Who’s the most important person in the NHS?

#GPFUQ 97 Who’s the most important person in the NHS? The patient in front of you

#GPFUQ 98 Why do we need a primary care- secondary care system? In a good health care system there should be good access, high quality and low cost. The primary care- secondary care system seems the best way to achieve this ideal. A good system is when a patient can easily see their GP, and the GP can give all the needed appropriate care to most of the patients. The few patients who have more potentially serious problems are identified by the GP and referred to the appropriate specialist who then does all the necessary tests. For example a GP may see 100 patients with a headache and knows that 96% are likely to be self-limiting and don’t need referral. The GP may identify 4% who he is worried about and refers them to a specialist. That’s a 4% referral rate. When the specialist sees this 4% of patient he expects them to have a more serious problem and will usually exhaustively test them to make sure they don’t have a serious illness. A bad system is when the GP over investigates or refers too many of the patients or when the specialist fails to investigate his patients enough. If a GP is risk averse he will refer more patients to a specialist. It only needs GPs to refer 5% rather than 4% of patients to increase hospital workload and costs by 25%. If there aren’t enough GPs then patients will end up getting poorer access to more expensive services and lower quality over-medicalised care.  

#GPFUQ 99 How many GPs do we need? The UK consensus is that for a balanced primary care – secondary system of health care we need 50% GP and 50% the other specialties. NHS workforce planning has allowed this to fall to <40% and is currently funding training of 40% GP and 60% hospital specialties. Following a 3 year training scheme there will be a shortage of GPs and following a 6-7 year training scheme for other specialities there may be a shortage of jobs for these other specialists.

#GPFUQ 100 How much work is there in primary care? There are >300m consultations each year in UK primary care (90% of all NHS contacts) and 20m contact per years in A&E. Each day there are 150,000 GP contacts, 5,000 Hospital outpatient and A&E contacts and 600 hospital admissions. Even a marginal shift from primary care to secondary care will overwhelm secondary care.

#GPFUQ 101 Can GPs increase patients self treatment and reduce the need for medical involvement. If GPs don’t do the work – will GPs lose their special relationship with their patients? General Practice can be like being a good parent it involves not just quality time but also routine stuff so being a good GP means being available for the minor worries, coughs and travellers' diarrhoea as well as for major physical and psychological pathology. By dealing with the former GPs can build the relationships they need to be able to help with the latter. However many minor ailments could be self managed. IMS Health survey Dec 2007 shows 57m GP consultations annually involve minor ailments, (51.4m involve MA alone), 18% GP workload is for MA, 50% MA consultations are for 16-59yr olds, costs to NHS £2b pa (80% are for GP time), averages 1hour/day for every GP http://www.pagb.co.uk/information/research.html#tns

Suggestions for action  

·               GPs should develop a strategy for promotion of self-treatment of minor ailments, and a triage process. Setting up self-treatment facilities and advice.

·               RCGP should script Video and podcasts for use on the practice website and in the waiting room that tell patients how to look after minor ailments. Use the same RCGP script in different practices but with the local GPs as the ‘actors’ to promote local interest and validity. The video and podcast are accompanied by a printed handout on the management of minor ailments. You can have video added to video broadcasts in waiting room

·               Set up an ‘Avoid the queue, self manage your illness’ area in the practice to advise on initial best management for the following conditions which are the commonest minor ailments back pain, dermatitis, heartburn and indigestion, nasal congestion, constipation, migraine, cough, acne, sprains and strains, headache, earache, psoriasis, conjunctivitis, sore throat, diarrhoea, haemorrhoids, cystitis, hay fever, warts, nail infections, colds.

·               Produce an evidence-based handout on How to manage your minor ailment for each of the common minor ailment conditions.

·               Identify patients who have presented with minor ailments from the consultation records of the electronic health record and after the consultation mail the patient the information sheet How to manage your minor ailment for the relevant conditions- invite patients to return feedback sheet to enter into a prize draw

·               Gain greater value from previously under-utilised sources. This may include: enabling patients, carers and communities to manage and improve their own health and/or contribute to the process of healthcare; empowering members of the healthcare team whose contribution is at present limited owing to lack of training for example; and/or removing barriers that are standing in the way of obtaining full value from all members of the healthcare team eg ‘practice to the limit of the licence’

·               Triaging, consulting and prescribing for common benign conditions without red flags e.g cold, sore throat, UTIs in women, acne minor skin problems etc. Transfer most care of minor illnesses to triage by others and taught self care

·               Getting experienced staff to deliver some of doctors duties, i.e writing prescription for minor illness

·               Use local newspaper adverts about management of minor ailments

·               Provide more information for patients to record and track their symptoms and signs eg A one page leaflet to record and track symptoms of pain

·               The RCGP should publish a template for best practice

#GPFUQ 102 How do you become an expert? An expert is someone who has made a lot of mistakes. You will miss every common treatable problem once in your professional lifetime. Disasters happen as a chain of small mistakes. Try to learn from the mistakes of others, you won't have time to make them all yourself.

#GPFUQ 103 What the difference between experience and making mistakes. Experience reminds you and makes you recognise a mistake when you make it again. It’s inevitable that you will make mistakes – that fuels learning. It you keep making the same mistake – that’s incompetence.  Success gives you a habit, failure gives you learning

#GPFUQ 104  Are most problems in primary care trivial or self limiting?  Yes Trivial and self limiting illnesses are not difficult problems. Good GPs know that patients may present with a simple illness but often have an underlying worry about their health that needs to be identified and addressed. You can use the opportunity that trivial and self limiting illnesses give you to build your relationship and advising patients on healthy lifestyles and opportunistic health screening opportunities 

#GPFUQ 105  How difficult can it be to manage self limiting illnesses?  It’s easy to manage self limiting illnesses. It can be difficult to manage the patients that have the illnesses.