To visit or not to visit?

The problem with home visits is that they happen at lunch time. They are therefore inherently BAD. If I get called to do a visit, I don't get a lunch break, it's as simple as that. I know that there are one or two doctors out there who claim to love doing visits, but I'm just not sure that I believe them. True, in comparison to your average consultation they do have their advantages. It can sometimes be very helpful to see a patient in their home setting, giving you an idea of what their living conditions are like and how well they are managing. In addition the patients are usually extremely nice to you because they are so grateful that you have come. Occasionally you even get a cup of tea or coffee. Despite this however, for the simple reason that I do really like my lunch breaks, each time I see the words 'home visit' pop up on my computer screen, my heart sinks.

The problem with this attitude (apart from coming across as rather greedy and uncaring...) is trying to remain objective when deciding whether a particular patient warrants a visit or not. When you are coming from a starting point of; 'I wonder if I can get out of this?', it can be pretty testing.

Up until now my solution has been to stay on the cautious side, visiting more often than not, particularly if the patient is unknown to me. It's safer, but often frustrating, and particularly so this week.

Mrs Hazel is a perfectly nice, elderly, middle class lady, living in a smart flat, with plenty of family and friends nearby. She had recently been discharged from hospital with a urine infection and a particularly pushy friend was demanding that I visit. Initially I was a little surprised at the request, since I had seen her in the practice only days before and presumed that she was still mobile enough to attend the surgery. However, after nearly falling out with her friend, I gave in and trudged over, stomach grumbling. Mrs Hazel was absolutely fine. One slightly swollen ankle, nothing more. As I grumped my way towards the door, her friend pulled me aside to ask me the question that had been troubling her;

"We are going out for dinner tonight and also have tickets to the theatre. Do you think that we should cancel the theatre since Mrs Hazel has been so unwell?"

Unbelievable. So she can manage to make it out for dinner but not the short stroll to the surgery? I had missed my lunch for a 'theatre' assessment?

I really don't like home visits....

Wierd or Wonderful?

I've never liked the word 'Quack'. It's a word used by conventional doctors to describe those with alternative views on health and healing and I've always felt it to be steeped in smug superiority. Instead, I have tried to be fairly open minded when it comes to alternative medicine. I will happily support those patients of mine who seek to gain relief from acupuncture, homeopathic medicine, reflexology and the like. I can't say that I actively encourage it, but I certainly accept it. This week however, my tolerance has been pushed to the limit. Now I too have taken to using the Q word.

First there was Jonathan, who appeared in a desperate state after three weeks worth of homeopathic medication had failed to clear the pus oozing from his tonsils. Is it not irresponsible to encourage someone to believe that a watered down potion, with no evidence to support it, could cure a condition that a GP would throw 10 whole days of a strong penicillin at? What's wrong with penicillin anyway? Surely it's about as natural as it gets?

Then came 4 week old baby James, a healthy looking boy suffering from a touch of colic. Nothing particularly unusual there. His mother, however, had visited a cranial osteopath to find a solution to his woes. The osteopath had explained that his suffering was being caused by damage done to his spine during labour and subsequent squashing of his gut. For a healthy sum however, the problem could of course be fixed. It took me a whole consultation to persuade this now terrified mother that James did not need x rays of his spine to look for this devastating damage.

Lastly, and most fantastical of all, came my introduction to the art of psychic healing. Melanie presented requesting an MRI of her spine, following the revelation by her psychic healer that she had two slipped discs. A full physical examination of her back and neurological testing of her legs revealed no pain, no abnormal neurology and absolutely no evidence of any back problems whatsoever. It took me 15 minutes of NHS time to persuade her that an MRI was unnecessary, that she had no back problems and that psychic healers might not always get it right. The truly frustrating thing about this story is that Melanie is determined to continue to see this expensive healer. She is vulnerable, not long out of rehab for extensive drug addictions, and in my view is being preyed upon in a wholly unethical manner.

There's a fine line between trying alternatives, and being conned. I'm a firm believer in the principle that 'anything that helps is good', but given the large amounts of cash involved, my great concern is that not all practitioners are as honourable as we would hope.

So are GP's any different? Well, if there's one thing to be said about the NHS as it stands at the moment, it's that you can be absolutely sure that your doctor is committed to your health. What other incentive is there? Yes, GP's get paid for hitting targets, but these targets are generated to improve health care and thus also benefit patients. Sadly it may not always be so. With the current trend to privatise NHS primary care services, GP's may soon be added to the list of practitioners who just might be more interested in your money than your health. Perhaps I am being overly pessimistic, but I can think of plenty of examples to suggest that when there's money to be made, ethics tend to come second to profits.

Practice Boundaries and Home Visits

I have an overwhelming sense of deja-vu. As part of the government's plan to scrap practice boundaries, the suggestion has been made that someone other than GP's could take over the responsibility for out of hours care - oh sorry, I mean home visits. This of course coming at the same time as GP's are being asked to take back control of out of hours care which was seized from us (albeit gratefully) just a few years ago. Unfortunately of course that grand plan has left a wake of debt, poor care and unnecessary deaths. But I'm sure it will be different this time...

The debate on practice boundaries is an interesting one. The idea of increasing patient choice is of course appealing, but is fraught with problems, none greater than how to manage home visits for patients who don't live locally. Never fear though, the Department of Health is going to resolve the problem with one of the four potential solutions:

1. Creating rules to identify which patients practices should arrange home visits for, and which PCTs should be responsible for.
2. Asking GP practices to continue to provide or arrange home visits for all patients.
3. Allowing patients to register with two separate GP practices.
4. Removing all home visiting obligations from GP practices, making PCTs responsible instead.

Here are my thoughts on the above:

1. Logistical nightmare which would exacerbate the 'postcode lottery' effect and be wholly unfair to patients living just beyond the boundaries set (who may previously have been covered by their practice).
2. Impossible. Should I pop out to visit my sick patient in Kent, in between consultations in Islington?
3. Potentially workable if we had an IT system to support it, allowing both practices up to date information on consultations and prescribing. We don't.
4. Ludicrous. Much as I grumble about home visits (home visit = no lunch break), they provide an essential service to the sickest patients. Imagine the dying cancer patient, requiring regular home visits, being seen by a different PCT doctor on each occasion? It has the out of hours fiasco written all over it. Can this government really make the same mistake twice?

It seems to me that none of the government's options are workable. Yet the push for it continues because at first glance, 'it seems like a good idea' (may win votes). Perhaps even more importantly, opinion polls show quite clearly that it is only a small minority of patients who would wish to register with a different local practice or with a practice close to work (18% and 6% respectively). Does the enormous expense that this re-structuring will incur provide the tax payer with value for money when it will benefit only a minority? With the rest of the public sector under immense pressure to cut costs, is it really as Andy Burnham would have us believe "the right move at the right time"?

The majority of patients can already choose between a number of local practices. In addition, it has always been possible to be seen as a temporary patient in any practice in the UK, giving easy access to NHS primary care services wherever you are. So my point is this, where exactly is the problem?

Poly Politics

I've been racking my brain for a word that starts with 'poly' and which defines something positive. It's surprisingly hard; polymyalgia, polycystic, polyarthritis, polyuria, polyester, polytechnic, polygamy, polyp... polyclinic...?

Now this is a tricky one. I understand the concept of polyclinics to some degree. To be able to pitch up at a spangly new medical centre, see a doctor, dentist, physiotherapist and nutritionist in quick succession, possibly even get an X ray thrown in for good measure, well, it sounds appealing. A one stop shop for all your medical needs, free of charge and courtesy of the NHS. It definitely has its attractions and it could work brilliantly for a young, largely healthy population - a student health centre perhaps, or something for London's working masses.

But what of those who don't want or aren't able to travel to a large centre like this? Those who have multiple problems, or a chronic illness and would much rather see the same doctor on each visit? Those who believe that having some sort of a relationship with their GP is important?

What of the doctors? All GP's will remember what it feels like to start in a new practice. How much harder it is when everyone is a 'new patient', when you know little of a person's past medical history, their social circumstances or what's really important to them.

This week one of our patients, whilst filling out yet another survey (as Dr Grumble notes, happiness must be measured in the NHS), admitted that it was because he liked his doctor and the practice so much that he had decided not to move out of London. I suppose it's only right to add that his doctor is not me but a collegue, but all the same, I found it touching. I also found it very sad - the way things are heading, this kind of relationship may soon be a thing of the past.

So no matter what advantages I'm told they'll bring; how they'll rescue overcrowded A&E departments and make GP's more accessible than ever before, I just can't make myself feel positively about polyclinics. Apart from anything else, the name just doesn't bode well...

"Next!"

If there's one thing that I dislike about being a GP in the NHS, it's the terrible ten minute appointment slots. Let me take you through a typical morning to show you why:

8.30am - Patient 1 arrives

8.40am - Patient 1 leaves (well done me I think, an impressive start)

8.43am - Patient 2 arrives (he doesn't think he's late, I do)

8.50am - Patient 3 arrives

8.55am - Patient 2 leaves. Patient 3 enters and promptly bursts into tears.

9.00am - Patient 4 arrives

9.10am - Patient 5 arrives

9.20am - Patient 6 arrives

9.30am - Patient 7 arrives. I'm still with Patient 3. Very subtly (years of practice) I manage to flick to my computer's control screen. I see the word "waiting" repeated again and again down the morning list. I panic. I manage to lose Patient 3. But it's too late. I know that I am now destined to spend the rest of the morning frantically trying to catch up on time at the expense of listening to my patients. The day will pass in a frenzy of irritated patients, inadequate consultations and an increasingly stressed me.

I suppose to be fair, there are a few things that can be done in 10 minutes. Dealing with coughs and colds, toenail infections, diagnosing an ear full of wax, boiling an egg, having a shower, feeding the dog (I hasten to add that not all of these are recommended work time activities). There are however, many things that can't. Managing depression, admitting a patient to hospital, dealing with a new diagnosis of diabetes. Oh yes, and of course the; "Well there are a few things actually doctor - I've made a list so I wouldn't forget them". Groan.

Thankfully the BMA have recently acknowledged this problem, detailing the need to lengthen GP appointments in their pre-election manifesto. Unfortunately however they have also admitted that this can only be 'an aspiration' since it would require many more doctors which is clearly unrealistic in the current climate. More groans.

I however have been lucky. The practice I have now joined does offer 15 minute appointments and whilst an extra 5 minutes may not seem like a lot, it has revolutionised my working life. I have started to enjoy my job again and I feel that I can do it properly now. I am happier and my patients are happier. I have more time to listen, time for health education, time even perhaps just to chat. We of course are fortunate that we are a small enough practice to do this and still be able to offer enough appointments to meet our targets, the majority can't. But having seen it work and seen the difference it makes, I will be championing the idea that in the case of appointment times, we really do need quantity to achieve quality.

Money well spent?

I had an unusual consultation this week with a man in his 40's who has extremely poorly controlled diabetes. He seemed rather sheepish throughout, with his shoulders hunched, fidgeting nervously. It was clear that there was something he was ashamed of. Eventually it came out. To my surprise it wasn't anything to do with a fetish for cream cakes or an inability to steer clear of deep fried mars bars, as I had been expecting. Instead, it was the furtive admission that he was seeing a private specialist.

Shock and horror. Imagine my fury at this blatant betrayal of the NHS. He began to spurt excuses that it was only because he had insurance through work and so he thought he 'might as well use it'. He was upset, and clearly felt that he had somehow been disloyal. I was amused to see that he seemed genuinely surprised when I explained that I was not in fact hurt by this revelation. Instead, this piece of news meant that I would be getting speedy help in managing a complicated patient, and I was delighted.

The reality is that this particular patient is likely to get better care privately than he would through the NHS. His disease is poorly controlled, largely due to a lack of motivation on his part, and a patient like this often gets lost in the NHS. He is someone who, after years of not taking much interest in his health, has suddenly decided he must sort himself out. He needs to be seen quickly, while his enthusiasm lasts.

And so I am back to the debate that I so often have with myself on the relative benefits of private medicine versus the NHS. My instinct has always been to reject private health care in favour of the NHS, the core values of which I respect enormously. The concept of providing health care for all irrespective of status or wealth sits better on the conscience of a doctor than demanding cash for your assistance. And yet the NHS has become all about money too. True, it's about saving money rather than making money, but is that any better for the patient?

As a GP, I have actually often thought that working within the constraints of the NHS tends to result in a better level of care. Due to the fact that resources are limited I have to think much harder about what investigations are really important and which patients I do or do not need specialist help with. I hope most would agree that this is actually better medicine than just subjecting anyone who comes your way to a barrage of tests. Where the NHS fails however is in those situations when an individual is unwell and needs investigations quickly, but is not quite ill enough to be in hospital. These patients often have to wait weeks rather than days for vital tests which increases anxiety and delays treatment.

In truth, I am the NHS' biggest fan and if I was ever seriously ill it would be the NHS that I would want to look after me. I do believe however that there is a place for private medicine for those who can afford it. Not only can it reduce the demands on the NHS, but in certain situations it can be better for the patient too. If the two can work together, all the better, and perhaps then my diabetic would feel less of a traitor.