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The Rime of the Ancient Physician

Friday 27 September 2019

It is an ancient Physician,
And he stoppeth one of three.
'By thy nervous tic and trembling lip,
Behold the CQC.
The protocol files must be opened wide,
We’ll peer in every bin;
The inspectors have met, the schedule set:
Let the bloody ordeal begin.’

Apologies for coming over all Samuel Taylor, but it’s been quite a fortnight. I’m still hyped after two brushes with the CQC last week, and at the weekend Mrs. Chair and I enjoyed a ramble along the fabulous Coleridge Way. On Wednesday we held the second meeting between the GP Board and our Primary Care Network Clinical Directors (CDs), and then a GP Board meeting the following day, all against the increasingly frenzied backdrop of imminent and significant contractual changes for North Petherton Surgery and our staff, Artex® issues notwithstanding (don’t start me).

This episode was always going to feature the CQC. The LMC has been concerned for some time about what appears to be a change in approach from the regulator, with increasingly stringent inspections and a sense out there that the goalposts had shifted. Perhaps too many practices had been rated as ‘good’ or better? This isn’t just a Somerset problem: we understand that the GPC had heard similar reports from all over the country and were planning to take it up with the CQC at a national level. Of course, the CQC has a legal duty under the Health and Social Care Act to regulate Primary Care, as it does the rest of the health and care sector, and so has a job to do. The LMC would never condone poor care in whatever form that takes; there will always be services which need to change or improve, but we must have consistency across the system, and proportionality.

Registered Managers receiving notification of inspection are invited in the same letter to peruse the ‘Key Lines of Enquiry’ section of the CQC website, and they may stumble across another, ‘What does inadequate practice look like? All examples from our GP inspections’. Be warned: they are not a comforting read, and unless you have a whole fleet of staff already buffing the protocols, audits and curtain rails, you might feel tempted to dob yourself in immediately to the CQC, thereby cutting out the middle man/woman, and while you’re at it, removing yourself from the performers list, to save anybody else the trouble.

As the fabric of General Practice is stretched increasingly tight and starting to fray, misplaced or overzealous scratching and digging by inspectors can risk the whole thing falling apart, and an adverse CQC inspection will have a calamitous effect on the morale of staff and the recruitment prospects for a practice. We know of GPs who have timed their retirement to avoid the stress of another inspection. With this in mind, it’s been helpful to establish regular meetings with our local inspectors, and our latest gathering was in the diary for last Thursday.

By chance, and as a result of something I must have said/not said on our Annual Regulatory Review call, the CQC had scheduled a visit to Pethy the previous day. We’ve heard that many more visits are being arranged after the ARR calls than the CQC first anticipated- it’s not really clear why. Although we were prepared, or as much as it’s possible for a small practice to be, I was still anxious about the outcome, not least worrying about how it would look if the LMC Chairman’s and Medical Director’s practice was summarily shut down, although at least that would have provided easy and incendiary blogfodder, so not all bad.

In the event, the wind was somewhat taken out of our sails for the LMC/CQC meeting. The inspector and doctor (there were only two on the team this time) were friendly and supportive, whilst at the same time acting thoroughly and fairly to get the information that they needed to satisfy their enquiries. None of the staff they spoke to had felt intimidated, and the verbal feedback at the end, whilst not perfect, was generally positive and encouraging, and we hope will be reflected in the final report when it arrives.

There’s still perceived inconsistency in approach between inspection teams, as witnessed by colleagues who’ve had a number of inspections across multiple sites. When we meet at the LMC, the CQC have always sought our views and feedback, and recognise that there are aspects that they need to improve, not least their website and ‘Provider Portal’ (breathe, Nick, breathe). We consider our relationship with the inspectors to be generally constructive, but the LMC will continue to ‘ride shotgun’ on CQC inspections if practices wish us to do so.

I’d thoroughly recommend the Coleridge Way. Mrs. Chair and I walked the classic 35-mile route from Nether Stowey to Porlock, staying in two excellent hostelries along the way, the Notley Arms at Monksilver, and The Royal Oak at Luxborough. There are longish climbs in places, but the scenery is stunning, even to an old lag who’s lived in Somerset for most of his life, and ranges from ancient woodland paths and deep valleys to open Moorland.

Samuel Taylor Coleridge moved to Nether Stowey in the last years of the 18th century, and he and Wordsworth (who’d moved with this sister Dorothy to Alfoxton to be close to Coleridge) would often be out walking together on the hills, covering vast distances by day and night. According to a contemporary account, they were an unlikely couple: Wordsworth was tall, gaunt, purposeful and elegantly pantalooned, whilst Coleridge, tubbier and with ‘jutting brows, thick lips and bad breath’, was usually zigzagging ahead. He apparently preferred composing his verse on uneven ground, ‘or breaking through the straggling branches of a copse-wood’, feeling that it helped his poetry. Hmm- that’s as maybe, but he was famously off his rocks on laudanum- a tincture of opium- for much of the time and that probably influenced him more. You don’t plough through Kubla Khan and attribute it’s other worldliness to it all being a bit boggy underfoot.

In a letter to a friend, Coleridge describes his experience of taking opiates, although it’s widely thought he first started taking them as a young man for ‘nervousness and stress’:

“I was seduced into the ACCURSED Habit ignorantly – I had been almost bed ridden for many months with swelling in my knees – in a medical journal I happily met with an account of a cure performed in a similar case … by rubbing in of Laudanum, at the same time taking a given dose internally – it acted like a charm, like a miracle! … At length, the unusual stimulus subsided – the complaint returned – the supposed remedy was recurred to – but I cannot go thro’ the dreary history – Suffice to say, that effects were produced, which acted on me by Terror & Cowardice of PAIN and sudden death.”

Early evidence, if it were needed, to back up the advice not to use opiates for the treatment of musculoskeletal pain. At our practice’s Medicines Management meeting recently, we were shown a graph that showed that (in England) between about 1998 and 2015, opioid prescriptions in terms of mg equivalent/1000 population had risen from 190,000 to 430,000, i.e. more than doubled. During the same time there has been a 400% increase in deaths attributed to opioids in England and Wales- about three per week in 2018, but dwarfed by the US figures where they had 915 deaths per week in 2017.

It’s easy enough to come up with a list of patients to wean off their opiates/gabapentinoids/benzodiazepines, but quite another matter to achieve it. The patients have almost invariably arrived from somewhere else (who else remembers the old days when the notes would arrive, rammed into a terrace of Lloyd-George envelopes, by wheelbarrow?); we don’t know them as well and certainly won’t immediately share the level of mutual trust needed for the task. What would really help would be a properly functioning pain clinic. I went to a meeting many years ago when one of the pain management consultants gamely offered to take on any patients we wanted to wean off their opiates, but he only did it the once.

Patients, patients every where,
I feel my patience shrink;
Patients, patients every where,
And EMIS on the blink.

My Tuesday duty day this week was tricky. It’s a big ask to get colleagues together from across the patch after a hard day at the coalface, but we had a good turn-out that evening for our GP Board/Clinical Directors meeting. I had one of the shorter trips to get there, but a combination of events (home alone, dog in season, car being serviced, IT problems, news of vaccine delivery delays and a frankly unbelievable chain of emails between our solicitors about the hazardous potential of Artex), on top of a heaving practice, meant I arrived a teensy bit fraught.

A dejangling glass of Malbec and heap of curry helped, and it felt a bit like the old days being flanked by Hazza and Bazza, both taking notes on their iPads as we enjoyed a productive discussion about the proposed role for CDs in a rejuvenated Somerset Primary Health and how that would link into the GP Board. There needs to be further discussion between all the CDs- and refinements to the model following our discussions, but we will be writing to practices as soon as we are able to lay out the principles. We also discussed the many requests for Primary Care representation from around the system and how to rationalise these, and the ongoing legal challenges that could trip an unwary PCN. We agreed to facilitate a meeting for the CDs with our tame legal experts, and there should be more information from the centre available at the Southwest PCN event being held in Taunton on November 12th.

Yesterday afternoon I was back in East Devon for a medical golf event. Also in the clubhouse was the man we resuscitated 73 days ago (Shocker at the Short 10th), not back playing golf yet and ribs still on the mend, but very much alive. Emotional stuff, everywhere you look at the moment.

Ancient Nick

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