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The Blog Cycle

Friday 4 August 2017

Let's start on an upbeat note. We had an encouraging meeting yesterday afternoon at Monk’s Yard to discuss the further development of the Somerset GP Board (Team GP). The overwhelming majority of the feedback we’ve had so far from the rest of the Health and Social Care system locally regarding the SGPB has been positive. We had invited representatives from the LMC, SPH, COG members, Federation chairs and other local GP leaders to discuss wider representation on our board, and to discuss the specifics of how the board should work. We’ve got to ensure we become the authoritative and respected voice of Primary Care, at least in the STP process initially, and communicate effectively with everybody, not least our local practices. We’d picked the date and time of the meeting from three options using a doodle poll, and inevitably there were quite a few people who couldn’t attend, given the time of year and relatively short notice.

I’ll admit to feeling somewhat apprehensive before the meeting, given some concerns we’d heard and that needed to be addressed regarding the make-up and geographical representation of the group, but I think we aired these and identified a few elephants as they lumbered past. We’re never going to get a completely united view from anything more than a couple of GPs about anything, and given the well-advertised constraints we all face, we can only strive to do the best possible. However, the attitude of those around the table was positive, and I sensed a steely determination that the perceived current ‘limbo’ status in other parts of the system should be seen as a major opportunity for us to establish ourselves, rock-like, in the middle of the STP process. Any sailor will tell you it’s always a good idea to know your rocks before you set out on a voyage: they can be valuable navigation aids, but ignore them at your peril. Colleagues should be heartened to know that there are some knowledgeable and motivated individuals all around the county, doing their best to support and strengthen Primary Care. We plan to ask the LMC reps to discuss the SGPB with their constituency practices in the near future, and in a week or so we’ll be presenting the SGPB to the STP Programme Executive Group, with the clear intent that we can have an influential role at an earlier stage in the process, and avoid a repeat of a recent scenario where a paper that could potentially have a significant impact on Primary Care (Discharge to Assess) got waved through with no significant input from any front-line GPs.

In an unwitting effort to become even more empathetic with 51% of my patients, starting last May, I’ve come over all periodic, albeit on a 14-day basis. That’s half a synodic month, or 1.4 Scaramuccis, my favourite new unit of time. Day one is a Saturday, the day after the blog is done, dusted and dispatched, and I know I can relax for a week or so before I have to start thinking about what might be blogworthy and suitable for the following week. Usually there’s at least something I can pin my hopes on, but if not, my blogger blues will start to build until I’m in full blown PBT by the latter half of that second week. At my ‘time of the fortnight’, I’m told I can be distinctly tetchy to live with. Whatever the date, however, working in the modern NHS means we have to be braced and ready to cope with the ridiculous, whenever it might strike.

Take last Friday afternoon; we were three GP sessions down for the day with two regulars away, but it had been manageable, bar a couple of ‘off-legs’ and sepsis admissions, before I hit the buffers. It started with a simple email from the practice manager at 3:14pm. One of the partners had made a referral to CAMHS of a young patient recently registered from another practice. His referral letter made mention of a potentially serious incident in the past and he’d written that he didn’t think it had been referred to the police or social services at the time. CAMHS had phoned the practice manager saying that we needed to inform the safeguarding team about this historical incident. Not tomorrow or when he got back from holiday, but now. My esteemed colleague was and still is on leave munching his way through the Channel Islands’ crustacean stocks, I’ve never met the patient or even heard the name before, and so this was hardly a welcome additional task in the middle of a busy Friday afternoon surgery.

Being an excellent GP, my colleague had included in his referral letter the mobile number of the patient’s support worker. I dialed the number more in hope than expectation given that it was a Friday afternoon, and was pleasantly surprised when it was answered. Even more so when she said that yes, she remembered the case well, it had been reported to safeguarding and investigated, but it was decided that no further action was necessary. With a massive sense of relief, tempered with a shard of irritation that the CAMHS worker could have made the same call, I relayed the joyous news back to the PM. Within a few minutes a further email arrived. CAMHS had been duly informed, but were now insisting that I also refer her myself to safeguarding that afternoon, and furthermore, they would be phoning the relevant department after the weekend to check that I had done as they suggested. I sat staring at the screen in disbelief for at least a second or two, before phoning CAMHS to, er, express myself. The anger was still bubbling when I arrived home, and I was still only on day seven.

This week I was called to see an elderly patient in a local nursing home and asked to sign a ‘verification of death’ form, enabling the nurse to declare life extinct. There are several bits of this process that I struggle to comprehend. Most registered nurses seem pretty adept at relaying patient observations, and you’d have hoped that by the time several of these are registering zero, they might have an inkling of what’s going on, especially if they’ve also been on one of their special courses to further refine their talents. I assumed this was a transferable skill, and I’ve never understood why they have to be signed up to do it for individual patients. We’re only asking them to verify death, not issue a certificate as to the cause. The Coroner tends to want to know if a death is unexpected and we can’t help with a certificate. That aside, what is the possible rationale for our having to re-sign the form for the nurse every 14 days? Good clinical practice means that you’d be reviewing any patient in this situation at least once a fortnight (if only for certification purposes), and it’s hard to envisage a circumstance in which you’d suddenly lose confidence in an individual’s ability to recognise the expected death of a particular patient, unless of course you’d taken a frantic call from a spooked undertaker in the meantime. I remonstrated briefly with the nurse on duty, unfairly so as it clearly wasn’t her fault and she was just following orders, but when you try and get to the bottom of nonsense like this, nobody can ever tell you who is responsible, or more pertinently, who has the authority to put it right.

A colleague in Minehead was contacted this week by the speech and language therapists, who had seen one of his patients referred with a speech problem, but who had also turned out to have swallowing difficulties, requesting a further referral (to them!) to allow them to start an assessment for that. There are many such examples that drive us all bonkers, and given that we’re generally all very busy, it’s often quicker just get on and do something (the JFDI option), rather than getting into a protracted discussion/argument to try and arrive at a definitive solution. Please do send examples like this into the office, and I’m pleased to say that the LMC and SPH together are developing a desktop tool that that will enable more effective collation of examples where the new hospital contract terms, designed to reduce additional bureaucratic burdens on GPs are not being adhered to.

Before we left the meeting yesterday, Jill showed me a team photo of the latest bunch of radiant Somerset GP registrars, who have just qualified as fully fledged GPs. They look a promising and enthusiastic bunch, and we know that quite a few are staying to work in Somerset. I was feeling happier as I left Monk’s Yard and headed north to tackle the weekly Violent Patients slot in the surgery. It was a fairly typical VP session; I finished my paperwork, the receptionist read the paper, and the security guards gorged on our best biscuits, before we all called it a day and went home.

Not bad for day 13.

Nick Bray

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