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?

Love in a cold climate

At the end of a routine consultation, Mr Howard playfully announced that 'romance was in the air'. He said it with a wide smile, a twinkle in his eye and a wink. He is 85 years old. There was no hiding how delighted he was, and it made me grin from ear to ear to see it. How absolutely wonderful that this frail old man had found someone with whom to share his days at the ripe old age of 85. I couldn't have been happier for him. He offered to show me a photo. Reaching into his coat pocket he withdrew, not the gleaming photo that I was expecting, but a small white business card. A little unusual perhaps, but it did indeed include a tiny photo and he offered it to me with great relish. I was a little taken aback. I had, I'm afraid, been expecting a little old lady in a floral dress and sensible shoes. Instead I saw the face of a rather pretty Thai woman who I guessed to be in her late 40's. "She's only 48 years old" he told me proudly.

I hope that outwardly I managed to maintain my buoyant manner, but my head was full of worrying questions;

"What does she see in him?

Perhaps she's after his money?

Maybe a passport?

Does he know what he's doing?

Should I say something?"

I elected to keep quiet, but I have since been contemplating my reaction. Was I concerned purely because of the age gap, or was it because she was Asian? Would I have reacted in the same way if she had been British? Would I have felt differently if she had been French, or Indian? I had made an assumption, a judgement of her, based on a photo. A tiny photo at that. I now feel rather ashamed at the speed at which I had sized this photo up and placed her in a 'category'.

It's not the first time I've caught myself at this. Only a month ago I saw a rather grand lady, well spoken and well dressed, who had come in with an itchy rash. It looked like scabies, but it seemed so unlikely in this woman. As a result, I dished out the usual multipurpose, 'bit-of-everything-in-it' cream and asked her to return if it didn't improve. It didn't improve. After much procrastination, I reluctantly mentioned scabies, suggesting rather sheepishly that perhaps she might have been away somewhere where she could have picked it up? I was expecting to be met with outrage, but she didn't seem surprised at all. It made me wonder about the reality of her home life behind that grand exterior.

I've begun to realize just how many judgements we make about our patients from day to day. How intelligent is our patient, and how competent? How motivated, how sensible, how realistic, how honest, how vulnerable? When I think about it, nearly every clinical decision that I make is based on at least one such assumption.

Yet I am young, and my experience of this world is limited. All of a sudden I feel rather under qualified for the task.

Body Language

We are taught at medical school of the importance of communication, verbal and non-verbal. We are shown how to arrange a consulting room to best nurture the doctor-patient relationship, advised on what to wear (mini skirts out, sensible frocks in) and made to watch ourselves on video to see how we perform. It forms part of the new 'touchy-feely' approach to teaching medical students and whilst I acknowedge its importance, I don't think many of us took it very seriously at the time. I always believed that either you found it easy or you didn't.

Nowhere are communication skills taken more seriously than in GP training. You attend courses, (pretend to) read books on the subject, and swot up on models and theories put forward by learned professors who have dedicated a lifetime to consultation analysis. But here again, I couldn't help thinking that most of it was a waste of time and effort. I learnt a few useful tricks, but on the whole, I felt that I was lucky enough to find talking to patients pretty easy, with or without the help of Roger Neighbour et al.

I have learnt not to be so smug.

On Monday afternoon I met Mr Hussain. He turned up for the first appointment after lunch, ten minutes late. That made me cross. As a result when I called him in, I failed to give him my welcoming smile and left out the usual pleasantries. Instead I ushered him in to sit, and asked, in a fairly cool manner, how I could help.

"Oh" he said, "I was hoping to see Dr Jones."

I could feel the hackles go up. My initial mild irritation intensified as I explained that Dr Jones was not in today. I emphasized that I would be happy to make him an appointment with Dr Jones the next day if he would rather. More than happy.

There was a long pause during which Mr Hussain simply stared at me. More annoying still. But then I saw something in his eyes that I hadn't noticed before. He looked anxious and timid. I realised that in his silence he was weighing up whether or not he could confide in me, looking for the smallest sign from me to proceed. I felt ashamed of myself. I uncrossed my arms, sat forward in my chair, and met his gaze. It was enough.

"It's man trouble" he said.

Ah.

So I've been taught a valuable lesson. In being complacent about my perceived aptitude as a communicator, I have missed the fact that with this comes the danger of complete transparency. In essence, my communication can be a little too effective. I run the risk of communicating hostility as well as kindness, impatience as well as patience, apathy as well as sympathy.

My challenge therefore is not to communicate what I'm feeling. Not to let Mrs Smith know that I'm miserable because I've given up wine for lent; not to let Mr Jenkins see how distracted I am by his comb over; not to make Mr Hussain feel uncomfortable purely because I'm annoyed that he's late.

Perhaps a gentle word of warning then to those who believe, as I did, that they are born communicators. For you may be giving away rather more of yourself than you'd wish...

What's wrong with the British?

Last night I watched the BBC's 'The Day the Immigrants Left'. If you didn't see it, I fully recommend a trip to the BBC iplayer (making the unmissable, unmissable) and an hour of your time to reflect on the current state of the British population. The words; slovenly, chippy, ignorant and ill-tempered come to mind.

I'll give you a short synopsis. Evan Davis (of Dragons' Den fame) travels to Wisbech, a Cambridgeshire town that has seen a huge influx of immigrant workers since the extension of the EU in 2004. There is a general consensus in the town that the immigrants have stolen jobs from the locals, are draining resources and giving little back to the community. An experiment to test an alternative theory, that the average Briton is too lazy and work shy to perform the unskilled jobs that the immigrants fill, is performed. Foreign asparagus pickers, potato packers, restaurant workers and builders are laid off for two days so that twelve unemployed locals can fill their places and prove their worth.

What an embarrassment. Of the initial twelve, four did not turn up for work on day one. Not a great start for the Brits. Of the remaining eight, two turned up half an hour late and one gave up halfway through. A couple of them (once they had finished whinging) did reasonably well, but overall it wasn't a pretty picture. On the other hand the immigrants we saw excelled themselves. They were polite, smiling, cheerful, helpful and hard working.

It's not just Wisbech. This week a patient came to see me for help with weight loss. She was a new patient in the practice and until now had been taking the weight reduction aid, Reductil (Sibutramine). This has now lost it's license in the UK and so I informed her that I could no longer prescribe it. She had tried all the other medications available and nothing had helped. She looked at me moodily and remarked; "I suppose I'll have to try exercising."

What have we become? We'd rather pop a pill than have to exercise, collect dole money than work and blame anyone but ourselves for our misfortunes. I know it's not easy to lose weight, and I know the job market is horribly tough at the moment, but is a bit of effort too much to ask?

The real highlight in this horrifying program was Ali, an Indian restaurant owner, with his new British staff. Well, the one that actually turned up. Ashley, aged 19, was trying his hand at being a waiter. He was struggling. To be fair he seemed like a nice enough guy and he did give it a decent go, but it was too much for him. He gave up halfway through the lunchtime service. Ali, with a warm smile, insisted that Ashley should have something to eat before he left and sat him down for lunch, on the house.

Earlier on Ali had described himself as British, having lived here for most of his life. On the basis of this program, he is far too good a guy to call himself that.

The QOF Express

As the end of the tax year approaches, the race to meet our annual targets is on. Like squirrels gathering nuts the practice must collect as many QOF points as it can in order to get paid. It's not unlike those lucky contestants at the end of The Crystal Maze, scrabbling around in the wind for £5 notes. But whilst we engross ourselves in desperately trying to squeeze in any outstanding foot checks for the diabetics, breathing tests for the asthmatics and blood pressure checks for just about everybody, I can't help wondering what our patients must make of all of this?

What has struck me most is just how much we put them through. We expect them to oblige us by continuously appearing for blood pressure measurements, diabetic examinations, COPD checks, elderly care reviews etc etc and to cheerfully knock back as many medications as it takes to achieve the 'right' results. It's one thing if you've only got one medical condition to worry about, but for many patients, and perhaps most commonly for elderly patients, there are multiple problems meaning multiple assessments, blood tests and the like. Of course it's all well intended, but until recently I had never really considered the impact that all of this must have on their lives.

Mr Mitchell, an elderly gentleman and a prominent author, was recently diagnosed with atrial fibrillation (picked up incidentally when we dragged him in for a blood pressure check). For anyone who doesn't know, this is a relatively common irregularity of the heart's rhythm. As in this case, it often doesn't cause any symptoms, but unfortunately it does put you at a greater risk of having a heart attack or a stroke. Mr Mitchell was thus advised to start warfarin treatment, to thin the blood. He was referred to the warfarin clinic and bundled out with an armful of tablets. There wasn't much discussion, this was the best treatment for him and that was that. But Mr Mitchell has not taken his tablets, and he will not attend the clinic. In the several discussions that we have had on the matter since, he has made it quite clear that he would rather take his chances than become 'a patient'. He has no intention of swapping his independent lifestyle for one which must revolve around a multitude of clinics and blood tests.

Whilst from a medical viewpoint this may seem like the wrong decision, I do completely understand his rationale. It has made me wonder how much of our screening, interventions and health checks patients actually want? How much of our time do we spend getting so carried away with our efforts to treat a disease that we forget what we are actually meant to be doing; treating the patient?

Target driven health care does not help. The truth is that the majority of GP's pride themselves in treating the person and not the illness. It's what we specialise in. We know about patient autonomy and we know that the best treatment for one person may be very different from that for another. If we are lucky (and do not work in a polyclinic) we have the time to get to know our patients, making it easier for us to help them to make the right decisions. What QOF lead health care has done is place too much emphasis on results leaving little scope for tailoring care to the individual. It's robot medicine and it's not what we're about.

Weighed down

A patient of mine died this week. Now I know that I should expect this to happen from time to time, and despite my youthfulness as a GP it has indeed happened to patients of mine before, but this time was different. This was completely unexpected. This was a man in his early 60's who was, or seemed to be, fit and well.

I had been seeing James regularly for the last few weeks whilst we tried to perfect his diabetic control. His kidneys had been playing up a little, but with a few alterations to his medications we had managed to sort things out. His blood pressure and blood sugar were now well controlled, his kidneys back on track and I must admit to feeling rather satisfied at the improvements we appeared to have made.

I last saw him a week ago and had arranged to see him on one further occasion for a final blood test to ensure that all was well. As I arrived at work on Monday I was told that he had died suddenly over the weekend.

I was shocked and saddened, but also almost instinctively sick with anxiety. Why hadn't I seen this coming? Could I have done something to prevent it? Worst of all, could it have been in some way my fault?

I have poured over his notes for clues, studied every blood test result and scrutinized every action that I made. The logical part of my mind tells me that there is nothing that I could have done, that this wasn't my fault. The emotional part has other ideas. I can't seem to shake the notion that perhaps it was something that I did, a change that I made to his treatment, that had somehow triggered this catastrophic event.

An older and wiser colleague reminded me that we cannot take responsibility for our patients' diseases, but only try and help where we can. I know that he's right, I've even spoken about this myself in a previous post. I know that what I need to do is to learn from it and move on. But suddenly being a doctor seems too 'high risk', suddenly caring for all of these people competently looks like an impossible task. So whilst I know what I should be doing, I can't help wanting to hang up my stethoscope here and now and take up gardening instead.

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...