How could the NHS save money?

[think about it]

I guess that I can only really address that which I know as I am one of those much maligned NHS managers. So I’ll start with that, the reason I have a job is effectively to allow my employers, the GP’s to concentrate on actually being doctors and not circumnavigating the literally mountains of administrative and legislative work that it pushed our way. So, my job is to look after the accounts, make sure we’ve got staff in the right place at the right time, deal with complaints, look after the buildings, do all of the HR stuff that comes with having staff members, negotiating with suppliers and insurers and private companies all baying for a moment of our time and an NHS contract, arranging locum cover, recruiting staff, managing the quality and performance of our clinicians against the Qualities and Outcomes Framework, claiming for non NHS activity, making sure the electricity and gas don’t get cut off and that’s just this morning. Want to get rid of me? Get rid of the tedious box ticking and centralise the administrative side of things but for the love of god, don’t ask Capita to do it...

 

So, what of 8 til 8, seven days a week. Well, when we stopped laughing it was difficult not to cry. Here’s why, you don’t need an NHS manager to tell you (although I’m going to) that we’re in the midst of the most significant GP workforce crisis ever. Why? Because they’re getting old and retiring and younger doctors don’t want to do the job which has become the “whipping boy/girl” of the entire NHS. And, it’s not just managers and GP’s that are in the firing line, now it’s our receptionists too when the national press vilify them for asking a simple question so that they can direct you to the most appropriate appointment.

 

Do you know why they have to ask? Because there aren’t enough GPs for someone to just pop in for a chat about a slightly troublesome ache in their back, a physiotherapist is far more appropriate, want to discuss medication? Well, there’s a pharmacist that can help. And, for those who say “I only want to speak to a doctor” fine, we’ll accommodate your request as best we can but I’d ask this: do you only speak to the chef when you eat out?

 

Use of other health professionals to deal with day to day cases is unfortunately the only current viable path in primary care, there’s simply not the capacity to do it any other way and before Nigel Farage or one of his fiends (I made the spelling ‘error’ on purpose) turns up and starts quoting health tourism, well, it’s not an issue here and I still have a capacity problem. It’s driven by lack of education on self limiting conditions, by demanding employers expecting their staff never to be ill, by the DWP effectively hanging out the sick and disabled to dry and by an aging and increasingly chronically unwell population, not someone who’s travelled from somewhere else so they don’t get shot.

 

I know I’ll be making enemies as I type, but it’s true here, perhaps though it’s different elsewhere. So back to seven day opening; I have three GP’s here they each work from 8am until 6:30pm Monday to Friday. So they’re already working 52.5 hours each a week to stay afloat. There’s no such thing as the lauded 3 hour lunch break, use Monday just gone as an example, 08:00 to 08:30 processing Friday’s blood results and contacting patients with abnormalities, 08:30 til 12:00 a patient every ten minutes, 12:00 til 13:00 do referrals and look at incoming clinic letters, 13:00 til 14:00 ‘emergency appointments’ one every ten minutes (FYI, a sore finger that’s been bothering you for weeks now – not an on the day emergency), 14:00 til 15:30 – 16 home visits between the 3 GP’s to the housebound and palliative patients, 15:30 til 17:30 an appointment every ten minutes and from 17:30 to 18:30 emergency on the day appointments.

 

Theoretically the day (well, our contracted hours) ended there, we were here til 20:30 finishing things for the day off. Now, I don’t purport to be a time-management wizard but if you can tell me where I can lose a GP so they can have a midweek rest day to work over the weekend then I’m literally all ears. But, one thing is for certain, if you slice a cake 7 ways instead of 5 then everyone gets less, the cake doesn’t miraculously get bigger. This isn’t a funding issue, it’s a people issue, chuck all the money you want at me because if I can’t get a GP then you can’t have an appointment at 19:30 on a Sunday night it’s that simple.

[think about it]

Hi Sali, in one way or another I've been around the healthcare system for as long as I can remember, professionally however my first experience was in 2002 working for a national out of hours deputising service. I was there in one capacity or another for about two years before being made redundant after the new GP contract came in in 2004. Fast forward nine years and a chance application found me in my first GP Practice management post after a long stretch in the charity sector.

 

I'll do what I can to answer your questions in turn, but if I miss one please feel free to remind me.

 

How have things changed? Well, there has been a considerable shift to 'near-patient' care, so we have a whole list of patients whom we care for under 'shared care agreements' with hospital consultants, these patients come to us for blood testing / egg / consultations / dosing and treatment rather than going back to the local hospital. Undoubtedly it's better for the patients but it adds two full mornings of work each week to our schedule. We're seeing this in a less formal manner with things like pre-operative assessments, discussing results and other interventions. It can be challenging to fit those things in around our routine care. So, more patients? No, not really. More face-time? Definitely.

 

There's another layer to that, a far more scary one in our opinion.

 

I'll apologise now for using analogies, it's easier for my brain after the week I've just had. In order to keep this clear in my mind at nearly 11pm on a Saturday I'm going with this...

 

General Practice and A&E are the 'front door' of the NHS, gatekeepers if you will. It was/is our job to see 90% of the NHS' patients and move them around as necessary. Most of 'em we'd send home with a smile and reassurance, others we'd refer to more qualified colleagues for specialist opinions and the very worst we'd blue-light in for lifesaving interventions. We're jointly reliant on there being capacity in the system beyond that gate that we're charged with keeping. Or, to use my hospital colleague's analogy we're the open end of the funnel.

 

Funnels are great until you block up the narrow end. Once you stifle that flow the water starts to back up. Once you slash funding to social care and close cottage hospitals, once you close wards and create a perfect storm of recruitment issues, falling morale and make the whole system work harder to achieve the same results as before then you're blocking the exit door from the system and telling the person at the front door that it's their fault there's people queuing outside. Capacity is just that, once it's reached you have to reduce occupation rates somewhere except you can't. There's nowhere to send those well enough to leave hospital but who still require a helping hand, councils are slow to react, families no longer see it as their duty to care for their elderly relatives and still we're closing those cottage hospitals that provided that step-down from a full-blown hospital bed to somewhere to convalesce.

 

Sorry if I'm going on a bit but I'll get there I promise; because there's nowhere to discharge people to safely, the new patients haven't got beds to go to - neither us or A&E have yet been fitted with pause buttons to let those closer to the spout of the funnel catch up so people end up on trolleys waiting, they end up visiting their GP on multiple occasions as their hospital referral is taking months not weeks, they end up having their routine surgery cancelled because there's no vacant critical care beds because those well enough to vacate the critical care beds don't have vacant medical beds to go to because those well enough to vacate the medical / surgical beds don't have a social care place to go to and all along more people keep arriving at the front door.

 

This is a capacity and flow issue. If you block up the drain, the sink will overflow. Make the sink smaller and it overflows even quicker and it spreads to the floor and along the unit, keep it like that for long enough and the damp sets in.

 

Moving on. Yes, we're obliged to treat anyone that asks us who reside in our practice area. We're currently in conversation with the NHS and a lot of other stakeholders as our practice population may be about to double over the next ten years due to proposed development in the area. Our building can't accommodate any more clinicians so if this actually happens we will need to move, to where? Who knows, I'm not sure there's a suitable building in the area. It's a major cause of concern for us all at the moment.

 

How else have things changed in GP-land? We cannot get GP's, in an almost bizarre twist I feel the recruitment process is about to turn on it's head and rather than having to advertise vacancies those GP's looking to move will end up being bidded for. Top of my head figures are something like 1/3 of all GP surgeries currently have a vacant post.

 

I mentioned the lack of education / awareness and increasingly chronically ill population. I'm not a Dr. Never once thought I was but as part of my role is to monitor usage of appointments sometimes I can't help but wonder what some people are thinking. If you've got the vomiting bug and you're otherwise healthy, don't share it with us unless you're a good few days down the line. Follow the guidance available almost anywhere. Sore throat? Well, research suggests that even if it is bacterial (and it probably isn't) then taking antibiotics will only reduce the duration of the illness by 24 hours (again, if you're otherwise healthy). I could go on but I won't.

[think about it]

no worries, have put one in. which has bumped up the rep

 

still no one in the industry any thoughts about the actual proposed measures currently before parliament, rather than chit chat? never know, the private bill might turn into something significant with enough interest.

 

Thanks all for your kind words, they're much appreciated.

 

Ford, to be absolutely honest I've only skimmed over the bill as it's 'English' and the Welsh NHS is devolved so we're separated from it in a number of ways. That said, on the face of it it seems like a good idea but I really need to sit down with it and pull it to pieces to fully understand it all and tonne able to comment fairly on it.

 

It's always with interest that I read about de-marketisation, of course General Practice is and forever has been the acceptable face of privatisation in the NHS with it's GP partner model and contracts. I've likened it to a franchise arrangement in the past, lots of separate companies all wearing the same uniform and working to the same ends under a brand. A bit like Subway without the MSG and badly mixed fizzy drinks.

[think about it]

I think there's a few sides to this, the call handling team aren't clinically qualified so don't have any discretion over what is relevant and what isn't even though their inner common sense alarm is howling. What's an annoyance for patients is even more so for the staff as they're doing it on every call they receive. The consequences of not doing so however are probably a short cut to a p45.

 

I'd go and have a chat with the GP if you're son is experiencing breakthrough pain so severely. I was given a small bottle of oramorph for my post operative recovery after having my back done. I only ever used it once but it was comforting to know it was there if I needed it.

[think about it]

It is shocking, and it's playing out all over the UK. I'm going to stay off my political soapbox but this is what happens when systematic underfunding and rot sets in.

[think about it]

I had mine cancelled three times for the same reason.