, should she so choose. I don’t know whether or not my new appraiser reads the blog, but I’m happy to push this out there to see if it floats, in every sense. I’m thinking of going into the ferry business.

You might have heard that HMG has awarded a ferry contract worth £13.8 million to a company- Seaborne Freight- that hasn’t got any ships, or indeed any maritime experience, to provide an emergency ferry service from Ramsgate to the continent in the event of a no-deal Brexit. The company is apparently a new British ‘start-up’, and has all of £66 worth of assets listed at Companies House. Understandably, there’s been a bit of a stink in the media, and I wouldn’t be surprised if Chris Grayling was forced to go to re-procurement. Well, I’m ready and willing to pitch in for half that amount. I’ll bet I’ve got more nautical experience and skipper’s certificates than anybody in that outfit. Moreover, I know exactly which cargo and drugs that I’d be bringing in as a priority after March 29th (chocolate and antidepressants). I understand that Ramsgate harbour needs a bit of dredging to clear the channel, but having grown up on Woolacombe beach, I’m also a dab hand with a bucket and spade.

I’ll get round to marking it with conventional buoyage in time, but for now look for the sticks in the sand.


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