What’s the weakest link in the chain of care?

#GPFUQ 193 What’s the weakest link in the chain of care? Attempts to reduce emergency hospital admissions should focus on all the people (patients, their carers and clinicians) at high risk. If better care is available outside of hospitals the rising demand for the care of patients with chronic conditions is hard to understand. It’s the weakest link in a chain of people at risk that’s important. The links are weak and the risk of emergency admission high when patients, their carers and clinicians each has to struggle to cope with a mix of complex medical and social conditions, the plethora of services available, perverse guidelines and incentives that confuse best practice, and the lack of effective feedback loops to inform their choices about care. The weakest link can be anywhere in the chain of people and services.

For example one of the many factors in the mix is the GP. A series of studies of GP Out of hours services in Bristol (Reference 1) showed a marked (a four fold) variation in emergency referrals between the top and bottom quartiles of referrers and a ten fold difference between the top ten and the bottom ten referrers. A low `tolerance of risk' by the GP seemed to be the weak link that predicts emergency referrals. Strengthening this weak link and each weak link in the chain by making the differences in behaviour visible by better feedback to the patients, carers and clinicians might reduce variation in performance and improve quality. Better knowledge and understanding of risk needs to be shared with out patients when making decisions about their care. 

Reference

Risk taking in general practice: GP out-of-hours referrals to hospital

Authors: Ingram, Jenny; Calnan, Michael; Greenwood, Rosemary J; Kemple, Terry; Payne, Sarah; Rossdale, Michael

What is connection culture?

#GPFUQ 189 What is the unintended consequence culture?

Its when in modern health care every possible approach to improving health care can have an unintended and unwanted consequence. For example improving health seeking opportunities for patients may enable either their dependency or self-care; transforming the interactions with patients may increases the opportunities for greater risk or reassurance and reconfiguration of 'work' practices may cause more burden or empowerment for patients.

#GPFUQ 190 What is connection culture?

It’s when you shift from using ‘I’ and ‘you’ to ‘we’ in your language and heart. If you can connect with someone you can talk about anything. If you are disconnected from someone its what you do next to get connected that’s important. When we are disconnected we feel different from the experience of others and this limits our ability to empathise and understand, to problem solve and manage risk. Seeking connections with people helps us respect different points of view and cultural diversity. We learn to be curious and more tolerant.

#GPFUQ 191 What is entitlement culture?

In British society everyone usually feels entitled to something. This sense of what we’re entitled to changes with the times, and seems to get stronger with each generation. The problems occur when sense of entitlements clash. For instance government and public may feel entitled to have an 8 till 8, 7 day a week routine NHS, but until the rest of the country works exactly similar hours the NHS staff feel entitled to have a roughly 9 to 5, 5 day a week routine NHS. The clash continues when patients believe they are reasonable to want faster access to more services for more of their problems, whilst GPs feel overwhelmed by the increasing workloads fueled by what they consider unreasonable expectations.

#GPFUQ 192 What is reality culture?

This is the Trilemma dilemma. Whilst we want fast accurate and cheap solutions to problems we can only ever usually achieve two out of the three. For example the answer to the Government rhetoric that its manifesto pledges it to push for increased access to GP services via 'seven day working' is that we already have a fast and cheap GP service  24 hours a day seven days a week  that is working  via our GP Out of Hours services. If we want to extend the routine five/six day services (that are already are under extreme pressure) quickly so that the seven day service is more ‘accurate’ or ‘routine’ we can’t do it with the present resources. It must be more expensive, or will take a very long time to bring about.

What do patients remember most and longest about their doctor?

#GPFUQ 185 What’s special about being a GP? A GP is a specialist in the health of the whole person who understands risk, solves problems and can fairly access the finite resources of the health service. In addition a GP is an advocate for patients a teacher, a leader, a business person, and an innovator. Being a GP is a challenging, difficult and highly skilled specialty requiring a breadth of knowledge and the ability to deal with ever increasing complexity and new challenges. Its never routine. GPs care for people not organs and have a continuity with their patients that simply cannot be replicated in secondary care. Patients are people and managing their needs entails not only basic medical management but also the added complexity of dealing with their personality, values and beliefs, their wider family and friends and everything in between. It's the difference between being any doctor and someones GP.

#GPFUQ 186 What do patients remember most and longest about their doctor? They only remember how their doctor made them feel not what their doctor said.

#GPFUQ 187 What the biggest problem to overcome in healthcare? Sometimes when things go wrong it leaves a legacy of unresolved anger and mistrust that is difficult to overcome.

#GPFUQ 188 What are the main obstacles to transparency in health care? Fear of litigation, fear of media criticism, and fear of damage to reputation. It needs compassion and bravery to overcome these obstacles?

How often will GPs see a condition that statistically they will never see?

#GPFUQ 181 How often will GPs see a condition that statistically they will never see?  About once every ten years.

#GPFUQ 182 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 minor ailments alone), 18% GP workload is for minor ailements, 50% Minor ailment 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 183 How should GPs assess their professional networks? Ask can you find and spread best practice any faster? The success of social networking websites shows how quickly networking tools spread. A ‘spread strategy’ is being part of an effective network of knowledge that works for you. Networking in one shape of form seems the most usual way that GPs already spread ideas. Formats include any professional meeting, peer group discussion and social events in practices and other group meetings and discussion in the wider world  (e.g. focus groups, internet groups, site visits, conferences, educational meetings, email communications, the media medical press, networks like CHAIN, doc2doc, Resilient GPs on Facebook, other social networking, chiefs meetings, champions, GP cooperatives, practice visits, annual appraisal, study groups, and on-line discussion groups). Most of these meetings are part of the professional and social fabric of the world we live in, and the networking is mostly unstructured and informal. However although it is clear that this networking connects almost everyone,  it may need improvement to make it more efficient and effective e.g. keeping up to date knowledge on any clinical topic like diabetes will be more robust if you can link with more than one network source about diabetes. Many of these networks have become prescribed with the formative processes involved in annual appraisals, and the various practice inspections (e.g. trainers reaccreditation) and provide a regular process of checking that every GP is part of a functioning professional network. Modern general practice where we work in groups and often have special responsibilities for certain clinical areas in the practice favour a networked approach to learning and being clear how each of us is connected to these networks for updating our knowledge and skills.

Suggestions for action

·           Map out your main networks and document them (who they are and what they link you to) for your next NHS appraisal. At your appraisal discuss whether there are any important clinical or business gaps in your links. What can you do to improve the efficiency and effectiveness of your networks? Circuit testing your learning networks at an annual appraisal process is a simple way to check up on the networks that each GP relates to. Whilst its too difficult to document all the networks, its is reasonable to test and trace the networks with hypothetical questions like how would you be confident that you would learn about and discuss a new innovation in practice management or new evidence in a treatment

·               Meet regularly with local colleagues to discuss difficult cases or to reflect on where they are and what can/must be improved

·               Buddy up with another practice to share expertise and resources

·               Look outside medicine and learn from business colleagues and friends

·               Have a relationship with secondary care colleagues- so that you can resolve local problems easily

·               Meet with wider social care/community nurses regularly to discuss patient referrals

·               Visit neighbouring practices to see what works well then discussing it at practice meetings to see whether the practice could learn from this

·               Continue any regular meetings with other GPs that has an agreed task of say support and sharing good ideas – and clear achievable and measurable aims eg Balint groups / Learning groups / Co mentoring

·               Undertake an evidence-based journal club weekly for 1 hour

·               Encourage all staff to attend practice meetings, not just partners. Involving them means they're more engaged with the practice.

·               RCGP should promote network groups- Unofficial groups abound, particularly among recent CCT holders. Make a census so they're known about.

·               The RCGP should publish a template for best practice

#GPFUQ 184 How do you improve GP? You need the feedback you can get either from a mirror or from a village

Whats wrong with the regulators?

#GPFUQ 177  What’s wrong with the regulators? A paradox of the new regulation of professionals like GMC Revalidation and the Care Quality Commission (CQC) that aims to reduce unacceptable variations in their performance is that the regulation itself can create unacceptable variations in regulation with poor quality assurance of both the structure and process of regulation creating variable outcomes. 

#GPFUQ 178  When is it the best treatment to stop medicines? If it improves patient outcomes. Risk can outweigh benefit when too many medicines are prescribed in patients with too many co-morbidties. Reducing and stopping drugs can then become the best treatment. There are 5 steps (1) check  all drugs the patient is taking and the reasons for each one; (2) consider the overall risk of drug-induced harm in individual patients before a  deprescribing intervention; (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential; (4) prioritize and agree with the patient the drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen and monitor patient  for improvement in outcomes or onset of adverse effects.

#GPFUQ 179  What’s the problem recording shared-decision making (SDM)? The use of electronic templates to gather data for whatever reason has shifted consultations from being patient-centred to computer-centred. The paradox is that the more time we spend recording SDM, the less time we have to actually do it.

#GPFUQ 180 When shouldn’t we ask for extra money for health care? If we are already spending money doing something pointless, or if we are looking for technical solutions to existential problems.

Who wants to be a GP?

#GPFUQ 171 Who wants to be a GP?  Surveys of UK medical graduates show that in the 1970s, over one-third of all newly-qualified doctors wanted careers in general practice, rising to 44% in 1983, but falling to 20% in 1996. A study in 2011 of cohorts of 2000, 2002, 2005, 2008, and 2009 showed the percentages of doctors who expressed an unreserved first choice for general practice in the first year after qualification, in the successive five cohorts, were 22.2%, 20.2%, 23.2%, 21.3%, and 20.4%. Percentages who expressed any choice for general practice, whether first, second or third, were 46.5%, 43.4%, 52.6%, 49.5%, and 49.9%. Three years after qualification, an unreserved first choice was expressed, in successive cohorts, by 27.9%, 26.1%, and 35.1%. Doctors from newly established English medical schools showed the highest levels of choice for general practice.

Information about early career preferences matters because early choices for general practice are highly predictive of eventual careers. For example, in previous cohorts 82% of doctors who specified that they wanted to become GPs in year 1, and 92% who specified this in year 3, eventually practised as GPs.

#GPFUQ 172 How do medical graduates choose a career?  We don’t know but likely influences  include,  student perspectives of the demands, rewards, and prestige of the specialty; national dialogue about health care reform; turbulence in the economic environment; lifestyle issues; the advice in medical school, the impact of faculty role models, peer group pressures and the availability of opportunities.

#GPFUQ 173 Will we have enough GPs in the future?  We can hope. The production of all doctors and GPs in particular remains insufficient to meet the current and anticipated need to support the UK's NHS infrastructure.’

#GPFUQ  174 How does learning happen in general practices Most learning in small organisations takes place in the workplace through work processes. It is multi episodic, mostly informal, usually problem based and takes place on a just in time basis. Despite the reality of how we actually learn, most organised learning on offer still tends to be based on a traditional model with modules, lectures and seminars and these are increasingly transferred from face to face interactions to onscreen interactions, but still keep the standard tutor/student relationship and the reliance on formal and standardized course material and curricula. Reviews of the effectiveness of  "traditional" style e-learning in health care show that there is little evidence of change in behaviour or improved patient care and suggest that change in behaviour requires a social /collaborative approach that allows the exchange of explicit and tacit knowledge. Such social/collaborative approaches applied face-to-face have been shown to work when bringing together professionals to share their experiences and learn together using problems based on their own working experience However, attempts to introduce online collaborative learning have often failed, perhaps due to a lack of understanding of the health care context and user requirements.

#GPFUQ 175 What is Bellman medicine? The belief that repetition is a form of validation. It’s from The Bellman in Louis Carroll’s The Hunting of the Snark. It’s the continued presentation of discredited data, or the disregard of data from an another study which comes to a different conclusion

#GPFUQ 176 What’s the latest in educational reform? Three generations of educational reforms characterise progress during the past hundred years. The first generation at the beginning of the 20th century taught knowledge from a science-based curriculum.  Around the mid twentieth century, the second generation introduced problem-based learning, and taught any relevant knowledge that would help solve the problem.  The next generation is now evolving.  This is systems sourced solving and is will provide a work environment in which core professional competencies get automatic support and teaching in specific contexts, whilst drawing on global knowledge to improve the performance of health systems