What should GPs do for their patients?

#GPFUQ  89 What should GPs do for their patients? You should never do for others, what they can do for themselves. 

#GPFUQ 90 How can todays GPs survive a 40 year career

Not Waving but Drowning. Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
 And not waving but drowning.

Poor chap, he always loved larking
And now he's dead
It must have been too cold for him his heart gave way,
They said.

Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life And not waving but drowning. Stevie Smith

Every career in general practice changes.How can any GP hope to survive a 40 year career with increased  demand, for care, extra expectations of GP expertise, more external regulation of quality, against a background of difficult changes and austerity. GPs need to develop an informed plan for a long, progressive and mostly enjoyable career in general practice..

All the world's a stage, And all the men and women merely players; They have their exits and their entrances, And one man in his time plays many parts etc . Shakespeare

#GPFUQ 91 Whats a GP personal development plan? Identify what you want to achieve and your learning or development needs, prioritise them, match those needs with opportunities to learn, check it worked. GPs need to do this as part of NHS appraisal. The most important parts of a PDP are not what you what are going to do in the next 12 months anyway, it’s the longer term planning you need for a 30-40 year career. You may not be able to think in terms of 30-40 years but you can make a plan with milestones for the next 5-10 years. You can make changes to your plan as you progress in your career and as opportunities arise.

#GPFUQ 92 How can GPs manage the demands of  the ‘Get a note from your doctor’ culture GANFYD,

This includes sick certificates (or fit notes) for employment, social control certificates for school and housing issues, sick notes for students and school children (so they don't lose their bursary for one day), certifying long term sickness absence without knowing any of the workplace adjustments achievable, filling in review forms for multidisciplinary panel meetings, dealing with some agencies problems / agendas regarding shedding responsibilities for care – e.g. the home care is concerned but the relatives are absent, completing paperwork for other government agencies, and housing forms

Suggestions for action

·               Have a rubber stamp made or automatic letter – e.g. I am unable to answer this request for a ‘note from your doctor’ in a meaningful or informative way

·               Provide instruction and facilities for patients to self write sick notes or other notes and ask patient to complete the sick or fit note ready for signing by their GP. In many of these circumstances there are no objective symptoms and signs of illness for a GP to document or certify, a doctor has to rely on the patients report of how they feel or felt. Whenever possible the patient should complete the text of the relevant certificate and a doctor can sign the certificate to attest the reasonableness of the text. No appointment to see the doctor would usually be necessary, or a telephone or email consultation might be sufficient.

·               Always charge a fee for certificates that are not part of NHS GP work.

#GPFUQ 93 Why is it sometimes important for a GP to pretend to have the memory of a goldfish? So as not to get upset over a long career when the endless circle of changes  brings back old ways of working as new bright ideas again and again.

#GPFUQ 94 Consultations – How difficult is it for GPs to schedule more efficient and effective patient consultations ‘how to get better time for consulting with patients’

Patients will always want time to discuss their problems. The appointments system (including face to face, telephone and e-mail consultations) must meet their expectations. The best appointment processes seem to manage the first contact with patient better, avoiding any user-unfriendly barriers, allow the patient to get through to someone who knows them, and provide open access scheduling so that everyone who wants an appointment that day will be seen that day. GPs should use telephone consultations more and structured e-consultation to make the process more efficient and effective and ‘stopping the ping pong of emails and with patients’.

Practices who triage all calls seem to manage their workload better ‘telephone triage of same day requests works well (done by GP's with personal lists)’ ‘our telephone triage service saves time’

Suggestions for action

·               You must know how many appointment you really need and always have enough appointments to meet demand – ‘it reduces stress for patient and staff’.

·               The appointment booking systems must have enough capacity both in terms of the number and types of appointments and be easy to use. This will ‘reduce the amount of time spent coping directly or indirectly with the consequences of poor systems’.  You may need to change appointment system to reflect the local demographics.

·               If you can’t provide enough appointments to meet demand, you must change your way of working eg more triage, more telephone and e-consultations, more delegation and skill mixing.

·               Have a health professional sift the booked appointments in advance and plan what else needs to be done before or at the appointment eg pre-consultation checks (BP, weight, urine) by a Health care assistant. Clinical prompts and pop ups on the GP computer system do the same as long as they work.

·               Protect routine work from the demands of urgent work. Provide a dedicated duty doctor +/- nurse practitioner: this protects others clinicians from fluctuating and urgent demands. They also have time to deal with patients more thoroughly and appropriately, rather than rushing urgent work alongside routine clinics

·               Have fewer face to face consultations, more phone and email consultations if medically appropriate

·               Provide a mix of appointment times - short/medium/long

·               Provide longer appointments. 10-12 minute appointments may be the current standard appointments but 15-20 minute appointments seem needed so that fewer patients are more thoroughly reviewed with as many problems as possible dealt with in each consultation ‘you can get done in 15 minutes almost as much as in 2 x10 minute appointments and the patient doesn't have to take 2 half days off work and you don't spend several minutes each consultation saying hello, goodbye and trying to remember what was going on’. ‘Longer appointment times might allow more problems to be fully resolved in one visit’.

·               Vulnerable people eg learning disabilities and patients with complex need more time - target them for 20min appointments.

·               Arrange for multiple chronic pathology patients to be seen for half-1hr appointments once or twice a year for co-coordinated management planning.

·               Have telephone triage of same day appointment requests

·               Follow up of patients with phone calls rather than repeat appointments

·               Provide Online booking

·               Use SMS text to communicate with patients

·               E-consultations - The best process seems to provide a structured email consultation route ie one that patient can access via a web page but ensure that patient uses a structured process in the consultation. This avoids patient writing a letter and clinician having to ping pong emails backwards and forwards - see HHC example xx

·               The RCGP should publish a template for best practice

#GPFUQ 95 when does a GP need to do a visit to a home or residential care home? Some patients do need a home visit. But compared to face to face consultation in the practice, home visiting limits the resources available to the GP, and can also be a less efficient use of a GPs time so has to be managed effectively. Is a GP visit adding value, or would some other action be better?

Suggestions for Actions

·               Identify the truly housebound patients, and make sure their status is clearly visible in the electronic health record

·               Set up alternative transport arrangements for patients who could be seen in the practice e.g. set up a patient volunteer transport service, make an arrangement with a local taxi firm

·               Try to have personal lists or one doctor for the practice per care home

·               Have nurses visit the housebound and residential care homes

·               Provide a weekly "ward round" visit to a local nursing home to provide better care of all the patients and decrease unnecessary acute admissions to hospital.

·               Have regular pre-emptive meetings to discuss the best care of the housebound and residential care homes

·               Avoid pastoral home visits, routine and repeat home visits

#GPFUQ 96  What is NHS idle chatter?  We should be discussing the ideas and ways for improving the NHS, not the events,  nor the people who run the NHS.