General practice adaptation

In 2001 Richard Smith, then editor of the British Medical Journal (BMJ) wrote an editorial titled, Why are doctors so unhappy?  and found the source of their unhappiness in a bogus contract in which medicine promised too much and delivered too little to the mutual disappointment of doctors and patients.

In 2013 John Launer responded in an essay titled, Doctors as Victims in which he called for doctors to reflect on how powerless they felt despite being in possession of far more power than their patients.

Returning to the theme, and linking these two pieces together, Smith has responded with a much less sympathetic blog for the BMJ this week,

General practitioners have replaced farmers as the profession that complains the most.

I have no sympathy for them. I want them to stop being victims and become leaders, people who solve problems rather than complain about them and expect others to solve them. I’ve preached this message to meetings of GPs several times in the past, which has not made me popular, but the current orgy of moaning has urged me to put finger to iPad.

When I was editor of The BMJ I seemed always to be reading studies of stress in doctors. Why, I wondered, were there so many studies of stress among doctors but few among single mothers, the unemployed, schoolteachers in rough areas, aid workers, rickshaw drivers, asylum seekers, or the billions living on less than $1.25 a day?

Seeing yourself as a victim, he says, is unedifying when others are so much worse off than you are.

Smith never practiced clinical medicine. Disturbed as a medical student by the realisation that medicine can do serious harm as well as good, he avoided having to personally take responsibility for others lives. He doesn’t know, as I do, what it feels like to kill someone when you were trying to save them. As an aid-worker in Afghanistan in 2004 I was evacuated after several of my friends and colleagues were shot dead. I’ve always worked in rough areas and every day I listen to the stories of asylum seekers, victims of torture and domestic violence. Despite my happy childhood and financial security, I have a pretty good idea what stress feels like. Faced with a depressed patient, the last thing you do is tell them that they’ve got little to be depressed about because you’ve just seen someone whose situation is far worse who is coping much better. One thing most depressed people suffer from is the guilty feeling that they don’t deserve another’s sympathy because they don’t have enough to be depressed about.

Faced with a patient (or a profession) that is in distress, the first thing to do is acknowledge and explore their emotions, and your own. GPs are feeling depressed, anxious, angry, exhausted, confused, despondent, miserable, hopeless, powerless even. Smith is feeling frustrated, impatient, angry even. The next step is to try to understand the emotions. Acknowledging and understanding  feelings are the affective and cognitive aspects of empathy. The next, compassionate step is to try to identify needs. According to the recent BMA survey, the majority of GPs want to spend more time with their patients, less paperwork and better continuity of care. Recent articles in the Journal of the American Medical Association and BMJ Quality and Safety have argued for the importance of finding joy in medical practice through professional autonomy, meaning and respect. Penny Campling has clearly articulated the need for professionals to work in a culture of ‘intelligent kindness’ if their work with patients is to be also kind and caring. I guess Smith wants medicine to be more humble with regards to its science and more radical in its politics. He wants doctors to be more like him.

Demanding solutions without exploring feelings and needs is a form of violence, according to Marshall Rosenberg, who has pioneered ‘non-violent communication’. People with feelings and needs need to be heard without criticism or demands. Smith’s conclusion,

a moratorium on moaning and a festival of ideas for reinventing general practice.

will not be taken up by a profession whose distress is dismissed.

Having said all that, I have spent some time thinking about what might enable GPs to find more joy in our work. The following is a sketch of some of the things that we could consider if we are to thrive in future. It is not a prescription to be swallowed hole, but a menu of suggestions, there should almost certainly be more options and some that are unpalatable. But it is my response to Richard Smith’s challenge, and I hope some of it will help.

General Practice adaption

GPC Chairman, Chaand Nagpaul’s 2015 LMC conference speech received a long, standing ovation from the assembled GPs last month as he described ‘the triple whammy of morale, workload and workforce pressures’ and quoted the Health Education England Taskforce review  describing a ‘GP crisis’ because present numbers of GPs are unable to meet current demand. Numbers of GPs per head of population are set to decline with up to 10 000 planning to retire in the next five years, many training places unfilled, and one in five trainees planning to emigrate.

General practice clearly needs mitigation to attract more doctors to the profession and the case for this is clearly stated by Dr Nagpaul  but it also needs adaption to cope with a future in which there are significantly less GPs per head of population than there have been before.

The following are suggestions about how General Practice can adapt. There is almost certainly a bias towards urban General Practice, because that is where I have worked, and these are suggestions, not a prescription. But there is no doubt that we will need to change, wherever we work.

Rethinking the gatekeeper role.

The GP gatekeeper role should be reserved for situations of medical diagnostic uncertainty and clinical management support. In most other cases and especially when patients want self-management support, they ought to be able to refer themselves to a specialist. In many instances patients can already self-refer to the services listed below, but this is not the case everywhere and I have referred patients to all the listed services in recent years. I would suggest that patients should be able to refer themselves directly to these services without having to make their case to a GP. The services would have to adapt by having their own effective triage system so that patients are supported on a spectrum from advice to specialist intervention as appropriate. Patient education and self-management support should be part of every service at every level.

• Abortion
• Alcohol services
• Ante-natal care
• Audiology including paediatric
• Dietician
• District nursing
• Exercise/ gym
• Falls team
• Family planning (contraception)
• Family support services
• Health trainers (see below)
• Health visitors
• Occupational therapy
• Palliative care
• Physiotherapy
• Podiatry/ foot health
• Psychology/ counselling/ bereavement counselling
• Rehabilitation (after major illness, e.g. heart attack/ stroke etc.)
• Sexual health
• Smoking cessation
• Social prescribing
• Social services
• Speech and language therapy (paediatric and adult)
• Specialist nursing, e.g. asthma, copd, dementia, diabetes, epilepsy, heart-failure, stroke, wound care etc.
• Substance misuse

Patients should also be able to refer themselves back to hospital after a missed or cancelled appointment. A considerable and infuriating amount of time is spent re-referring patients back to hospital with the same problem.

Triage

When a patient presents with a problem, for example stomach ache, they may not know whether they need to see a GP, a nurse, a pharmacist, a gastroenterologist, a general, urological, gynaecological or vascular surgeon, a hepatic or renal physician or whatever. An expert generalist at the point of first contact can minimise the steps required to solve the problem. This is why many practices are choosing to phone patients before they book appointments so that if possible they can deal with their concerns immediately and where not, they can make arrangements for their patients to be seen. At present, this system still relies on receptionists taking the initial call, and making a basic triage decision: can they wait for the GP to call them back, or do they sound so sick that the GP should be immediately informed? Furthermore, with this system, GPs might find themselves spending a lot of time signposting patients to services or giving simple advice, a role that health-trainers (or similar) could do very well. If the first point of call was to a clinically trained receptionist, such as a health-trainer who had immediate access to GPs in case of concern, then GPs could spend more time with patients who need them.  Where possible, every point of contact should have some clinical training so that, for example instead of making an appointment for a blood pressure check, everyone who works in a GP surgery can check a patient’s blood pressure and teach them how to do it themselves next time.

The GP team.

The traditional GP team has expanded over the years from a GP and a receptionist/ manager to include practice nurses, nurse practitioners, health-care assistants and more. Not long ago health-visitors and district nurses were based in GP practices and many GPs wish the close working relationships could be re-established. The advantages are better continuity of care and clearer lines of communication. The extent of the team will vary according to the size and needs of the practice, but larger (>10k patients) practices could include:

• Auditors, at practice and CCG level to regularly audit practice, guided by GPs to choose the areas to be audited, but not to waste time on the audit process itself.
• District nurse
• Health trainers/ community health workers to support self-management of chronic diseases, including hypertension, diabetes, asthma, COPD and lifestyle change including: weight loss, smoking cessation, exercise, alcohol reduction etc. They could also proactively follow up vulnerable patients who are not good at attending appointments and visit housebound patients. Here is a good guide to Brazil’s Family Health Strategy and use of Community Health Workers (Agents). One of their most important roles is to pro-actively engage people who are in need of care but do not choose to go to their GP.
• Health visitor
• Legal and financial advice
• Pharmacists to support medication reviews, polypharmacy rationalisation, prescribing audits, repeat prescription requests, changes in prescribing guidelines. Excellent blog by Ravi Sharma, a GP based-pharmacist explaining his roles
• Physiotherapist
• Psychologist/ counsellor
• Social worker

GPs should not be spending time on human-resource management (HR), occupational health, and finance-management. A lot of this work could be carried out at scale for federations of practices with patient-populations of >100 000

IT

Patients should have online access to their medical record. This can improve the accuracy of the record and will enable patients to show it to every health-professional they meet and keep it safely updated. This is not without risks; consider for example an adult that discovers that they were once subject to a child-protection order, or a woman in an abusive relationship whose partner forces her to disclose her record. Risks need to be mitigated and shared between GPs, NHSEngland and patients.

Social media.

Secure online platforms for patients and professionals should be set up so that expertise can be shared. Self-care protocols could be set up and time-tabled specialist presence so that patients and professionals know when to look for answers with effective moderating and curating so they know where to look.

Community specialist teams.

We need teams in areas of high need such as nursing homes / homeless / mental health with the commissioner working with providers and third sector organisations to design contracts that stimulate innovation. Nursing homes are in a parlous state with providers squeezed desperately as a result of government cuts to local authority funding. When nursing home care fails, patients end up in hospital. Joint health and social care budgets might force commissioners to fund care where it is most cost-effective, which is almost certainly in nursing homes with expert-medical support. GPs, working in teams with geriatricians, psychiatrists and specialist nurses are in an ideal position to work here. But many hospitals are carrying enormous debts from the reduction in payments by tariffs and PFI costs and cannot cope with any further loss of funding.

Team working.

One of the greatest dangers in general practice is professional isolation. Older GPs remember a time when they would have weekly meetings at the local hospital and knew many of the consultants personally. The intensity of their workload now means that many GPs are isolated not only from their hospital colleagues, but also one-another. It is vital that time is made and protected at least weekly, both online (as suggested above) and face to face for GPs to discuss the patients that they and their colleagues are concerned about. Almost all the changes above increase the size of the teams within which GPs work and effective teams need good lines of communication.

Relationship-based care.

For almost all patients, and especially those at the end of life and those with serious, chronic illnesses, complex multi-morbidities and enduring mental health problems, continuity of relationship is essential. Although most patients will be cared for by teams, continuity within teams should be a priority and every patient should have their own named, responsible GP. Health care is a moral practice that involves people treating people, and yet we are in danger of treating medicine as if it were science treating disease by protocol. If we let it go that way even more than we already have, then we will dehumanise our patients and ourselves, to say nothing of recklessly ignoring the complexity of human lives and human suffering.

Estate change.

Chaand Nagpaul quoted the LMC survey showing that 40% of GP premises are inadequate to provide essential care and 70% do not have space to expand. NHS England has secured a £1bn infrastructure fund which will benefit 1000 English practices this year. We need fewer, bigger GP practices providing more services with space for specialists to work in the community where they can train and leave legacy. BMJ podcast on buildings for health: GP practices  should be community centres.

Patient-centred care requires buildings that are easy to access and navigate, promote care and recovery for patients and good health for everyone in them. They are not only places for work, but must also provide peace, natural light, healthy food and time and space for everyone in them to meet, learn, reflect and rest.

GP training.

This should be a ‘better fit’ for the needs of the future GP (RCGP 2020) with a greater emphasis on elderly care, palliative care, multi-morbidity etc. There should be much more attention to patient-centred care, in particular shared-decision making and self-management support. Training should reflect the shift from a GP as an independent practitioner to a multi-disciplinary team player.

Out of hours and 7 day a week general practice.

There are not (and will likely never be) enough GPs to keep every surgery open 8-8 , seven days a week operating as the presently do. However in places like Hackney that have taken back responsibility for out of hours care with a locally run GP co-op, the quality of out of hours care and patient satisfaction levels are very high. The infrastructure: phone-lines, receptionists and clinicians is already in place, and with a little more investment could be set up to offer patients appointments with GPs and other members of the primary care team, at weekends.

Less is more.

Finally, there is a global coalition of medical professionals, journalists and patients who have realised that a great deal of modern medicine is not effective and that cutting down on waste requires that patients and professionals are given the right information and enough time to make the right decisions about care. We could start be stopping unsolicited health-checks and dementia screening as well investigations like MRI scans for the vast majority of patients with back pain and headaches.

BMJ Too Much Medicine

http://www.lessismoremedicine.com/

Innovation, evaluation and emulation.

General Practice is a hot-bed of innovation, but innovation is incredibly patchy, poorly evaluated and rarely emulated. The Royal College of GPs should support innovation, evaluation and emulation so that good practice is backed up by good evidence and shared so that patients and GPs everywhere can benefit.

Further reading:

RCGP Blueprint for general practice May 2015 http://offlinehbpl.hbpl.co.uk/NewsAttachments/PGH/Blueprint.pdf