Friday, 31 May 2013

6 reasons why out of hours is out of control

There's a lot in the press currently about GPs and out of ours cover. The claim is made that the loss of  out of hours responsibility since 1996, is chiefly to blame for our A+E departments being overwhelmed. I very much doubt it. However something has changed in the demand for out of hours medical attention.

For the first half of my GP career I was on a rota with the rest of my partners and a neighbouring practice, for out of hours cover. This roughly broke down to one night during the week and one weekend in five. Calls at night were infrequent and I guess I had to get out of bed and visit roughly 30% of the time. Just about always the visit was appropriate. But in the early days of GP co-ops and the night shifts which I did, it became quickly apparent that demand for medical advice at night was sought much more readily, and for ever minor problems. Why the increase? Here's some suggested contributing factors:-

1. The resident older population  had grown up with the development of the NHS. Calling the doctor was a big deal. For my parents generation born in the 1920s, make do and mend, didn't just apply to sewing.
2. Not only did respect and deference prevent calls to the doctor for minor problems, but there was a greater resilience  (which likely also contributed the semi-mythical, 'blitz spirit').
3. As a child, I still recall having to cycle a few hundred yards to the public phone box to call the doctor for my mother. The eponymous mobile phone makes it all too easy to ring 111.
4. The influx of many from different cultures has had a massive effect upon out of hours demand. There are language problems, a different attitude towards A+E (in many Europen countries it is expected that you will just rack up at A+E with any medical problem), and often a lack of resilience, partly resulting from very tough social circumstances and perhaps poor parental mentoring.
5. Some of us GPs are perhaps to blame, for not establishing good relationships with patients, and not taking the time and trouble to educate them about managing symptoms overnight. However I realise that colleagues with ethnically diverse lists have massive challenges to communicate  well when language and cultural expressions of symptoms make good GP nigh on impossible.
6. The 24 hour culture of shopping, whether it be online or the ubiquitous Tesco, has had a significant, and I would say unhelpful  effect upon expectations. I can understand why one might want to buy petrol in the night, but do I really need to buy groceries at 3am?

Monday, 27 May 2013

Common grace Russian style

Common grace at work.

And in his book The reason for God,  Tim Keller points out
'This means that no matter who performs it, every act of goodness, wisdom, justice and beauty is empowered by God. God gives out good gifts of wisdom, talent, beauty and skill 'graciously'- that is, in a completely in a completely unmerited way. He casts them across all humanity, regardless of religious conviction, race, gender or any other attibute to enrich, brighten, and preserve the world.'

Wednesday, 22 May 2013

Teamworking in General Practice

Keep it simple

Sir Matt Busby is said to have been quite simple in his instructions to his European cup winning Manchester United team. 'Just get the ball and give it to George (Best).

It's a challenging time in General Practice and easy to lose focus on the patients and their well-being. So many letters, emails and phone calls. So many requirements in terms of prescribing, referrals, and protocols. So much data collection, and soon a new computer software system, to all intents and purposes ,'forced' upon us. And much more beside. But what often gets forgotten, or rather ever considered, is the GP as an employer. In other words, do we look after our staff?

It's fresh on my mind since we spent 3 hours this afternoon as a practice team, looking at our surgery and brainstorming where we might do better. We didn't have an expensive facilitator, nor did we meet in a swanky hotel. It was a simple format and it 'worked'. We basically just talked and listened to each other!

We were divided into six groups of four, each having either a GP or the practice manager in it.

1. We began with a brief team building game where people were divided into pairs and asked to have a conversation beginning  with one person choosing a holiday destination, eg, 'I'd like to go to Australia..' The partner then had to reply with a, 'yes, but....' answer. To and fro the conversation then went for a few minutes, each responding with, 'Yes, but..'. The next task was to have a similar conversation but this time with the response, 'yes, and...' Seeking to fill out the other's reply, 'yes and...we can go to New Zealand on the same holiday etc'. It's a simple game but enables people to see how much more supportive a 'yes and' approach is, especially before a brainstorming session when we are all quick to shoot down others ideas.

2. In our groups of four we were then challenged with the question, 'If money were no object, what would you do to improved this surgery and the service it offers?'  The catch? The answer had to be drawn with no speaking! It lead to some creative thinking about the building which interstingly, were perhaps better highlighted by engaging a more creative part of the brain than from straight discussion.

3. In our groups we then debated what would be the main thing we would like to change  to improve the working of the surgery. Having asked for one thing, I then allowed 3 or 4 which were fed back to the whole group, in reverse order of priority. It lead to some very helpful discussions. From all of the groups, the top three came out as:~
*improve communications (predominantly internal)
*increase nurse availability
*increase doctor availability

And after a vote, it was nurse availability which just came out as the top request, beating improved communications.

4. We then discussed what would be the one thing which would improve our individual job satisfaction.  This again was very helpful, not least in hearing others verbalise what mattered to them. And this was so helpful for doctors who may cocoon themselves in their consulting room, oblivious to the stresses and strains which the staff are under.

5. Then we discussed, 'what is the most common positive thing you hear said about the surgery?' It was really great to hear lots of encouraging things, and made many feel proud to be a part of our surgery.

6. Finally with the clock ticking  we asked, 'what is the most common negative comment you hear about the surgery? Parking, the need for confidentiality at the reception desk,  and availability of appointments, featured mostly.  There were certainly areas to work on.

Three hours really well spent. Quiet receptionists speaking up during the feedback time. The opportunity for all to be heard and taken seriously. We'll be doing it again in 6 months.

Friday, 17 May 2013

Doctor, doctor

One of my wonderfully resilient and feisty 90 plus year olds phones today to report on her medication.
"Do you want me to tell the truth (that she has not taken my carefully prescribed pills), or tell you what you want to hear just to please you ?"
"I guess you're going to lie",  I hastily respond.
"Indeed so".
"Ah well at least you're honest"

Thursday, 16 May 2013

An unlikely pilgrim

The Unlikely Pilgrimage of Harold Fry by Rachel Joyce is a charming book. Indeed I enjoyed it from the very first sentence,
The letter that would change everything arrived on a Tuesday....
Unusually for a contemporary novel, it begins before the first page with a quote from John Bunyan,
Who would true valour see, let him come hither. One here will constant be, come wind and weather. There's no discouragement shall make him once relent, his first avowed intent, to be a pilgrim.  John Bunyan, Pilgrim's Progress.
According to the Oxford English Dictionary, a pilgrim is simply someone who is on a journey, a person who travels from place to place, a wanderer, an itinerant. In Joyce's novel the somewhat unlikely pilgrim is recently retired and hen-pecked, Harold Fry. He sets out fully intending to post a get well card to a former work colleague who is dying, and finds himself striding past the local Post Office having decided to deliver it by hand, and by walking the 500 odd miles form Kingsbridge in Devon to Berwick upon Tweed!

The walk gives Harold plenty of time to think and review his life. Indeed that seems to have been the motivation for the tradition of religious pilgrimages throughout the centuries. Such thinking nearly always brings a mix of regret and gratitude and can result in a new determination to do something worthwhile with one's life. The very act of walking was indeed Harold's attempt to make sense of his life and to bring relief, healing even, to someone else.

Like any good country song, it's a tale of love and loss, of hope and confusion, and even of redemption. It's beautifully observed, with some wonderful dialogue. Meeting a girl who serves in a garage soon after his walk begins, the girl says,
"My aunt's got cancer. I mean it's everywhere. You have to keep positive though.". Harold stopped eating his burger and mopped his mouth with a paper serviette. "Positive?" 
"You have to be believe. That's what I think. It's not about medicine and all that stuff. You have to believe a person can get better. There is so much in the human mind we don't understand. But, you see, if you have faith you can do anything." 
Harold gazed at the girl in awe. He didn't know how it had happened but she appeared to be standing in a pool of light, as if the sun had moved and her hair and skin shone with luminous clarity. Maybe he was staring too hard, because she gave a shrug and chewed her bottom lip. "Am I talking crap?"
'Gosh no, not at all. It's very interesting. I'm afraid religion is not something I ever quite got the hang of." 
"I don't mean like religious, I mean trusting what you don't know and going for it. Beleiving you can make a difference." She twined a strand of hair around her finger.
It's interesting how even in such a gentle conversation, 'religion' is contrasted with believing you can make a difference, and even contrasted with 'faith'. Perhaps like most novels written by secular authors, the only kind of religion that surfaces is either hypocritical churchgoing or fanatical obsession. And yet the Christian life is a pilgrimage, a journey of gratitude, not an attempt to find favour with God. It's a gift of grace. Indeed I think if we believers were more attentive to God and his Holy Spirit, in our regular, day by day life (on the Frontline as Neil Hudson of LICC would say), we might live life more as a pilgrim with adventures on a par with Harold Fry!

I'm not suggesting the novel is good theology, but it does remind us that life can be an adventure. And it points us to a more reflective life, in a way that is quite counter-cultural. The so called fast pace of life is almost universally encouraged and fostered (think of the millions who listen to Chris Evans on BBC Radio 2 in the mornings, or who watch the Apprentice). As Simon and Garfunkel would say, 'Slow down you move too fast'.

Yep, a lovely story. Well worth a read. Go get your shoes on...


Monday, 13 May 2013

What's wrong with me?

Next week sees the publication of the 5th edition of the DSM (aka The Diagnostic and Statistical Manaul of the American Psychiatric Association!!). Apparently there are now 347 differing psychiatric diagnoses. It seems there's something wrong with all of us.

"Most boring book ever written"
Professor Simon Wesley from the Institute of Psychiatry in London is skeptical of its value and suspects that even the head of the DSM would not be able to name half the supposed diagnoses (indeed he calls it the most boring book ever written). It seems that in the American context at least, until you have a named diagnosis, medical insurance will not pay for treatment by a psychiatrist or therapist.  Hence the need to find diagnostic labels. This has prompted ongoing debate about the medicalisation of normality, so that shyness is now social phobia and normal grief is classed as a depressive illness etc.

I lie somewhere in the middle of this debate, since in practice I see the benefit of the traditional medical model being applied to mental illness. So that having reached a diagnosis, a treatment plan appropriate to that patient and their diagnosis, can be formulated for that them. And this may well include prescription medication. However I also recognise the complexity of  human beings, with all the various differing influences placed upon us. These range from our genetics, to our learned and copied behaviour, the slings and arrows of outrageous fortune, and much in between. Neat categorisations are not appropriate, and in this sense much of psychiatry is merely descriptive of constellations of symptoms with the blurring of boundaries between one diagnosis and another.

In the Christian understanding there is one fundamental diagnosis, but a myriad of presentations and symptoms. Underlying all our frustrations, relational difficulties, disappointments and much more beside, lies the single diagnosis of sin. This is the  inherited bias within all of  us which resists the loving rule of the God who made us. Oh yes there are plenty of other 'secondary causes' along the way, and much of psychiatry and counselling aims to alleviate them. But the root remains.

I was reminded of this recently when a female patient, struggling to cope with her husband's infidelity,  said to me, 'Forgiveness is so hard'.  I guess there may be some psychological approaches which might alleviate some of the difficulty of forgiveness, but since all of our wrongdoing is also against God as well as each other, there remains what you might call the divine dimension. It's this that lead Dietrich Bonhoeffer the German pastor who was executed by the Nazis to say,
Only by recognising in penitence God's mercy for you will you yourself then also be capable of forgiveness.
There will never need to be an updating of this old diagnosis of sin,  it's as old as the ages and will continue until there is a new heaven and new earth

Sunday, 5 May 2013

Only a breath away

Today was like most other Sundays: church in the mornng and then time to eat. Except unusually for a  Sunday, today we had a sandwich in Cafe Nero for lunch.  We were visiting our daughters in London,  and we had eaten well on Saturday evening.

All was well with my sandwich until I tried to cough and clear my throat.  Quickly it became apparent that I was choking. It's one thing hearing loud stridor in a patient, and quite another to be the patient. I appeared to be making the most deafening rasping noise as I tried to breath in to facilitate my cough. The harder I tried to breath in the worse the situation got, as normal nreathing was becoming impossible. By now I was outside the cafe and beginning to be in serious bother. Fortunately I was slapped on the back several times by various family members and even resorted to a finger down my throat (my own finger I should add). Thankfully after what felt a long time but probably wasn't, the stridor began to clear, although the feeling of an irritation in the throat lingered for a while. The crowded cafe was remarkably unaffected by my rather terrifying experience.

But thanks be to God.

And all to say just how fragile life is. I know I should realise that at my age, but like most of us,  I guess I take each new day for granted, and expect be around for tomorrow. In the words of the New Testament letter of James,
Why, you do not even know what will happen tomorrow. What is your life? You are a mist that appears for a little while and then vanishes.  James 4.14
We had been to the funeral of the son of a longstanding friend last week. He was only 38 years old. The ageing Pentecostal pastor who gave the message spoke briefly from the New Testament about being ready for this greatest of all appointments. The one we must all face and which Bunyan called the 'last enemy', even death itself. Although I have much to regret in my sins of omission and commission over the years, I have a rock solid confidence in the merits of Jesus Christ, which will carry me over when my last day comes. What a relief that is. And in the words of  Charles Wesley

O that the world would taste and see the riches of his grace
The arms of love that compass me would all mankind embrace.

A message from the other side

No, not that side! But thank God got through surgery ok yesterday. And thanks to all for love support and prayer.