This interesting ‘Views from the NHS frontline’ article by Dr David Turner, a GP working in London, in today’s Guardian shares some interesting insights into how GPs in the NHS think about the work they do before calling for “an open and honest debate, not just about what the NHS should be doing for patients, but what patients could do to make the NHS run better“.
“If the health service is going to thrive, patients must use the system more efficiently by keeping their scheduled appointments”
I think it’s clear that we all need to move beyond the idea that the product we are making is scheduled visits.
“The patient in front of me is five minutes late for her 10-minute appointment. As she sits down she tells me she is feeling suicidal, as her father has just been diagnosed with cancer and she is about to be evicted from her flat for non-payment of rent. It is 9.05am on a Monday and the waiting room is already standing room only. This is a slightly extreme scenario, but it does happen”
The first question should not be why this Patient is 5 mins late but why anyone would want to see a Patient with needs like this at 9.05am on Monday morning (the busiest period in a GPs week)?
It’s highly unlikely that the appointment was scheduled over the weekend, or that her father was diagnosed over the weekend or that the non-payment of rent was an issue that manifested itself over the weekend so this is a Patient who’s probably been worrying and losing sleep all weekend and has probably had to take time off work (no doubt further escalating the problem of unpaid rent!).
In London in 2015 you don’t need to wait for an available GP appointment to get financial advice. The Citizen’s Advice Bureau has a website, telephone number, local offices and a self-help website (adviceguide.org.uk) that provides practical, reliable information and suggestions like online budgeting tools that you won’t find within any medical school syllabus.
In London in 2015 you don’t need to wait for an available GP appointment to learn about the issues of caring for a father with Cancer. Cancer Research UK for example have forums dedicated to Caring for someone with cancer within their “Cancer Chat” Forums.
In London in 2015 you don’t need to ignore a packed waiting room for 5 minutes while you work out your Patient is late simply install a Patient Arrival System to manage your waiting room Patients so you can automatically begin seeing other Patients in this schedule gap.
When you appreciate that difficulty getting out of bed is often a symptom of depression I think it should be abundantly obvious that the best place to share your feelings about depression aren’t a rushed appointment in your GPs office at 9 am on Monday morning. I wonder if this Patient picked this time slot or if it was prescribed by the front desk receptionist when the Patient called in to make an appointment?
“Whenever general practice is discussed in news reports, the main complaint seems to be that people cannot get appointments with their GP. There are many reasons for this. Chronic underfunding, combined with ever-increasing unfunded work being dumped on us are two major reasons why it is harder to see your family doctor. Another important reason, which the media seems to pay scant attention to, is the misuse of the system by patients themselves”
I think this is just a design issue. GPs are trying to get away with a one size fits all model and the varying complexity of illness means we can no longer do this eg. Does ‘John’ need your time or attention?, the 2000 year old model of healthcare is broken forever, etc.
“The practice I work in has four doctors and more than 7,500 registered patients. We have an average of about 50 appointments not attended every week (DNAs). Not cancelled appointments, just appointments that patients failed to attend. That’s 500 minutes of doctor time wasted every single week. We are not unusual; most practices will tell a similar story. We advertise the fact of this wasted doctor time in the waiting room and text patients to remind them of appointments, but it does not seem to make much difference”
Yes mobile appointment reminders are a big help and ‘please confirm your attendance at tomorrows consult’ reminders can also help but they’re not a silver bullet solution to the failure of GPs to use the tools of our time.
When your GP surgery only offers in-office appointments why is anyone surprised that some Patients are making them and then not going? Is it really that hard for us to predict this behaviour? When appointments are limited and offered on a first come first served basis (without even attempting to consider the particular Patients needs) is it any surprise that Patients and Carers will want to confirm appointments when they know they don’t really need them because they are frightened that things might get worse later when the available appointments for that particular day are all gone?
“We don’t have any spare consulting rooms and there’s no extra funding to hire consultants. In addition to this we have a dozen or so appointments cancelled at short notice. This is when patients phone to cancel but leave it so late that an appointment cannot be reused”
Funding is a really big issue for innovation within NHS primary care. One solution I think is very promising is the Prime Minister Challenge Funding (the AskMyGP product qualifies for this so NHS GPs can have a secure online portal that can get a product added to their existing IT systems that can begin tackling capacity/demand challenges without the need to pay for all those expensive innovation consultants, IT experts, Pilots, Audits, etc).
“Another area that needs highlighting is what a GP appointment is and what can be realistically achieved within it. When I started work as a GP 15 years ago many doctors were still operating on five-minute appointment slots. That gradually changed and now most surgeries will offer 10-minute appointments as routine. In those 10 minutes the patient has to walk to our room and explain their problems. We have to examine them, make a diagnosis and explain any necessary treatments or tests and then do the associated paperwork. Finally, we have to summarise all this to the patient then write our notes and do the required box-ticking for the government so we can get paid”
A great reminder of how the modern NHS GP consult is increasingly being influenced by external political, financial and administrivia that sadly all too often have nothing to do with what’s best for the Patient or Doctor.
“This, where I work, is often complicated by the patient speaking little or no English or the consultation taking place through an interpreter”
Taking a history is hard enough but trying to do it through an interpreter is impossible with the demands and lack of resources being made available to GPs in the NHS today. It’s obvious that consultations that take place through an interpreter can be greatly aided by the use of interactive Medical History Taking software and with so many foreign trained NHS GPs it also enables better use of NHS talents eg. if there’s a life changing result that needs to be shared with a Patient it’s probably best to refer them to a Doctor colleague who speaks their language than to try and relay such sensitive information back and forwards through an interpreter.