Choose and .....?

When the hallowed choose and book system first hit our aged computer screens, I liked the idea of it. It claimed to be system that allowed patients more choice about where they were seen and who they were seen by and it seemed like the right way forward. In the early days my patients too were delighted with it. They could pick their hospital, pick their doctor by a name they liked the look of and sometimes, if I was feeling particularly generous, they could even book their appointment during our consultation, there and then. Amazing.

Unfortunately however things no longer seem so rosy. Over the past few weeks I have been plagued by hoards of angry 'choose and bookers', furious with the service they are (not) getting. Their telephone line is always busy, with patients having to call over and over again to get through. It takes days. My absolute favourite is what happens when you try and make an appointment with the local musculoskeletal clinic. Here, when you do finally get through, the telephonist cheerily informs you that there are unfortunately no appointments left at the moment and to please try again in a few weeks. What?

It's not great for us doctors either. I tried to hurry along a review appointment for a patient of mine the other day. He had been seen by a neurologist in early January with a review planned post test results. The tests were done in February. The review appointment was booked for September. This might have been acceptable if all the results had been normal, but in this case they were not and the patient was deteriorating. I called the consultant's secretary but they do not book appointments anymore. I called the appointments line but they were not able to make changes without the request of the secretary. In the end I sent a total of three faxes and telephoned both the secretary and the appointments line twice a week for three weeks before I achieved my goal.

How I wish I could just write an old fashined referral letter...

Loneliness

In a drive to be ever more organised when it comes to completing our QOF tasks by April, this week has been a 'Vulnerable Elderly' review week. These reviews involve long consultations with endless questions about hearing problems, mobility, hygiene problems (I never quite know how to ask about this one?) and to finish, the dreaded mini mental state examination.

As a quick aside, can I just say how much I loathe the mini mental test. If the patient is completely coherent, asking what year it is, what country we're in and to follow ridiculous commands involving fingers, ears and nose is just embarrassing. Many are offended, many just think you're wasting their time. If on the other hand the patient suffers from a degree of dementia and can't answer the questions, watching their embarrassment is even worse. All in all a hideous experience.

There is however, one question that I dread asking even more than I dread the mini mental test. It's this:

"During the last month, have you often been bothered by feeling down, depressed, or hopeless"

It's part of the depression screening, and the tragically high number of positive responses provides the basis of many a disheartening conversation. For some, these feelings stem from financial problems, family disagreements or the loss of a loved one. For the majority they are simply due to loneliness. Those without local friends or family, too frail now to make the journeys they once used to.

One patient told me that he insisted on going to the supermarket every single day, because so often the brief conversations with checkout staff provided his only human interaction. Another mused that she had simply lived too long, her husband and all of her friends having died before her. She could only give me her cleaner's name as her next of kin.

So they score a positive on my depression screening, but what of that? Should I give them antidepressants? I can't see how that would help. Psychological therapy? Somehow I don't think so. I've tried to get patients such as these involved in day centres or community activities, but I find that many are simply unable and some too proud.

It's hard to know how I can help and now I too am feeling down, depressed and hopeless...

Sun, Silence and Solitude

Usually, predicting how awful my day might prove to be is near on impossible, but not this week. With forecasts full of bright yellow circles on a background of beautiful blue, I can go to work with a smile on my face. Glorious sunny days bring glorius empty waiting rooms and a calm and civilized working day.

Yes, the world is a better place when the sun shines.

During open surgery yesterday morning I saw a grand total of three patients in three hours. Amazing. So whilst I quietly read through clinic letters, enjoying the novelty of a bit of time to myself, I pondered this question: What proportion of appointments are really necessary at all?

As doctors we like to believe that we should be spending our hours tending the sick, making heroic diagnoses and curing people left, right and centre. Thus my initial response to the question was; probably very few. I sneered at the predictability of the good weather phenomenon and imagined how much time I must waste on a daily basis seeing patients who don't need to be seen.

How arrogant. The real truth is that the role of a GP is much simpler than this. It is to provide basic medical care for our patients. To listen, to treat, to check blood pressures, to organise blood tests, to provide repeat medications. Of course much of this is not urgent. An appointment to collect your contraceptive pill can wait a few days, a visit to obtain treatment for acne can be put off. That's why my surgery was empty yesterday, not because I wasn't needed, but because my sensible patients chose not to sit indoors with weather as glorious as this.

It's lead me to a more basic realisation. Seeing a GP has to fit in around people's lives. Because so much of what we do as GPs is non-urgent, routine medical care, patients can't possibly be expected to take time out of work to attend. Much as I hate to admit it (a nine to five day is clearly preferable to any sane GP) our out of hours service really does have to improve and it looks like the new government feels the same.

Terrible news for me, great news for patients.