Saturday, 19 May 2018

Continuity of care - again

We all know that continuity is good for patients - well in theory we do, there's a growing name-checking of the subject in the official looking documents I read which is welcome but precious little actual implementation of policies designed, let alone monitored, to achieve it.

But what you may not realise is it's very good for clinicians too.
A patient I saw a while back brought this home, as seeing real people usually does; it is the point of medicine after all.

But starting where we are...
The NHS abcess that is access obsession (the ineluctable policy focus for an under-resourced service) seems to me to be tacitly supported by a number of false, vague but widely held assumptions, which I have not seen explicitly expressed, but which seem to sit in the background of NHS documents aimed at 'increasing access'.

So at the risk of setting up a straw man, they are:-
1) Clinical work is essentially mechanical. Particular symptoms inevitably mean a particular diagnosis which inevitably means a particular treatment. Ok so I'm over-stating it but an underlying bias in that direction appears to be the logic behind the current penchant for online consulting via apps and questionnaires (as a soft excuse for the real financial one) and the prevailing simplistic approaches to screening and health checks. A scan will sort you out.

2) Following from 1: An adequately trained clinician can follow the mechanics and so all adequately trained clinicians are essentially interchangeable. ie experience does not count so what's the point of seniority payments to GPs for example. (Nod is given to 'complex patients' but still the assumption is that all GPs are equally up to the task, so again why bother with seniority)

3) A shared electronic health record and the generic clinician render personal continuity unnecessary

This to me is the politically-chosen-NHS-poverty-necessity / corporate-commodification-of-medical-time tail wagging the workforce philosophy dog. Reality seems to be ignored in the drive for access; after all, if the above 3 are true, continuity is an irrelevance and the greatest happiness will follow from the greatest access.


So how does my patient's experience illuminate this? A lady in her late 20s develops a nagging intermittent abdominal pain over several months, which she puts down to a muscular cause and, as she is otherwise well, is none too bothered by. However after another mention to her partner it becomes a 'thing' and once a symptom-set becomes a 'thing' it materialises as solid as a snooker ball. It must be dealt with by the system, preferably by being expertly pocketed first time into either 'Normal range, no worries', 'Spot diagnosis, no worries', 'More thought needed, clear management plan, no worries'. Any response that doesn't have the 'no worries' element will result in the ball bouncing around the cushions until it meets a clinician who can pot it because these 'things' crave 'no worries'.

Unfortunately this lady met a centrally driven scheme to improve access, often staffed by inexperienced doctors where there is no continuity or mentor-ship in their role. But hey the doctor was straight out of the GP sausage factory with a fresh MRCGP label and expiry date 5 years hence and had access to my lady's GP record, so all criteria 1, 2 & 3 met - sorted, yes?


When I saw her for her test results a few weeks later she related how she had become progressively more anxious in the consultation as the doctor's inexperience manifested in doctor anxiety as potting this one with 'no worries' was clearly outside their capacity. She began to doubt her own reassuring self-diagnosis; doubts that were confirmed when the doctor ordered FBC, U+E, LFT, TFT, Bone, HbA1c, Coeliac disease screen, Vitamin D, CA-125, abdominal ultrasound and a chest x-ray!

So I saw her on the sixth NHS contact after her initial appointment request (1 Dr, 1 phlebotomy, 1 USS, 1 X-ray, 1 call to book me). We had a chat; she was well, and funnily enough the pain had gone away. I went through her 26 test results (some of the above tests have multiple readings). There were two abnormal results - one of the bloods was slightly out of normal range and a minor benign finding on the scan (which the patient already knew about). But as in a battery of 26 tests with a 5% abnormal cut-off, it's 3 times more likely that at least one of the results will be falsely 'abnormal' than none abnormal and as my clinical assessment put her pre-test probability as extremely low, I was happy to reassure her on that 'abnormal' result. Pocket made 'Patient diagnosis likely correct, natural resolution, tests unhelpful... no worries'.

Had she seen an experienced doctor first off, the pot would have been a swerve around the black of inherent clinical uncertainty putting the mildly anxious red straight into the 'Spot diagnosis - muscular pain, no worries' pocket in such a convincing way that it would have become a self-fulfilling prophecy, even if not quite correct. (The endorphins generated in the patient (and Dr!) by such a shot boost the immune system & sense of well being that ill-ness often just melts away - that's the pharmacology of the 'drug doctor'.) That's one consultation, no tests, no follow-up, same result. Yes experience is literally worth every penny of seniority. (And yes, I do feel sore about this.)

Now, I'm not getting at the doctor; the problem here is a system that de-prioritises continuity. And further, our health system simply cannot afford this way of doing medicine! This doctor may have seen the results but they didn't see the patient again and are very unlikely to in an access-prioritising system. So this doctor has lost out on one of the main tools for effective continuing professional education in the real world - the patient feedback loop. 

But supposing my patient had first seen a doctor in a context where the doctor could call upon experience or could see her again? They might have ordered the tests, if experience hadn't intervened, but when they saw her again they would learn they will never need to order those tests in that situation again, as they will naturally re-calibrate their response to that symptom-set. Further they will learn a bit more too about the bit of history they didn't take first time; that the patient wasn't actually very worried - which for this sort of person means they don't need to be either.

As it is, NONE of this learning will occur and the anxious doctor will continue to make the same decisions and the costs to the NHS will mount...
(I did toy with giving my feedback but I don't know the doctor and have no formal professional responsibility there, can't do it face to face & have no idea how it would be received, although I do feedback to members of my own practice & staff I know. But this is my point; we don't rely on people doing a good turn to make sure the aircraft engines are ok - it's there by design.)

Back to the assumptions.
1) is just plain wrong. The technical stuff of history and diagnosis exists within an intensely personal and complex context which modulates it. Inexperience focuses on the technical but as you get more experienced the technical just becomes incidental to the personal, which is where real medicine is really at, or at least should be.
2) is plain wrong. Most newly minted GPs mainly know that they don't know that much; experience counts - it's called 'practise' after all.
3) is plain wrong. Ironically because personal continuity is much, much more information rich than any current IT system and it uses intuitive real-time data retrieval and application.

If the assumptions are wrong then this obsession with access is harmful to both patients, doctors and NHS finances!

My advice to young doctors. Yes you may want to avoid partnership just now, but get a job in a place that values continuity, training and offers mentor-ship or, at the very least, the chance to chat to colleagues about your work at work. It's how you learn and get more confident. Spurn access-only; it won't develop you.
Please yes we need access but we need continuity for the benefit of all concerned and policies that actually make continuity work.

PS I have changed details so neither patient nor doctor are identifiable

Thursday, 9 February 2017

Continuity of care - who needs it!

Ladies and Gentlemen I have some good news and some bad news and then some better news!
Good news the NHS is set up to cope with anything: If you were Tim Peake, Britain's Astronaut, hurtling towards the earth in a Soyuz capsule to land in Kazakhstan and you were injured during that landing the NHS was already prepared. Yes if Tim had been injured his GP would have been able to add the Read Code T55z0 'Spacecraft accident NOS, occupant of spacecraft injured' to his medical record. Had, heaven forbid, his parachute failed, the NHS was ready for that too, the code is X711Z Failure of parachute on descent. Indeed the NHS would have been code ready if the Soyuz capsule re-entry motors had failed or they had suffered a loss of air supply or even if they had been hit by a passing passenger jet or meteorite. Yes we have spacecraft accidents covered - there are 57 varieties of code for spacecraft accidents. Or maybe you have been bitten by a hippoptamus - we have a code for that too X717Z. Or maybe your GP wants to record your pasta intake Ub0A3.

Bad news: But suppose you are in that highly unusual situation of being an older person with multiple chronic diseases and needing the personal continuity of being seen by the same clinician each time, not only for your own safety but your sanity too. 'If I have to tell another doctor the same story again I shall go mad!' Supposing your healthcare record needs to flag that up? We don't have a code for that!!! No not one. Typing 'continuity' into a read code search engine will give you codes for 'disorders in continuity of bone or heart valves' but nothing on continuity of personal care! The nearest you can get is the code XaKZN Provision of continuing care, but even this is more about Continuing Healthcare Funding than continuity of care. Our coding system has evolved to reflect successive governments' obsession with access to appointments to the exclusion of continuity despite a wealth of evidence that continuity delivers on quality, cost, safety and patient satisfaction. There are hundreds of codes about getting, making, attending, not attending or cancelling appointments by any number of different providers! So if you are a politican remember patients love continuity and those patients tend to be older and those older patients turn out at elections. #justsaying If you are an NHS Finance person remember patients who get good continuity take their medications better and tend to choose cheaper less invasive Rx options when discussing risks with their trusted GP. #justsaying If you are a clinician out there we know that Drs or nurses with good continuity show better job satisfaction #justsaying. If you are a patient well you know all this we just need to listen to you! #justsaying

Better news: It doesn't have to be like that. Continuity at last features in our CCG plan. The new Snomed coding system that will eventually come into NHS actually as about 4 codes relating to continuity of care. Practices can use the Usual Doctor system to help direct patients to the best person to see them. But sometimes with teh additonal pressures we face that needs a bit of extra help. Two years ago we introduced a system whereby, using that one sort of continuity code, we flag certain patients who really do need to see the same GP as far as possible. Using that flag reception staff are then able to ensure as far as possible that when those patients need attention we direct it to the same person each time, whether its getting that doctor to ring back or booking them in to be seen or handling a medication enquiry or call from an outside agency. We have been able to show that in addition to using the usual doctor system for assigning doctors to patients and vice versa, this provides an additional improvement in continuity of care on top. Yes you can measure continuity of care - it's just that those who set the rules have chosen not to. In addition we are experimenting with developing virtual teams to help prevent patients getting lost in what is now a bigger organisation. So let's start organising and commissioning and regulating and funding for continuity of personal care...

Saturday, 20 February 2016

Suppose we do actually need GPs?

Suppose it turns out we do actually need GPs after all? And we find out 5 years too late...

Everyone seems to be trying different ways of delivering primary care with fewer trained GPs per head of population. We have the appointment of pharmacists, physiotherapists, advanced nurse practitioners, paramedics, physician assistants and community matrons. We have techno solutions aplenty; virtual appointments, email, online booking, telehealth, skype, health apps, text, pre-doctor questionnaires, algorithms, on-line consultations. All this is being driven much more forcibly now by, amongst other things, one problem; a failure to invest in the GP workforce over the last ten years to match population growth and the multimorbidity associated with successful ageing.

All this activity makes me anxious.

As I tell my patients, if there are lots of treatments for a condition viz cough remedies, it almost certainly means none of them work very well, if at all (unless they are all merely me-toos of one treatment that does). ie if there are lots of treatments you are probably best advised to have none. The fact that there are so many things being tried in GP land tells me that no one actually has yet hit upon something that is really effective, or we would all be doing it already.

The other reason for thinking this is the simple observation that GPs have always had an incentive to get someone else to do their job, pay them less and pocket the difference. So why after 60 years of the NHS has it not happened to a great extent?

The answer must either be that GPs are all wonderfully altruistic, forgoing monetary reward en masse to absorb the work themselves (no, I didn't think you would buy that) or that it is a hard problem or that GPs are what patients actually want or both. On the face of it there are lots of studies purporting to show that X% of GP work could be done by a physiotherapist, and Y% by a minor illness nurse and Z% by a pharmacist where X+Y+Z+... >100! So why am I still here?

I have no problem with exploring these options. Indeed my own practice is taking part in the pharmacy pilot and actively looking at developing practice sub-teams. It will be great if we can get it to work but it isn't going to be easy.

Evidence is mounting that some of these approaches are not going to work as well as hoped. Trials have been done looking at minor illness nurses in primary care showing reasonable outcomes and good patient satisfaction but, and here's the rub, not a lot of cost saving once you factor in the fact that they are less time efficient and need supervision. There is a cultural block too, not the false 'nurses don't make diagnoses' one but that nurses (and other HCPs) have been trained to be risk averse; that's what doctors are for. The trials also were not powered to detect possible adverse outcomes when rarer but serious problems presented to nurses. Recent reports of increasing claims and complaints against nurse practitioners suggest these concerns may have been justified.

Technology too is begining to take a hit with concerns being raised about the algorithms and medically untrained staff used by NHS 111 in assessing patients.

However the real reasons for a lack of diversion from GPs is less to do with safety concerns and more to do with practicalities. It may be true that 15% of GP workload could be handled by a physiotherapist but the problem is knowing that for sure in advance of the consultation. And even if you can discover it by triage or on-line questionaires that is going to be scuppered frequently by the real world of patients wanting advice on more than one thing at a time. It's the multiple presentation of multi-morbidities torpedo that holes these one-dimensional solutions.

Take the common example of a young mum presenting with back pain, low mood and needing contraception. To be sure a physiotherapist could deal with the back pain and a therapist with the low mood and a family planning nurse with the contraception, but they would need at least an hour and three appointments! And each would deal with their aspect of the problem and the patient might not think to mention the other issues. Now the FP nurse, like a GP, might make the diagnosis that it is the irregular periods caused by the progesterone only contraception that is contributing to the low mood and back pain and suggest an IUS say, but however good the FP nurse is under this system the patient still has to see two other HCPs to get to that point of integrated care.

No doubt too that a practice nurse could have sorted the 8yo I saw with ear wax (well, assuming their protocol allowed ear syringing in children), but would the PN have had the experience necessary to diagnose and manage the molluscum contagiosum and viral warts that also presented? Maybe, but not reliably.

I could go on to enumerate many thousands of combinations of presentations that are routinely dealt with by generalists in one consultation in under 15 minutes but could only be managed by many more thousands of consultations by non-GPs. There is a good reason why GPs exist - most people, most of the time present with multiple cross-speciality problems that are most effectively dealt with by a generalist with GP-like training. Most patients recognise this but also value being able to see someone they know and trust. So it seems that the GP solution could turn out in the end to be the most practical, safe, holistic and cost effective one as well as being the option most desired by patients. Let's hope there are enough of us left when NHS England comes to its senses and decides to properly fund the evidence on primary care.

Thursday, 6 August 2015


No one I know has any confidence that the 10 point plan developed by NHS England, Health Education England (HEE), the General Practitioners Committee (GPC) and the Royal College of General Practitioners (RCGP) in order to address primary care workforce issues in January 2015 has any chance of making a significant impact. I thought it might be worth exploring why.

The current crisis is down to too many GPs saying it's all too much, that although the job in principle is extremely worthwhile, the pressures mean increasing numbers just don't want to do it.

A way of assessing this is to look at willingness to do the job at different workloads as pay varies. If pay is high and workload manageable people will feel better about doing the job; if it is too low people may feel the job is not worth doing whatever other worthwhile elements or job satisfaction it offers.
A Commons Briefing Paper shows that between 2005 and 2013 real terms pay for GPs has dropped 22% from £137,108 to £107,331. 
The number of FTE GPs in the same period has gone from 29,248 to 32,075. However the estimated annual number of consultations has escalated from (my estimate) 267m to 340m over the same period. The workload (in consultations pa per GP) has therefore gone from 9,134 to 10,600, a 16% increase.
You will notice both measures are going in the wrong direction, meaning that the job in 2005 was 48% more worth doing than in 2013 when this is expressed as the change in Pay/Workload ratio. (Some may query my choice of 2005 as the baseline but bear in mind this was where we were after a solution to the last GP crisis was enacted and generally folk felt the crisis was resolved at that point and so this seems to me to be the most appropriate point to choose for a baseline.)

We can get a handle on the crisis by considering how pay and workload affect the proportion willing to do the job. 

Each line represents willingness to do the job for the same workload at different pay levels, with say 10% increases in workload between lines A through D. As the work stress increases there will come a point where the stress levels are such that willingness to do the job drops away rapidly as in C. In the most extreme cases where the job causes illness, work may become impossible and willingness drops out very rapidly as in D. I suspect that over the last 10 years we have moved from X to Y as real terms pay has dropped and workload shifted up a gear.
 My contention is that our current level of workload means pay vs willingness is not a linear relationship but has a steep slope, if not a cliff. I think there is good reason to think we are now at point Y on the curve C. This is very precarious for two reasons. Firstly, further drops in real pay, without a change in workload will continue to push us down the steep part of curve C. (Bear in mind GPs are generally very capable individuals who can and do switch to other parts of the economy or other economies.)
But this is not the worst thing that could happen. I suspect that secondly, like fissile material at critical mass, further increases in workload could trigger a chain reaction where loss of more GPs pushes up the workload for the remainder suddenly flicking us down vertically from Y onto curve D, in which large numbers just walk as the job becomes non-doable at that or any price. This disaster would be difficult and expensive to recover from! I think the level of anxiety in GP land at present reflects an intuition that this could happen.
So the solution to the crisis relies on finding ways to push us back up the curves to higher levels of willingness to do the job. (To be sure pay and workload are not the only reasons for doing the job as others have stressed (www.whyGP) which is why on curve A people with means would do the job voluntarily but these factors only shift the curve to the left, they don't change its shape at higher workloads: however fantastic you think General Practice is there is always a point when the stress of the job will make you unwilling to work. What makes this crisis such an issue is that the curve is likely to be already left-shifted by the intrinsic value of the job and the values of the profession compared with other jobs and yet we are still at Y.) My view is that reducing workload rather than increasing pay is likely to be more effective and you can see that from the shape of the curves - going from Y vertically to curve B is more efficient than a pay increase in getting people to stay, if I am right. The main determinant of workload is list size and so for an effective solution practices must be given the right to unilaterally close lists to contain workload, NHSE should commission to cope with the overflow and pay must not drop any further in real terms.

We are now in a position to understand why folk might be sceptical about the 10 point plan which fails to address the above adequately.
I will cover the points in turn

1 Promoting general practice 
This is a marketing campaign setting out the positive aspects of General Practice.

This will clearly make no difference to the Pay/Workload issue. It is possible that it might shift the curve to the left by convincing some to be more willing to do the job for the same degree of stress (but the curve is probably already as left shifted as it can go for the reasons listed above). This does rely on pulling the wool over many eyes in an age of social media, and them discounting their experience and the experience of the more experienced, which seems rather unlikely.

2 Improving the breadth of training 
HEE will work with partners to resource an additional year of post CCT training to candidates seeking to work in geographies, where it is hard to recruit trainees. 

This does nothing to shift the curve or address Pay/Workload once the doctor gets into General Practice and may increase work stress generally by taking a cohort out of full service delivery for a year.

3 Training Hubs  
NHS England will invest in the development of pilot training hubs, where groups of GP practices can offer inter-professional training to primary care staff, extending the skills base within general practice and developing a workforce which can meet the challenge of new ways of working.

This too will have no effect on the curves. New ways of working are likely to increase work stress at least in the transition (note there is no mention of transition funding), risking pushing us further down the slippery slope.

4 Targeted support
NHS England will work with the BMA GP Committee and the RCGP to explore a time-limited incentive scheme to offer additional financial support to GP trainees committed to working in specific areas for 3 years.

Once in a post after three years the Pay/Workload ratio is unchanged once the real work starts. Significant golden handshakes have not been very successful for post CCT GPs which rather suggests it is unlikely they will work for GPRs.

5 Investment in retainer schemes
NHS England will review the use of current retainer schemes and invest in a new national scheme, making sure it meets the needs of both GPs and practices. 

The Pay/Workload ratio is unchanged.

6 Improving the training capacity in general practice
The Government’s recent announcement that there will be an extra £1 billion for investment in new primary care infrastructure will enable increased training capacity and a more positive experience for medical students and foundation year doctors within general practice.  More broadly, NHS England will work with the BMA's GPs committee and the RCGP on the strategic direction of the primary care estate.

A nicer building does little to change the willingness to do the job. Current experience with GPR recruitment is not picking up despite the publicised investment and my City has several shiny underused buildings.

7 Incentives to remain in practice
NHS England and partners will conduct a detailed review to identify the most effective measures to encourage experienced GPs to remain within practice. Options may include a funded mentorship scheme, opportunities to develop a portfolio career towards the end of your working life, and a clearer range of career pathways.

The options suggested specifically do not address the Pay/Workload ratio. The options might decrease stress for the individual doctor but will increase stress on others as their contribution is reduced. This might help prevent things being worse than they would be otherwise but won't reverse the slide.

8 New ways of working
NHS England, HEE and others will work together to identify key workforce initiatives that are known to support general practice - including e.g. physician associates, medical assistants, clinical pharmacists, advanced practitioners (including nursing staff), healthcare assistants and care navigators.

Now this might work - but can only do so if it reduces the GP workload without decreasing pay, thus increasing the willingness to work. Unfortunately the recently released information on the Pharmacist Scheme where practices pay an increasing proportion of Pharmacist time means this is highly unlikely to happen.

9 Easy return to practice 
HEE and NHS England will publish a new induction and returner scheme.

See 2

10 Targeted investment in returners
NHS England will make available additional investment to attract GPs back into practice, increasing over time.   Targeted at the areas of greatest need, the scheme will offer resources to help with both the costs of returning and the cost of employing these staff.

Now this might work if they turn out to be serious in meeting the cost of employing these staff on a permanent basis but the numbers are not likely to be high. 

What is striking is there is absolutely no mention of pay or workload which are key to the willingness of GPs to do the job. They just don't want to talk about this Elephant.

So what will change the situation?

In order to increase general willingness to do the job workload has to be reduced. This will push us back up a curve.

I suspect too that it is this cooperation with such ineffective proposals that has contributed to a loss of confidence of a growing number of GPs in their representative bodies.

I'm afraid there really is no way out of this without increased investment in the primary care workforce (as well as buildings) which could be achieved within the NHS budget by stopping activity with poor evidence and diverting those resources. NHS Health Checks are a good place to start.

None of the current proposals reliably move us back up from Y to X and the GP contract is not set to change in a way that will address this.

Pay is set to continue it's downward drift and nothing significant is being offered to relieve the workload. Consequently the situation is set to worsen still, driving the profession down either a steeper cliff or to implosion. If JH does not realise this he is incompetent, if he does but does nothing he is either impotent or malicious - whatever #WeNeedToTalkAboutJeremy and the petition for a no confidence vote is entirely appropriate.

Thursday, 16 July 2015

A plan comes together

Don't you love it when you can deliver healthcare with an efficiency and quality even the 'A' Team would struggle to match?

My patient booked an appointment on line to see me about their thumb. He/she put in the free text 'I think I need an injection. :-( '
This text appeared on my screen under their appointment booking so I had the needles / steroid ready on arrival. Yes -  typical osteoarthritis of the 1st carpo-metacarpal joint. I did the injection clean into what can be a small joint to get into. My patient went away happy and left me with the feeling of a job well done.

Appointment on-line booking time by patient three minutes.
Consultation time eight minutes.
Reception time 0.
Admin time 0.
Medical record coding time 0 (part of my 8 minutes)
Invoice processing time 0.
Insurance assessment time 0.
Patient wait 0 (first appointment of session)
Time to claim minor operation fee 0 (integrated into our EPR)

I challenge you to find another healthcare system within Pluto's orbit that could come anywhere close to diagnosing and treating this condition from a standing start in 11 minutes total. Compared to the NHS most other systems would still be in the blocks by the time we'd finished the race and completed our third lap of honour.
Private medicine? You are having a laugh - 15 minutes to complete the first tranche of bloody paperwork!

So how do we do it?
No denying it, the technology is great and primary care IT like this is world class.

But here is a formula to note
Technology + Continuity = Quality + Efficiency

This could not have worked without continuity.

I had previously injected this patient's plantar fasciitis about 7 years ago and it worked a treat. So they knew I did injections and so knew to book with me.  They also knew my injections were 'ok' - reading on NHS Choices that someone else thinks you inject ok is not the same as knowing it (almost literally!) in your bones. It means patient anxiety pre-injection is minimal and I can get on with the procedure quickly without lots of explanation, consent forms, reassurance or medico-legal worry. All this makes the procedure itself less painful by eliminating nocebo effects.

An APMS contract (NB NHS England) could not have delivered this as with 5 year contracts it's highly unlikely the same doctor would still be around. This is only possible under GMS or PMS which NHSE very, very stupidly is not actively newly commissioning.

Technology alone could not have delivered this because technology cannot manufacture the trust that comes from long term personal care.

So Mr Hunt if you have a 25 year vision, make long term personal continuity part of the plan and stop wrecking GMS/PMS!

Stop blathering on about technology - I've been using computers in General Practice since 1989. I got it 26 years ago! We all get it in GP land, that's why we lead the planet.

You can have it all but only if you get and promote continuity of personal care...

Tuesday, 7 July 2015

New deal

You know that dissonance when as a GP when you encounter someone who turns out to be psychotic and they are saying things that are borderline possible but don't quite add up, you know how you have to seek independent witnesses to be sure - well that's how I feel whenever Jeremy Hunt (JH) speaks. He has just enough traction on reality to be almost credible, if your antennae weren't already twitching wildly. Of course there is no psychosis here just a deliberate skirting around the presentation of truth, as opposed to the mis-perception of it you get in mental illness. Sometimes the patient can be so near reality you begin to question your own grasp on things.

That is why on reading the New Deal speech I had to go back to evidence.

Much of the speech has already disintegrated of course - 5k GPs is now a maximum (but no minimum stated!), the 82% of not a lot and what seemed to be new money that wasn't. Then there is the oft-repeated semi-lie that the CommonWealth Fund voted our NHS number one last year - well yes but they always forget to mention that fact that this assessment was based mainly on data from 2011 and some from 2011-13. For some reason they don't claim that our number one status is (was?) actually the outcome of 10 years of Labour investment in the NHS - funny that.

And in a cracking self-contradiction JH goes on to say 'We rank best in the world for having a regular doctor who co-ordinates care' and subsequently berates Labour with another of his oft repeated misrepresentations for undermining 'the personal relationship with patients by scrapping named GPs'. So they undermined that relationship did they and seven years later we're still top for having a regular doctor? Does anyone read this before putting it out there? It's embarrassingly bad.

Reflecting on this speech is a bit like picking up a carefully crafted sandcastle in your hands - it just falls apart.

But what of this obsession with 7 day working in primary care?

I wondered if there was an evidence base. The Conservative Manifesto 2015 pg 40 (the main vector of the contagion) announces it under the subtitle 'We will make the NHS more convenient for you'. Nothing about reduced A+E attendance or measurably improved outcomes - nothing to suggest anything other than convenience - which as an aspiration is fair enough, but nothing to indicate it is actually needed.

An MP's Briefing Paper and PM's post election speech had no evidence either, apart from the generous reassurance that doctors weren't actually all going to have to work 7 days each week.
Then we get to the New Deal Speech where there are signs that JH is scrabbling around for something a bit more than the 'convenience' of the Manifesto, in belated recognition that actually yes there really does need to be a need, given the circumstances.

'The role and purpose of 7 day primary care is about much more than convenience – it is about making sure precious hospital capacity is kept clear for those who really need it. We have clear evidence from Imperial College London that a lack of access to GPs at weekends results in increases in urgent hospital admissions.'

At last a mention of something I can hold on to - alas no actual reference is given. A bit like my paranoid patient who says someone told him the neighbours were spying on him but then can't tell you who. Nor can Prof Majeed who co-authored some relevant papers but he kindly confirmed on Twitter 3 papers I had also found from Imperial that JH might be referring to.

The problem is none are about 7 day working or weekends specifically and only one is about hospital admissions... of children.

More dissonance.

One shows an association between patient reported difficulty accessing appointments 2 weekdays in advance when they rang in ordinary surgery hours and self referral to A+E followed by discharge (ie not admission). It concludes that better access might result in less self referred A+E attendances (maximum effect size possible I calculate is a 1% reduction in A+E attendance) but the effect is dwarfed by the effects of deprivation which are 4 times greater, which the paper does acknowledge. The evidence would suggest therefore that for maximum benefit we should be resourcing deprived area practices with more appointments in weekdays in usual hours to reduce A+E attendance (but the direct beneficiaries would probably not be Tory voters!). Oh yes that was what our PMS funding (now cut!) was for.

Another makes a rather speculative guess at the proportion of A+E attendances that were preceded by someone not being able to get a GP appointment at a time that suited them, based on the GP Patient survey. This again is an argument for resourcing in hours care properly as the Patient Survey was on patients who rang their practice in hours who presumably were looking for appointments in hours. It tells us nothing about routine GP access at weekends or emergency admissions.
This is consistent with the finding that there is a lack of demand for weekend appointments by many of the PM Challenge Fund pilots.

The last paper, which if you compare the original abstract which contains no mention of GP out-of -hours, with its summary, which does, bears the hallmark of being sexed up. But at least it looked at emergency admissions in children even if it cannot draw any meaningful conclusions about 7 day working. The authors themselves say 'we cannot infer causation' and the fact that the increase in admissions was seen in chronic conditions but not infectious ones led the authors to conclude that the study 'may indicate an adverse impact of financial incentive schemes focusing on chronic conditions in adults' rather than it being due to a problem with GP out of hours availability. 
Even the RCGP felt the need to issue a press release.

So the evidence JH seems to be referring to for 7 day working is ..well ..NOT evidence... unless he can come up with a paper Imperial College themselves don't know they have written!

Well at least it's not me that's losing the plot.

So it seems that JH is systematically misrepresenting evidence for political gain, again. So given I already work 45-50hrs per week, some already at weekends (work email, research coding, GP trainee eportfolio, appraisal, reading CCG documents, private study etc), can find no evidence of benefit from 7 day working, would have to pay a high premium on medical defence cover, face hitting LTA and pension charges, won't be seeing my patients (yes 'real clinical responsibility' is about continuity over access), won't see friends and family and like any GP my age who has read the runes has made sure I don't need the money, will I be working weekends mainly for the convenience of Jeremy Hunt?

Saturday, 6 June 2015

Mending primary care

So we know not for profit OOH is favoured by patients and that APMS practices on average deliver poorer quality care. So the evidence gives us something we should be moving towards (don't hold your breath!) - not for profit OOH and conventional primary care contracts but with an improved cost base from economies of scale while retaining an emphasis on optimising the access/continuity balance.

We desperately need to improve recruitment of GPs and nurses into a context where many work not just very hard but suicidally hard in a wholly unsustainable way. Working even harder is therefore not an option, so just paying more to do more won't work. Nor will back to work schemes without enough wanting to come back, golden hellos or unrepresentative assertions of rosiness without concrete action.

We have to get back to a non-punishing daily routine. I can still remember the only time I had a decent lunch-break in the last 4 years, which was on 16/5/2014. It was 45' long and I actually went home later in a better mood than I started the day for the first time in ages. I was still at work for 10 hours but was only actually working for 9 of them. This and better must become a daily experience if we are to attract folk.

A growing problem is that progressively more clinical and organisational responsibility is being carried by fewer and fewer shoulders. The financial and medico-legal risk run by many partners is no longer sustainable and also contributes to burn-out and early retirement. Further, the more people for whom an individual partner is carrying ultimate responsibility for, the less they are able to keep tabs on what is going on and the greater the anxiety. GPs face the doubly stressful work situation of both loss of control of their work and of control of clinical risk. We have to get back to a more even distribution.

And it is essential to guarantee any improvement going forward. No one is going to come into a profession when they think we will be back here again in 10 years when we have been here at least twice in the last 12.

Getting back to sensible working will happen because the current situation, ironically for health workers, is incompatible with their health and so will not last. The only real question is whether it's with or without a public health disaster en route. More of the same will collapse primary care as we know it and our NHS values along with it. Everyone has a limit and many of us could just walk away right now, taking experience and the training skills to produce the next generation with us, further depleting input at the bottom. Practices could tumble like dominoes as one takes out the next; some areas could be left with no primary care to speak of. The whole thing might be privatised and serious numbers of people would lose the right to primary healthcare as it becomes unaffordable as medical time is priced out of their reach.

This will eventually be OK for doctors though as price will limit activity and lunch times will be restored. Most GPs oppose this form of privatisation because they know only too well how badly large numbers of people will be affected. We could move to a US fiasco and public health and inequality go into reverse and still the overall costs escalate. Even if replaced by a comprehensive insurance system it will still be more expensive and very many will lose the kind of access to care they currently enjoy.

It's probably not too late for a more civilised route but I still have yet to see anything tangible. So what needs to happen?

Things that might help a bit or not at all are:-

Defining GP workload to limit demand. There was much talk about this around the 2003 contract negotiations and it was attempted but failed miserably. The role of the GP is constantly evolving and so as soon as you try to define it, it is out of date. It would require continuous re-working and is not worth the endless wrangling. And as we have discovered since 2003 'new resource for new work' just doesn't work.

Payment for activity. The main reason for cost effectiveness in the NHS is that doctors are NOT paid for activity; you end up with healthcare activity regardless of whether it is needed and this drives up costs. This will seriously damage NHS cost-effectiveness.

Co-payments for primary care appointments. This directly contradicts a core NHS value and discriminates against those most in need. The transaction costs are counter-productive anyway.

Cavalry. In the form of Physician Assistants or Nurse Practitioners. As effective as these can be there is no evidence they are cheaper over all and the jury is still out on the safety question when more serious disease presents and there aren't enough anyway. They increase the burden of clinical responsibility on the GP supervising (as if they have time!) their work.

Salaried Service. Many see the only hope is in a fully salaried GP service as they think the loss of autonomy will be compensated for by a contract that will have to offer acceptable working patterns. Personally, I think it is simply unaffordable in the current climate and will ultimately stifle innovation and patient advocacy, which is becoming ever more important as secondary care services return to 1990's waiting times.

So what will help?
We need a mechanism that is going to guarantee adequate, properly focussed funding of primary care and sensible work intensity. What is obvious is that no government can be trusted with this, otherwise we wouldn't be in this mess. We need a system where there is a powerful legal incentive for politicians to ensure that viable primary care continues, by containing demand and adequate resourcing. The current system provides neither.

Practices must be given absolute discretion over their list sizes. (I was pleased to see this passed as a motion at this years LMC conference and is a restriction that would be sensible to enshrine in law, Mr Osborne). By all means the practices should give warning they are about to cease taking on registrations and there should be some limitations eg they should close for a minimum of three months. It will focus minds properly on commissioning primary care if local politicians are faced with the realistic possibility of angry patients unable to register with a doctor. Currently, struggling practices are seen by NHSE primarily as the other local practices' problem when it comes to making up any deficiency in supply but not their own. Er, contractually it's not other practices' problem and nor should it be, the other patients are not registered and should not be automatically assigned. It's NHSE's (or jointly CCGs) responsibility, although practices may be willing to help, if able. The current system leads to lazy (non-)commissioning; it has to change.

The beauty of the above change is we do not need to worry about what a GP job is as the mechanism will cope with whatever it is, depending on the collective experience of coal face practitioners about a suitable list size.

Practice funding must reflect actual practice co-morbidity (NOT just age)
The current funding system actively discriminates against practices providing quality services that patients appreciate. How so? In an area where patients perceive a differential in quality between practices and vote with their feet, inevitably the high service users are the ones that switch practices. They take with them a higher than average workload but only an average capitation fee. Thus the 'good' practice becomes less profitable (greater workload per remuneration) and the 'poor' one more profitable. ie exactly the opposite outcome the patient choice agenda was supposed to achieve. In this inefficient application of NHS resource, it over-stresses popular practices while over-funding the less popular. Doh! (Current funding mechanisms do not take account of actual morbidity distribution between practices but smear an average deprivation factor over a geographical area.)

Evidence of this can be seen from QoF 2012 prevalence data from my patch of Leicester.

The coefficient of variation here is a measure of the variation of the disease prevalence distributions between seven practices serving the same geographical area of Leicester. There is, for example, a seven fold variation in the recorded prevalence of depressive illness between the practices, with the same pattern of variation for the other disease areas. Notice that there is much greater variation between practices for mental health / neurological conditions than for cardiovascular ones. As any GP will tell you the demand on GP time and emotional energy for the former is much greater than the latter.(1,2) We know also for example that depression associated with diabetes in the same patient is more time consuming for primary care than diabetes and depression in separate patients. The same is not true for hypertension and diabetes. (3). This variation, for reasons I haven't got space to go into here, is almost certainly down to prevalence variation reflecting patient choice / transfer rather than coding variation between practices.
A new funding mechanism based on actual practice multi-morbidity, assessed annually, is essential if meaningful competition and innovation is to be driven in primary care.

There must be more intelligent analysis of doctor behaviour. In exchange for discretion on list size GPs need to be willing to handle greater scrutiny over the areas that generate much secondary care cost, especially referral behaviour. Current initiatives such as the Unplanned Admissions DES simply don't work, but there are better ways.
For example there is a completely untapped seam of data which may give useful insights and potential savings here, as well as function as a useful educational resource. This is to audit GP referrals adjusted for the case load and case mix which form the background to this.
Years ago now we were struck by a 28 fold variation between different doctors in the crude count of their gynaecology referrals in our practice. I decided to adjust these referral rates by looking at the background of all consultations for gynaecology problems from which these referrals were drawn and adjusting for case load / mix and age. When you adjust for these factors the variation disappeared (moving from variation well outside 3 sigma to well within)!
Analysis of other areas such as neurology showed that less experienced GPs referred more patients for vague symptoms than experienced ones, offering an immediate educational and cost saving opportunity, that was not otherwise apparent.
I have been unable to repeat this work in SystmOne because incredibly despite 25 years of GP computing it is still impossible to create a list of all consultations by GP classified by the problem encountered even though our GPs have been recording every consultation properly!

The Doctors & Dentists Review Body (DDRB) recommendations must always be implemented fully by government with more than just a gentleman's (ha, ha) agreement to do so. Successive governments have shown themselves to be entirely untrustworthy on this. The DDRB in recent years has become a joke and ought to be experiencing some kind of existential crisis given the degree it is ignored by government. The deal that we don't take industrial action but DDRB recommendations are implemented must be restored by legal instrument and MPs must be obliged to take other peoples' review bodies as seriously as they apparently take their own.

The above combination should be able to ensure that workload is controlled at the practice level, remunerated according to need and funded adequately nationally. Importantly it will oblige engagement by reluctant politicians in an ongoing discussion about our NHS and what we want it for.

The main obstacle will have to be an acknowledgement of the repeated failure to manage primary care properly. It will be messy as I suspect a lot of practices will cease to take new registrations but the alternative will be much messier. It will cost because practices will have to be paid the same to do less to bring workload levels back from the suicidal. But it will cost less, be more equitable and a lot less messy than the alternative.

1. The workload of GPs: consultations of patients with psychological and somatic problems compared
Else M Zantinge, Peter FM Verhaak, Jan J Kerssens, Jozien M Bensing
British Journal of General Practice, vol. 55 no. 517 609-614, PubMed 16105369

2. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study
Chris Salisbury, Leigh Johnson, Sarah Purdy, Jose M Valderas, Alan A Montgomery
British Journal of General Practice, vol. 61 no. 582 e12-e21, PubMed 21401985

3. Implications of comorbidity for primary care costs in the UK: a retrospective observational study
Samuel L Brilleman, Sarah Purdy, Chris Salisbury, Frank Windmeijer, Hugh Gravelle, Sandra Hollinghurst
British Journal of General Practice, vol. 63 no. 609 e274-e282, PubMed 23540484