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Strops and Spots

Thursday 4 August 2016

The locum situation, previously merely dire, is now as critical as it has ever been. We know from the locum agency that there are hundreds of locum requests for August that they will be unable to fill. Not only are exhausted doctors unable to take much-needed leave, but it has also meant some of us haven't been able to get away to attend important meetings that crop up these days at increasingly short notice. It's becoming a real problem getting proper GP representation if we can't escape from our practices. The tight time-frame demanded by Simon Stevens for delivery of the STP has meant weekly meetings being arranged during August. Our practice manager made a gentle enquiry of the agency to see whether there was any possibility of a locum- she was told in no uncertain terms that there was no chance, and why do people arrange meetings in the holiday season in any event? The reality is that we simply can’t afford the luxury of waiting for things to calm down- it’s not going to happen- the whole thing is built on quicksand, and sinking.

Our Harry has been on fire this week- thankfully in the literary rather than literal sense, given recent reports on emergency service response times. He copied me into an email he'd written to the commissioners about some recent ambulance issues as blogged last time (and another horror story received since). Even by Harry's impressive standards, it was a masterpiece, his elegant prose corralling his targets gently into a corner, before skewering them with a withering final paragraph. I wrote back to express my admiration, and to enquire whether or not he might have made an early start on the Old Speckled Hen? Apparently not. He told me that he was just "tired and stroppy", which made telling it like it really is that much easier. It did occur to me that if we were to sneak Harry back onto the Performers List, not only could we make a titchy but valuable dent in the locum situation, but we could also ensure he was "tired and stroppy" most of the time.

One of the more enjoyable meetings in the LMC calendar is the quarterly get-together of the South West Regional LMCs, which was held last Thursday. Historically Somerset has always organised, hosted and chaired the meetings, which bring together the LMCs from Cornwall and the Isles of Scilly, Devon, Somerset, Avon, Gloucestershire, and Wessex. Like our county meetings, these used be held at Lyngford House before it was sold. We flirted briefly with the Holiday Inn, and despite its obvious convenience for the motorway, it fell down on nearly every other count, and so we now hold our county and regional meetings at Taunton Racecourse, where the going is good, the refreshments better, and the view exceptional. The regional meetings are a useful opportunity to hear first-hand from other LMCs about how they are trying to make sense of the current challenges in the NHS. Not only are there some very experienced and wise old lags in neighbouring counties, but also several members of the GPC, who are often able to give more insight into what is going on behind the scenes. We were just having a cryptic briefing about the planned indemnity top-up scheme, as the news was being broken by Pulse on Twitter.

At our last SWLMC meeting we had heard some worrying things about appraisal documentation, and in particular how confidential it actually was. There was an instance where a CQC inspector had asked to see appraisal material relating to a GP in a practice, and in another county, appraisal documentation had been used in a performance review. We needed to get some clarification and reassurance and so asked Dr Caroline Gamlin (the RO for our Area Team) to attend our meeting. We spent some time discussing the fact that appraisers are now encouraged to upload all the information centrally (and to inform the appraisees of this). She and her colleagues are about to produce a "Statement on Appraisal Confidentiality". We saw a draft version, which included the advice that doctors should NOT include anything that might be considered personally or commercially sensitive in their documentation. I suspect this might come as a surprise to some, who might have assumed it would merely act as a trigger for discussion during the appraisal itself. I confess that I usually hide at least one bombshell somewhere in the text, if only to check that the appraiser has actually read the whole thing through. We had also invited the complaints team from NHS England along, so they could hear from us just how dysfunctional the process could be, and the effect that it was having on practices and those working in them. Having spent a significant chunk of the meeting with our special guests, it was going to take a brilliant Chair to get the rest of the agenda finished in time for lunch.

We discussed the last 3 or 4 items between mouthfuls.

You might have read that the BMA is now advising doctors NOT to sign forms for firearms certification, but only on the basis that we are not able to charge a fee for this. I'm not sure that this really helps. Apparently the BASC (think of it as a rustic version of the NRA, in tweed) has told its members not to pay any fees that GPs might request for signing the forms. You can imagine the headlines in the Daily Wail if one of our patients chose to run amok, and it turns out the GP failed to inform the police on the sole basis that they weren't being paid a fee. I feel our best response if we're not prepared to sign the forms, is still to refuse to comply on the basis that we're being asked to confirm that our patients don't have a number of conditions that would make them unsuitable, including personality disorder, the diagnosis of which is beyond the ability of the vast majority of jobbing GPs. At least the system now demands a medical certificate before a licence is issued, unlike before.  Should you decide not to sign the forms, they should be returned, using the template letter designed by Devon LMC if you wish, as soon as possible.

We also had a meeting last week with the Director of Public Health (DPH), during which she told us that there are several outbreaks of measles in the region, and I’ve since heard from a Somerset colleague that she’d admitted a child with probable measles encephalitis. We discussed what you should do as a GP if you see someone you suspect of having measles, and in particular the issue of quarantine. How many of us older GPs know our measles immunity status? I'm not sure if portraiture was part of the core contract in 1962, but somewhere I have a drawing penned by my GP, who visited me at home when I was in bed with the big M. He's waving cheerily from the front path before getting back behind the wheel of his Triumph Herald. I look on from an upstairs window, my face flecked with red biro, with a thermometer poking out from my mouth at a jaunty angle. Astonishingly, the DPH tells me that this wouldn't constitute sufficient evidence to confirm I have measles immunity. I was just making a mental note to check what the correct procedure would be, when our brilliant and knowledgeable Vice-Chair informed us that she'd just diagnosed somebody who'd arrived in Somerset from Costa Rica with Zika virus, complete with typical symptoms, a rash, and the resulting implications for their sex life. Gosh. I was impressed and intimidated in equal measure, and could feel a significant DEN coming on. Normally, I’d be dobbing myself in on my PDP as an exanthematic dunce….

Maybe this year I won’t.

Nick Bray

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