Why is it bad for you if everything seems to be going well?

#GPFUQ 152 What’s it mean if there aren’t any problems? It usually means you have not been paying enough attention to everything around you and have not noticed the problems that are there.

#GPFUQ 153 Why may it be bad for you if everything really seems to be going well? If you’re not having any bad experiences it usually means you aren’t getting out enough or challenging yourself.

#GPFUQ 154 Can complex problems have simple answers? In real general practice for every complex problem there is always an answer that is clear, simple and wrong.

#GPFUQ 155 What do we need to do when the guidelines have no good answer? GPs have to us their judgement to help patients decisions about their care. This judgement is a major sink for risk in the NHS but we have to be careful because the risk we are taking is with other peoples lives.

#GPFUQ 156 When do guidelines and technology cause most problems?  It’s when they make us ask our patients questions that neither of us really want asked.

#GPFUQ 157 When is a patient’s urgent problem not an emergency for a GP? It’s not an emergency for the GP if the only failure is that the patient hasn’t planned their day.

Why is there a crisis in GP numbers?

#GPFUQ 149 What’s the big crisis in GP numbers? The recruitment problem is that not enough junior doctors want to train in general practice and not enough want to train in the under-doctored parts of the UK. The retirement problem is that too many GPs are aged over 50 and too many are deciding either to retire early or not continue working after the age of 60. The retention problem is in response to the changes in work that too many GPs are quitting careers in general practice too early.  The returner problem is that GPs who leave UK practice for more than 2 years but want to return have to have a period of low paid retraining. The regulation problem is that the bureaucracy of payments processes like the Quality Outcome Framework, and accreditation processes like the Care Quality Commission make GP work unpopular. It's clear that we have to challenge and change current recruitment, retention, retirement, returner and regulation practices if we want the NHS to continue with the primary care registered list that provides care for all patients and protects the secondary care from too many referred patients.

#GPFUQ 150 Why is there a crisis in GP numbers? The accumulation of past errors and current circumstances has created a perfect storm! These probably include the structural and process problems that allow the largest UK specialty (General Practice) to be relatively under-represented in all the organisations that influence the choice of medical careers; the rapid expansion in numbers of hospital specialists (possibly at the expense of general practice) with more sub-specialists who need more junior doctors to, the relative underfunding of primary care (compared to secondary care) at a time when workload is increasing, all the other portfolio jobs that can divert GPs away from clinical practice, the changes in GP workforce that necessitates more parental leave and more part-time working, the reduced pension cap that means many older GPs reduce how much they work to match their pension cap,  the burden of over regulation with revalidation and Care Quality Commission, the weekly onslaught of bad news about general practice in the media and the increasing demands that mean a GP’s day is often a busy 11-12 hour day.

#GPFUQ 151 How do you solve the crisis in GP recruitment? Hold the feet of the politicians, civil servants and medical speciality leaders to the fire on consequences of a NHS without effective primary care. Ensure each and everyone responsible is held accountable for their actions and inactions. Some suggestions include placing more medical students and Foundation doctors in the practices where they are most likely to be inspired to become GPs. Its not surprising that if medical students and Foundation doctors spend most of their time in hospitals, and have straight forward career paths in hospital they may be biased towards a career in hospital medicine. The status quo has failed to provide the balanced workforce we need.  A better way may be for medical students, Foundation doctors and GP trainees to spend at least 50% of their time in general practice learning medicine by following patients who have the specific health problems listed in their medical curriculum on their journeys though the health and social care services.  We must also promote Foundation and GP training in the under doctored areas otherwise the NHS will collapse in those areas. The NHS and Health Education England must use all the carrots and sticks at their disposal to get junior doctors working in the right numbers in the right specialities in the right areas.

Why do GPs use IT like its ‘paper under glass’?

#GPFUQ 146  How do you get big projects started and finished? 

This is the how do you herd cats question. First recognise and work on all the different elements; the political dimension, the personal dimension, human behaviour, organisational behaviour, other interests, motivations and blockers, the time and timing. Second make a start (it’s the essential first step), work at it (it won’t happen by accident), accept steady progress (it will take time to deliver), try to create independent brokerage (avoid any conflicts of interests), recognise any vested interests (pander to them when necessary), encourage friendship (like each other and be happy), bring dissenters inside the tent (use their ideas and energy), deal with key stakeholders individually (formally and informally and be flexible with your approach), be trustworthy, honest and open (but leave some room for secret manoeuvres).

#GPFUQ 147   What’s the secret of life?  

Honesty and fair dealing. If you can fake that, you've got it made.  Groucho Marx

#GPFUQ 148 Why do GPs use IT like its ‘paper under glass’?

Practices have been paperless for years but often they use the new technology to work in the old ways - the ‘paper under glass’ mistake. Practices fail to use IT to its full extent.

Some suggestions for action

·      Ensure consistent use of practice computer system by the practice team. This does require training and expense - but makes notes much more useable

·      Have regular sessions to share ‘top tips’ on how to use IT in the practice.

·      Find out and use all the shortcuts like macros on your computer system

·      Stop duplication of any work that’s on paper and computer

·      Have all the forms and letters you use formatted as mail merge so they are automatically filled by the computer

·      Build synchronized actionable alerts (i.e. they routinely prompt at the right time what’s needed for good long term care) in the EHR, and train the team exactly when to act on them in their daily routine.

·      Make sure that when you design something it fails safely. For instance don't send out emails saying "get back to me if there is a problem on this"

·      Gets patients to enter more information in the EHR - home BP, Glucoses, questionnaires

·      Use non-clinical portions of EHR templates to record other important information e.g. contact details for next of kin, key worker for mental health patients so that any clinician can find this information easily

·      Use internet technology that facilitates new ways of communication mechanisms e.g email consultations with patients, use web cam link from patients home to surgery, videoconferencing, facebook, twitter, shared documents etc

·      Automate data extracts and collection – e.g. on referrals, workload. Data drives improvement.

·      Use e-mail to ask clinical questions and to liaise with and get support from secondary care

·      Use email distribution lists, always use a subscribe and unsubscribe option

·      Use Youtube to spread learning e.g. instructions for patients on self management

·      Avoid looking at the screen instead of looking at the person - this is a false economy in terms of time, people need to feel listened to

·      Use Voice recognition software instead of typing to enter clinical notes and write letters

·      Get joined up with the other relevant health and social care IT systems. Liaise with third parties like Hospital Trusts to ensure GPs can access hospital IT systems from their desktop PC. E.g. access pathology reports

·      Insist on having ‘single signs on’ to access the various other systems you need to use on your computer. Single signs on will increase their use.

·      Integrate referral pathways from third sector partners

·      Use decision support tools that help you provide informed consent e.g. What are the numbers needed to treat for the intervention you are recommending

·      Make sure information does not need to be entered more than once

·      Allow patients access to a copy of their personal health record and gets them to check that its correct

Should GPs use their professional judgement or follow guidelines?

#GPFUQ 143 Should GPs use their professional judgement or follow guidelines? Is it more important to follow a pre determined performance pathway (like guidelines or payments for performance) that links all aspects of work (e.g. effort, achievement, values, purpose, and self understanding) to measures and comparisons of output? Professional judgement like any practical wisdom is a form of knowledge that is not formally taught and learnt but is acquired mostly through experience and informal conversations. Wisdom develops through continuing critical deliberation about what is the best thing to do in practice. This is more than learning from simple reflection. In general practice it is the use of a clinicians professional judgement that should help individuals manage the uncertainties and risk in their lives.  A modern paradox is that GPs are trained to use their judgement for the best interests of their patients but all the prescriptive legislation and guidelines doesn’t allow them to use their judgement anymore.

#GPFUQ 144 How should GPs performance be managed? If you can’t measure it then how can they manage it? The outcome of the most important work in general practice is more a journey than a destination. The role, and the expectations, of primary care continue to expand, creating a need for a thoughtful process of rethinking the work on a regular basis. Everyone needs to be working ‘at the top of their licence’ most of the time. This will not happen without performance management

Suggestions for action

·               Stop thinking that the job of a GP is an art form

·               Stop thinking that most GPs are above average

·               Stop working in isolation, without your work being observed

·               Have annual in-house annual performance management of GPs. Neither NHS appraisal nor GMC revalidation are effective or useful in performance management.

·               Have in-house performance measures that are important and relevant in your team. Choose measures that may be a problem and will make a difference for patient care

·               Train, value and have career progression for non-clinical roles as well as clinical roles.

·               Tell and thank your staff and colleagues when things are going well

·               Aim for communicating and coordinating care better for patients in the different settings (health, social care, community, home), with better self care of patients, targeted ‘at risk’ groups and better preventative health for the population

#GPFUQ 145 Should GPs be assertive advocates for overall patient care like quality and efficiency - not just in their general practice 

The best organisations are more likely to tell people outside they are great. Good Practices exceed rather than meet patient expectations

Suggestions for action

·               Make sure care is coordinated and /or integrated across all elements of the system and the patient’s community, and that a patients referral is tracked, results are tracked, the patient is informed of the results and knows there was an interaction between his/her doctors. The patients learns what to do next and somebody asks the patient if everything turned out OK

·               Have an easy to use  template and process that you can use to report any problems with quality

·               Always ask 'is there something else you want to address in the visit today. It’s a more effective question than ‘is there anything else you want to address in the visit today?’

·               Don't be afraid of feedback and comparing results and processes