Tag Archives: general practice

The doctor will see you now… if you are truly ill.

31 Jan

Why is everyone scared of missing cancer? [BBC Radio 4 PM, 30-Jan-2013]
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Personally public needs to (wo)man up and face the fact we die. And most of us die from heart disease or lung disease.

Doctors know, though many politicians and public do not, that early diagnosis of cancer often fails to prolong life of patient. For example, read Prof Baum opinion about breast cancer screening

Medical industrial complex loves us diagnosing cancer early because lots of tests, procedures, and drugs will be thrown at the poor patient for “extra” disease free months/weeks. Has anyone stopped to check the ROI for the vested interests in the management of people who are diagnosed early?

Meanwhile, earlier diagnosis of depression may be useful though you know that many people with “affective disorders” and other psychiatric c condition’s are also a construct of the medical industrial complex – DSM V is an opportunity to medicalise more situations that are part of normal living.

Perhaps, earlier diagnosis of erosive arthropathy may have benefits for sufferers. This population of patients is tiny compared with cardiac and respiratory and psychiatric patients.

So to cardiac and respiratory disease.  If the politicians are to be believed, people with BMI 19-25 who never smoke will not develop heart or lung disease.  This is magical thinking. One patient at my cardiac rehabilitation class who was thin, young, with cholesterol < 4 and no family history of heart disease, and never smoked.  Apparently cardiac rehabilitation clinics see significant number of such people.

Sadly there are a large number of people with chronic lung disease who never smoke – many of these people have asthma. Even with good inhaler use and compliance, many of these people will develop COPD which is supposed to be a disease of smokers only.

So in spite of the propaganda, seeing your doctor at your time and choosing is actually not going to save your life.  Remember healthchecks are useless. Thus, the media and many public voices should stop whinging about access to primary care and GPs.

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2012 in review

3 Jan

The WordPress.com stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 2,700 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 5 years to get that many views.

Click here to see the complete report.

NHS will order doctors to work at weekends

16 Dec

ImageHere is a list of my objections to the proposal by Commissioning Board medical director Sir Bruce Keogh announced in today’s Sunday Times for general practice in UK to be open for business at weekends

 

 

  1. For GP, it may be practices, not doctors ordered to be “open”
  2. Cannot see this working unless adequate resources released to pay the support staff, let alone the extra doctors. And the support staff will need to agree to work too!
  3. Will not be helpful for patients unless hospital services are also fully open for business when we are. At least Bruce Keogh understands this
  4. The idea that this is necessary is politically driven and not based on evidence. Accept that some areas may benefit from this (e.g. inner city populations) but rural areas and leafy suburbs unlikely to benefit.

It would be better to spend the money on a EHR which OOH GPs can access at any time (and write in!) – allows centralised OOH service allowing those who wish to work unsocial hours to do so.

In short, the proposal should be strongly resisted at the present time. Doctors (and nurses) need to be nurtured not threatened to get the best from us!

Finally, does the public really want their GPs to be available 7 days a week?

Shame

16 Nov

A superb essay on addressing “Shame” in order to help people recover from depression and health care professionals develop better emotional resilience.

A Better NHS

Masaccio: The Expulsion of Adam and Eve from Eden 1425

Through the concrete physicality of the two figures and the arid landscape around them, Masaccio makes believable the first dolorous steps of human beings on earth, in the solitude of the shame of sin and the dramatic experience of pain. Quoted from ‘Medicine in Art’ Getty Publications. p.292

One of my patients, June, was standing near the entrance of the surgery when I came back from a home visit. June and I had been through a lot together in the two years since she came to see me with a breast lump, her subsequent mastectomy and chemotherapy, her husband’s dementia and death, and her depression and redundancy, but in recent months she had been steadily recovering and rebuilding her life and her health. The last few times we met she had been really well and we had time to talk…

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EXCLUSIVE: Secret Tory steering committee working overtime to ready NHS for mass privatisation

11 Nov

Sadly what surprises me about this news is that no-one has spotted such a working party earlier, say at the start of the NHS in 1948.

The Slog.

Enquiries by The Slog in the later hours of yesterday evening confirmed that an informal but extremely powerful Working Group has been set up by the Coalition – separate from both NHS management and the Department for Health – to assess the best way to facilitate the handover of NHS Hospital Trusts to the private sector.

Although details are hazy as yet, a picture is emerging of a Group very obviously dominated by privateers and anti-State lobbyists. To the best of my knowledge thus far, not a single member of it is closely associated with (or technically proficient in the understanding of) Britain’s rapidly expanding mutuality sector.

In the midst of blanket 24/7 coverage of paedophiles under every care home bed alongside easily the most boring Presidential election since 1972, this NHS story may not gain much traction immediately; but it is nevertheless the clearest sign yet to emerge of…

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eLearning Needs in NHS Sept 2012 #mobimooc

13 Sep

Mobimooc 2012 is up and running.  2 webinars have been well attended.  Regrettably the timing is not great for me – but the team has recorded the lectures 

By coincidence two new systems are due to launch in my region of UK.  An electronic prescribing system (EPS) and new telephone triage service (NHS 111)

NHS 111

http://goo.gl/ra2IE points to introduction to the system.  The NHS has also provided online introduction with accompanying slideshow here with direct link to the video Introduction to NHS 111

Here is a great example of mLearning in action but the local NHS managers insisted on practice teams send delegates to a meeting somewhere in my town.  Clearly this was a poor use of time for my practice manager.  With such a good presentation created, it is clear to me that the time taken for many people to get to the meeting would be better spent watching the slide show.  How patronising of our service managers!  There is apparently good evidence that the new system will be good for patients and reduce some of the demand on emergency services from (trivial) emergencies.

It does look like no-one locally is aware of mobile learning project management.  Here is  an excellent opportunity which has passed us by!  Notice there is no system on the website to help visitors assess their learning after reading the transcript while watching the slide show.  Why is the slide show an embedded video rather than posted on Slideshare, Brainshark, or other public cloud service?  How hard would it be to have a feedback form?

Whether the UK really needs another emergency number is a moot point now.  As a GP, this system looks to me a threat for the future primacy of General Practice as the first point of contact for health care questions by UK citizens.  This is sad.  In the not too distant future UK may come to regret the demise of the family doctor as an independent gatekeeper to healthcare services.  That is a discussion for a future post.

Electronic Prescribing System

I wish to share the following from my local medical committee concerning the roll out of the new electronic prescribing service because the rational behind it is described and the questions from my representatives focus us on another opportunity for eLearning.

NHS Bedfordshire and NHS Luton are working for Electronic Prescription Service (EPS) Release 2.  This will mean that the PCTs would then be enabled to allow practices and pharmacies to take part in EPS, if the practices and pharmacies want to.  This is part of a national programme.  We were told that EPS has been available in Hertfordshire for some time and that just under 30 practices are taking part in EPS there.  
We’ve seen documentation from Bedfordshire and Luton about what EPS is; what practices would have to do under EPS; what the criteria would be for selecting patients who could use EPS and what participating practices would need to do to support patients in making their choice; how patients would nominate which pharmacy they want to use for EPS and what the participating practice would need to do to facilitate this.

Beds LMC members recognised the positive objectives of the scheme, e.g.
It is supposed to reduce GP work load ultimately
It may be more convenient to the patient
It may reduce waste
It is understood that EPS will be optional for practices.
But Beds LMC members did have some concerns:
To what extent is it a whole new area of unfunded work in general practice?
Beds LMC members thought that EPS would create the following work:
1. GPs will be expected to identify suitable patients.
2. The GP has to look at all applications for it and make sure they do not have any of the exclusions (large groups of patients such as those on controlled drugs, anticoagulants and some others).
3. The GP or GP staff will be expected to promote and explain the process and follow this up in writing and collect a signature 
4. The practice will be expected to telephone suitable patients and offer it to them.
5. Time will be need to train GP staff.  Nothing about backfill for this.
6. All prescribers will have to use smartcards and be wary of prescribing some formulations or brands of medication which do not have a suitable barcode.  Not all practices use their “smartcards” when consulting because they cause their system to run slow and time out.  So clinicians log in and work offline.
Patients with regular repeat prescriptions tend to be patients on chronic disease registers.
On the rare occasions when patients such as this come in “just for a repeat prescription” it gives the GP an opportunity to pick up on preventative care, QoF items and other aspects of the health and wellbeing agenda.  In other words, the aspects GPs do not always have time for when dealing with acute illness in a 10 minute consultation.  Could the use of EPS actually reduce the level of care available for some patients?
Concerns that the EPS will not be a simple scheme, as some items cannot be included in EPS, so there would have to be two prescribing systems for EPS patients: one for EPS-included medications and one for EPS-excluded medications
Is there any evidence that EPS has saved time for GPs or staff in primary care?
If any Hertfordshire practices who are using EPS would be willing to share any of their experiences or would be able to answer any of the specific concerns listed, it would be very interesting to hear from you?

Here is my response:

Wow! How can such a simple idea as electronic repeat prescribing become so complex?

FIrst thoughts: I want nothing to do with a system with more bureacracy to set up. We have enough to deal with without this additional burden.

Second: The system is doomed unless bandwith of broadband connections is increased to cope with the demand from our desktops (and mobile devices). Currently broadband speed is around 10megabits per second down and 0.5 mb/s up, at least in Watford. Divide this by 8 prescription terminals and you can see the speed drop makes the system inoperable.

Third: Barcodes are not immune from corruption; at least several times a week a popup warns there has been a problem and the barcode should be scratched out. How do you do that with an electronic script?

Fourth: The main benefit of EPS is prescribing from mobile devices. With 4G/LTE imminent this seems practical so long as all prescribers have feature phones with the necessary hardware. I fear the powers that be are focussing on the wrong systems. We need secure login systems for iPhones/iPads and android devices to make EPS useful (e.g. prescribing urgent scripts on home visits, or residential facilities)

FIfth: How are pharmacists supposed to be persuaded to adopt this?

Sixth: Prescribing2U is already available. How does this differ from EPS 2?

Seventh: All HCPs who access clinical system must log in with NHS Smartcard. If there are hardware problems managing this, the IM&T teams across our area must fix these before rolling out EPS.

This system is being imposed on us on the background of a longterm agenda to cut the printed script costs.  There is also an agenda to improve security of prescribing.  Since proposed several years ago, IM&T systems and devices have evolved.  Mobile devices are so much more capable than before.  For example, my smartphone (HTC One X) is more powerful computer than my desktop system 10 years ago!

There is nothing in my local medical committee concerns nor in the NHS EPS background documents to indicate any desire to develop a mLearning project to aid in the implementation of this system.

Conclusion

Two new systems are being implemented shortly with the intention of improving patient care in an NHS region.  Two sophisticated organisations are responsible for the roll out of NHS 111 and EPS.  Neither seems to embrace education technology which, in my opinion, would ease the pain involved in changing behaviour of health care professionals and the public.

There is clearly a very long way to go to embed eLearning into the NHS.  This is a terrible state of affairs for a developed society.  It is ironic that some countries with large health care burdens (e.g. sub-Sahara Africa countries; South America countries) may be receiving superb instruction in mLearning systems.

I would love to see some discussion about the particular systems described above – your experiences of similar systems in your country, ideas on how to improve implementation, or anything else you think would be interesting.

Thank you in advance…

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What doctors do | Abetternhs’s Blog

18 Jun

http://abetternhs.wordpress.com/2011/07/24/what-doctors-do-2/

Royal College of Surgeons of England ends quiet alliance with sister Colleges

8 Mar


At the EGM of the RCSEng tonight the illustrious Royal College Surgeons rejected joining with RCGP, BMA, RCN and other health bodies in rejecting the Health and Social Care Bill.

A clear break in the unity of the medical profession has happened.

The RCSEng folks should be ashamed of themselves for paying lipservice to the democratic process. The pre-meeting vote for withdrawal of the bill was in favour of this stance (84% of the 175 delegates).

In my opinion, history will show that this is the day (night) when the Royal of College of Surgeons loses whatever respect it held with its colleagues in the health service.

It is postulated that the RCSEng would not ally with the others because it wishes to remain apolitical so as not threaten its charitable status.

Whatever happened to the duty of surgeons to uphold the welfare of the citizens who are served by its members?

Has No 10 blackmailed, sorry persuaded, RCSEng executive that they risk something precious if they reject the health bill AND ally with the rebels?

A meeting stuffed with ex-PRCS’s and a Lord or 2 and a sitting member of the Government surely had nothing to do with an independent vote.

Primary care, where the bulk of the Health and Social Care Bill is focussed, has been betrayed by our (general) surgical colleagues.

Perhaps some of these surgeons should stop calling themselves doctors and accept they are primarily technicians who have no part to play in the politics of healthcare.

Grassroots surgeons and doctors who are dedicated to the welfare of their patients and work hard despite the constraints of an enlarging bureaucracy must stop being in thrall to the “elites” who populate the medical establishment. The top dogs, esp in RCSEng, but also in some of the other colleges, have shown their true colours – better to keep the government happy than nurture the respect of members of their institutions.

A very sad period in our profession is drawing to close with tonight’s decision.

In the past the RCSEng has been the worst offender in looking after doctors in training, esp GPs in training rotating through their specialties. That was over 10 years ago.

Presently, surgeons are no longer being included in undergraduate teaching clinical rotations because the teaching has been shoddy if present at all.

RCSEng is responsible for helping train the doctors of tomorrow. Well, I for one would like to see this role diluted further because frankly the surgeons cannot be trusted now to communicate the proper values we need for team working between disciplines.

Actions do have consequences. I would like to see the other medical royal colleges aggressively attack the RCSEng for failing to vote to join hands to protect the NHS.

Here are the motions and the votes:
(a)Considers that the Health and Social Care Bill, if passed, will damage the NHS and widen healthcare inequalities, with detrimental effects on education, training and patient care in England. ( Total votes cast 175)

For -101
Against -70
Abstain – 4

(b)Cannot support the Health and Social Care Bill without seeing the NHS reform Risk Register (Total votes cast 176)

For – 93
Against – 70
Abstain – 13

(C) Calls upon the RCS (England) to publically call for withdrawal of the Health and Social Care Bill (Total votes cast 176)

For – 76
Against – 99
Abstain -1

(D) Calls upon the RCS (England) to seek alliance with the BMA, RCN, RCM and other willing Royal Colleges and NHS stakeholders organisations to collectively call for the withdrawal of the Health and Social Care Bill. (Total votes cast 176)

For – 71
Against – 101
Abstain – 4

(e)Calls upon the RCS (England) to hold a joint press conference with the BMA and other willing Royal Colleges and NHS stakeholder organisations, to make a joint public statement calling for the Bill to be withdrawn. (Total votes cast 176)

For – 70
Against – 104
Abstain -2

Its Lovely To Have Days Like This

28 Feb

In my job as a GP it is rare to learn that what one does really does change lives.

One of the first patients today hobbled in looking happier than when last seen by me over 4 months ago.  “If it wasn’t for you, I would not have a place now”, he said.  Struggling to remember I flipped through his chart on my screen.  Then it came to me – this guy had been made homeless while in hospital for a broken hip. His landlord had not only given away his room, but also thrown away the tools of his trade worth many hundreds of pounds.

Homeless and with no means to work, he was in a dreadful state four months ago.  At that first appointment, he was desparate and despairing.  I spent nearly 40 minutes exploring his needs and contacting a couple of organisations.  The local homeless charity and the local chaplaincy team.  Within a matter of hours he had an emergency loan, accomodation and a few days later furniture and a fridge of his own.  In short, he had regained some of his self-esteem.

My last patient today also looked a lot happier.  3 weeks ago he was very depressed suffering a relapse after more than 8 years.  He was most upset by his denture problem.  As far as he knew, the only solution would cost nearly £2000. An amount that was unaffordable on his income.  I was dumbfounded.

This chap left my surgery with a copy of my assessment and encouragement to seek a new NHS dentist who would be compassionate enough to correct the problem paid for by the NHS.  Today he tells me the denture problem will be resolved within the next couple of weeks and he does not have to pay a penny.  His wife is also happier and so are his work mates.

Two different stories but with similar results.  I was not practicing classical medicine for either man.  What did happen was delegation and encouragement for both men to approach the right people and organisations armed with correct information.  Two lives have been rescued by my work.

It is a lovely to have such a day as this.

Does the average MP understand how general practice works?

14 Sep

One GP's Protest

On a previous post I included an email exchange with an MP. The MP had responded to one of my emails to MPs, on the topic of GP practice boundaries. The MP said: “I must say that I do have some sympathy with the idea of free registration.  I had an excellent GP in XX who I was with from the age of 19 when I went to University.  It seems strange that I could not remain with that GP when I only live 40mins away in YY.”

Now most GPs will think it is obvious why living 40 minutes driving distance (according to the AA route finder it is about 34 miles) is not practical. What is worrying is that this well-meaning MP, who is voting on the Health Bill which includes the GP boundary issue, is not aware why 40 minutes/34 miles is problematic.

What is the average…

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