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The Silly Season

Thursday 18 August 2016

I used to enjoy August. Tales of kitesurfing donkeys and vegetables shaped like Kylie Minogue made the front pages of the papers, simply because there wasn't any other news. The world would quietly shut down for the month to go on its hols, and our practices were quieter as well. This year it's all rather different- Trump, Rio, Brexit and the calamitous state of the NHS have, between them, kiboshed the natural order.

Our younger partner left us in mid-July to take up a partnership in a neighbouring training practice. We saw an opportunity to reshape our team, and hopped onto the cannibalistic medical merry-go-round as it gathers pace spinning around the county, appointing 2 experienced GPs from other Somerset practices, and also snaring a Nurse Practitioner from a local Trust. They start with us in mid-September, and until then we're all working extra sessions. We've never previously had trouble finding locums, probably because we do our best to look after them: we talk to them, fill them with cake, pay them on time, and if we really like them, let them park in the same postcode. Part of the rationale for expanding our team was to reduce reliance on the dwindling locum resource.

Workforce problems continue to cause concern across the patch and around the clock. A couple of weeks ago, Harry and I met with representatives from Vocare to discuss the situation in the Out of Hours service. It was interesting to hear how the pressures, and even the type of demand, differ across Somerset. We know that certain shifts are proving very difficult to fill, and late filling of slots by doctors causing headaches for those trying to sort the rota. They were keen to find out whether we had any cunning ideas that might help alleviate the problem. Whilst a poorly functioning OOH service impacts significantly on our in-hours workload, we can’t afford to lose GPs from the in-hours service either, and so we didn’t really have a lot to offer. In truth I suspect we were both a little distracted by events that were unfolding (and unravelling) at the same time elsewhere in the county.

Until I became Vice-Chair, I had little idea of the volume or scope of pastoral care that the LMC provides, and even now there is a significant amount of support being offered to practices and individual doctors that, rightly, I never get to hear about. As Chair I'm one of the Benevolent Fund trustees and so involved with decisions regarding financial support for doctors, and once a week I get together with Jill and Harry to discuss particular hotspots or areas of real concern. Our meeting with Vocare finished at about the same time that one of our practices was receiving the results of a CQC re-visit. The practice has been through a torrid time in recent months, and reports suggested the CQC visit had been less than sensitively handled. There was a palpable sense of dismay in the office, and sadness at the possible implications for the practice and its staff. If a practice was to have its registration restricted or withdrawn by the CQC, there needs to be some swift and clever joined-up thinking (sorry) between the practice, the CQC, CCG, NHS England and the LMC, and conference-calls were already being booked for the following days. Does NHSE have a cogent plan to deal with the fall-out if practices, whether urban or rural, start to slip below the waves?

Tuesday is Violent Patient day in North Petherton. 'Pethy' isn't exactly a byword for somewhere where it all kicks off with any regularity, especially if you ignore the brief but deadly rampage by an axeman in the late 1970s. One of my colleagues worked as a police surgeon for many years, and took on the VP work when it was spread around the county. The service was recently re-procured, and is now run by Devon Doctors. We seem to have secured the local gig, and at about 6pm every Tuesday, two very large security guards squeeze through the back door of the surgery and block out any evening sun in the waiting room. The agreement is that we're phoned during the day to alert us to any VPs coming our way, but the security guards turn up whether or not anybody is expected. In the two months that the new scheme's been running, we've yet to see a single punter. I worry about how 'fit for purpose' the scheme is, when we hear of the (frankly terrifying) thresholds of violence needed for patients to be removed from a practice list, while we have a brace of bouncers sitting in an empty surgery, sipping tea and providing a significant obstacle for the cleaners. Mind you, our cleaners are even more scary than the bouncers, and last Tuesday evening I left the four of them in a menacing face-off, and slipped out to the meeting in Taunton, organised by NHSE to spread the word on the GP Forward View.

I was attending the session arranged for practices from across the region, but had an idea of the format as Barry had been to the equivalent (but longer) meeting for CCGs and LMCs that afternoon. He has an astonishing ability to provide excellent notes from any meeting within a few minutes of it finishing, and had already emailed a four-page briefing in his own inimitable style, a sanitised version of which was linked in last week’s update. The GPFV represents a significant amount of investment (£2.4 billion) in Primary Care, and various initiatives to help practices. At the very least, it can be seen as an admission from the centre that there is a significant problem. When discussed at the LMC conference in May, the overwhelming response from delegates was that we needed bread today, rather than jam tomorrow. Why couldn’t the money just be pumped into our global sums, rather than giving us yet more hoops to jump through? The meeting was hosted in genial fashion by Dr Rob Varnham, a GP from Manchester. We could have done without a video message from the Director of Primary Care for NHS England, Dr Arvind Madan, who was “seeing patients” and so couldn’t be with us, but sent us some warm cuddly words- it felt a bit like the BAFTAs. We were invited to choose from a list of topics related to the GPFV to hear about in more detail, which meant that other areas weren’t properly covered. Our table, for instance, was keen to hear about the funding- was this new money for the NHS, and if (as suspected) not, then where did it come from? How was it going to arrive in our accounts, and under which headings? It was murkier than an Olympic diving pool.

It's hard not to feel some sympathy for an NHS manager tasked with presenting their plans for the workforce, but I think it's fair to say we rose to the challenge. It's always prudent to research your audience, and from Barry's account, the local workforce situation had already been made more “granular” for the NHS England team in the afternoon meeting. You would imagine that if you’re standing in front of group of battle-hardened GPs and Practice Managers from an area where only 30% or so of the training places have been filled, and you repeat the mantra that there will be 5000 additional doctors working in Primary Care (note no longer specified as GPs), you might need to display a little resilience yourself, and have some reasoned arguments for the masses. You probably shouldn’t allow yourself to get rattled by a gurning practice manager, even if she is quite good at it. Another of the senior NHSE managers left without explanation after an hour or so, missing most of the fun that followed, but also doing nothing to dispel the feeling that they are somehow detached from our struggles and frustrations. There was surprisingly little reference to how any of this might tie in with STPs, given that one of the nine must-dos for the STP is to "support, invest in and improve Primary Care".

There were some useful nuggets, though- specifically the “Time to Care” programme. This is funding and programmed support available for individual practices or groups of practices. We’ve already been in touch with the CCG and others to discuss how we could adapt such funding to our particular needs in Somerset- hopefully keeping as much control as we can, and avoiding things that we know don’t work. More anon.

It was my own fault, I suppose. I used the word “dysfunctional” in a comment last time about the NHS complaints system, and last Friday, for the first time ever, our practice received a complaint through the NHS complaints process. Obviously I can’t discuss the details, though believe me when I say that as a nascent blogger looking for entertaining material, I’d like to. You might remember that at our regional LMC meeting we met the NHS Complaints managers, and I’m able to report that the much-vaunted screening process did an incredible job (that's incredible as in completely and utterly unbelievable). On a possibly unconnected note, although for some inexplicable reason appearing in the same paragraph, I’ve found something else to put in my PDP. I haven’t yet picked a new appraisal toolkit to use, but as I'm happy to put my learning needs out there in these blogs, perhaps this will do? I know my appraiser is a reader, as she chided me (via my wife) on some dodgy grammar I'd slipped carelessly into a previous epistle. Anyway- I need to find a resource to learn about the significance of....let me get this right....turquoise glitter in the urine. I’ve come up with a few ideas myself already.

Silly season? It’s absolutely bonkers out there.

Nick Bray

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