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The Big One

Friday 10 May 2019

With only five days to go until the deadline for new Primary Care Networks (PCNs) to submit their applications to the CCG, there’s been considerable activity around the county with most areas sounding to be making good progress. It’s important to remember that the submissions aren’t necessarily cast in stone and can be amended later. Inevitably there have been unforeseen (and many foreseen) complications with the new contract arrangements, particularly in relation to the employment of staff, and there are national representations going on behind the scenes trying to find a way through these. Some networks are not immediately intending to employ extra staff, at least until the picture is clearer, but using the new arrangements as a way of working more closely with their neighbours and improving links with community services, in an effort to shore up Primary Care.

We heard at our LMC County meeting last week that most areas have now identified their Clinical Directors, which is an important step as they will have a critical role in linking the networks and dealing with the wider system. The GP Board is meeting next week and will be discussing how the CDs can form a significant part of a new overall ‘umbrella’ organisation for Primary Care providers across the county.

We had a full calendar of meetings last Thursday that we shifted around so that Barry and I, along with a CCG colleague, could attend the meeting in Bridgwater to determine the configuration(s) of the local PCN. Facilitated by the National Association of Primary Care (NAPC), clinicians and managers from the practices sat round in a giant circle discussing the various options and configurations that might work, using large sheets representing the practice units and their populations. At the end of the morning, we voted to go forwards as a single entity. Although many of us in the room remembered how we used to work more closely as a Federation, others had arrived on the patch more recently and what emerged loud and clear was how open we all need to be in future discussions, and I believe (and hope) that everyone came away with a better understanding of what mattered to every other practice represented there. The meeting was held at the YMCA, whilst a senior citizen’s group played badminton downstairs, and moored to the canal pontoon outside the building were two large vessels made up of canoes lashed together to form a self-propelled catamaran. One was red, the other blue, and I suspect that the NAPC team might have been planning to schedule some sort of ‘paddle-off’ had we failed to resolve the matter without assistance.

We would have backed ourselves to sort it out. Bridgwater has significant history of joint working, even before the practices got together to form only the second out-of-hours co-op in the country sometime in the last millennium. There was a time when relations between the two large town practices were strained, often for what would appear now to be trivial reasons (a contentiously worded sign, for example). I arrived at East Quay as a GP trainee in the summer of 1985, and the most egregious incident that year was during a Bridgwater Doctors cricket match when a certain young and enthusiastic doctor called the senior partner of Taunton Road Medical Centre through for a suicidal single, running him out before he was able to reach his highest-ever score for the team. The two doctors became respected colleagues, however, with one replacing the other as Bridgwater constituency representative for the Somerset LMC. Fancy!

We recently concluded negotiations with the CCG regarding the Local Enhanced Services and the PCIS (Primary Care Improvement Scheme) element. After significant and detailed discussions, the best minds at the CCG are now trying to convey the content and intent in a suitable form of words, and practices should see the final contract shortly. There will be additional investment for practices in return for limited additional service provision, which the LMC feels is achievable, certainly within the spirit of the contract as negotiated. One of the CCG managers told us recently that a colleague had said that the only thing harder than taking money out from primary care was putting money into it. I can see how it might appear that way sometimes, but in times of stress we need to make sure that what is asked of colleagues is achievable, an agreed priority, and most of all, that it makes clinical sense.

On Wednesday, the media was full of what we’ve known and been shouting about for years- the decline in the number of GPs, and the difficulties that can result for patients trying to book appointments. The analysis by the Nuffield Trust showed the number of GPs (headcount, not WTE) had fallen from 65 per 100,000 in 2014 to 60 per 100,000 last year, a rate of decline not seen since the 1960s. I’m not personally doing anything to help the situation, as from this week I’m reducing my personal contribution by 50%. Today is the first Friday of the rest of my Fridays.

Hitherto, I’d be at the coalface enjoying jocular jousts and brain-picking with m’colleagues Barry and Jo between patients, and the croissants brought in to celebrate the end of the week by one of our lovely nurses. I’ll miss all that, of course, but new challenges await. This morning, I’ll mainly be popping into the station to pick up an application for my senior rail-card, and then I’m off to M&S, to have a sit on the chairs just inside the door. Once I’ve finished the Express and feel suitably updated on statins/pensions/house prices/immigration policy and Brexit, and scared a few passing children, I’ll shuffle upstairs and buy myself a pair of those fetching shoes that look like pasties and fasten with Velcro. Meanwhile I’m constructing a list that I’ll take along to my GP outlining all the exciting medical complaints that now become financially viable to own up to, at least from my perspective. Brace yourself, Tim.

I’m not sure yet whether I’ll have any money. The NHS Pensions Agency are not the easiest to deal with. Colleagues may be aware that NHS GP Pensions are handled by Primary Care Services England, outsourced to our old friends Capita, who are doing their best to justify that additional ‘r’ we like to bestow on them. Here’s how it works when you’re planning to retire: at least three months before you know you’ll have had enough, you download form AW8 to apply for your pension and jettison it back. It’s fairly straightforward, unless you’ve had a nibble at a private pension pot, in which case a bit of extra maths is needed.

Two weeks after I’d sent in my application, the Practice Manager received an email from the Pensions Agency’s ‘no-reply’ address asking if the date I wanted to take my pension really was the date I’d put on the form, Friday 10th May 2019 - my 60th birthday - and the date stated on every bit of paper I’ve ever had from them?

She tried to reply, but no, they wanted to hear the news directly from me. Fab. It would have been far too simple to reply ‘yes’ to the email (it’s ‘no-reply’- cunning!) but instead I had to log onto the PCSE website and send them a query quoting my reference number. But which one to choose? In recent months they’ve sent me documentation referring to me as CAS-1522993-P9W7Z8, CAS-1522992-P9W7Z8, or CAS-1570974-H1T5V2. There’s another number on the emails as well- which do you think suits me better- CRM:0228001707 or CRM:0228001958? None of these bear any resemblance to my scheme membership number, which surprisingly doesn’t appear anywhere in the correspondence, presumably to prevent confusion.

There was nothing to let me know whether my message got through, but the site states (helpfully) that any queries will be answered within 30 days. It all went quiet, and then six weeks later, out of the blue an email arrived with a different reference number and a worrying theme about ‘opening a case’ and ‘working hard to resolve this issue’. Whisky, Tango and Foxtrot. Was there a problem? I thought twice before logging on again and sending a narky query- the level of nark judged to reflect my growing frustration/concern, whilst recognising that for now at least, they still have a firm grip on my lump sum.

The result has been further frayage in the synapses, and the popping of what few syllogistic rivets remain to hold my sanity together. I wasn’t holding out much hope of things going to plan until last week when I received a welcome letter from them, addressed to me by name and written on real paper, suggesting that they’d been teasing all along, together with the promise that Mrs Chair and I will wake up tomorrow morning to a pleasing tumescence in our joint current account.

‘Chez Chair’ is braced for an exciting event sometime in the next week and I need to buy a shedload of lavatory paper. For now, I don’t want to jinx anything by telling you why, just that it has nothing to with a birthday curry party tomorrow evening (hopefully), or indeed anything to do with senile potty problems. I’ll reveal all next time.

Old Nick (aged 60 years and 3 hours)

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