A plan comes together

Don't you love it when you can deliver healthcare with an efficiency and quality even the 'A' Team would struggle to match?

My patient booked an appointment on line to see me about their thumb. He/she put in the free text 'I think I need an injection. :-( '

This text appeared on my screen under their appointment booking so I had the needles / steroid ready on arrival. Yes -  typical osteoarthritis of the 1st carpo-metacarpal joint. I did the injection clean into what can be a small joint to get into. My patient went away happy and left me with the feeling of a job well done.

Appointment on-line booking time by patient three minutes.
Consultation time eight minutes.
Reception time 0.
Admin time 0.
Medical record coding time 0 (part of my 8 minutes)
Invoice processing time 0.
Insurance assessment time 0.
Patient wait 0 (first appointment of session)
Time to claim minor operation fee 0 (integrated into our EPR)

I challenge you to find another healthcare system within Pluto's orbit that could come anywhere close to diagnosing and treating this condition from a standing start in 11 minutes total. Compared to the NHS most other systems would still be in the blocks by the time we'd finished the race and completed our third lap of honour.

Private medicine? You are having a laugh - 15 minutes to complete the first tranche of bloody paperwork!

So how do we do it?
No denying it, the technology is great and primary care IT like this is world class.

But here is a formula to note
Technology + Continuity = Quality + Efficiency

This could not have worked without continuity.

I had previously injected this patient's plantar fasciitis about 7 years ago and it worked a treat. So they knew I did injections and so knew to book with me.  They also knew my injections were 'ok' - reading on NHS Choices that someone else thinks you inject ok is not the same as knowing it (almost literally!) in your bones. It means patient anxiety pre-injection is minimal and I can get on with the procedure quickly without lots of explanation, consent forms, reassurance or medico-legal worry. All this makes the procedure itself less painful by eliminating nocebo effects.

An APMS contract (NB NHS England) could not have delivered this as with 5 year contracts it's highly unlikely the same doctor would still be around. This is only possible under GMS or PMS which NHSE very, very stupidly is not actively newly commissioning.

Technology alone could not have delivered this because technology cannot manufacture the trust that comes from long term personal care.

So Mr Hunt if you have a 25 year vision, make long term personal continuity part of the plan and stop wrecking GMS/PMS!

Stop blathering on about technology - I've been using computers in General Practice since 1989. I got it 26 years ago! We all get it in GP land, that's why we lead the planet.

You can have it all but only if you get and promote continuity of personal care...

New deal

You know that dissonance when as a GP when you encounter someone who turns out to be psychotic and they are saying things that are borderline possible but don't quite add up, you know how you have to seek independent witnesses to be sure - well that's how I feel whenever Jeremy Hunt (JH) speaks. He has just enough traction on reality to be almost credible, if your antennae weren't already twitching wildly. Of course there is no psychosis here just a deliberate skirting around the presentation of truth, as opposed to the mis-perception of it you get in mental illness. Sometimes the patient can be so near reality you begin to question your own grasp on things.

That is why on reading the New Deal speech I had to go back to evidence.

Much of the speech has already disintegrated of course - 5k GPs is now a maximum (but no minimum stated!), the 82% of not a lot and what seemed to be new money that wasn't. Then there is the oft-repeated semi-lie that the CommonWealth Fund voted our NHS number one last year - well yes but they always forget to mention that fact that this assessment was based mainly on data from 2011 and some from 2011-13. For some reason they don't claim that our number one status is (was?) actually the outcome of 10 years of Labour investment in the NHS - funny that.

And in a cracking self-contradiction JH goes on to say 'We rank best in the world for having a regular doctor who co-ordinates care' and subsequently berates Labour with another of his oft repeated misrepresentations for undermining 'the personal relationship with patients by scrapping named GPs'. So they undermined that relationship did they and seven years later we're still top for having a regular doctor? Does anyone read this before putting it out there? It's embarrassingly bad.

Reflecting on this speech is a bit like picking up a carefully crafted sandcastle in your hands - it just falls apart.

But what of this obsession with 7 day working in primary care?

I wondered if there was an evidence base. The Conservative Manifesto 2015 pg 40 (the main vector of the contagion) announces it under the subtitle 'We will make the NHS more convenient for you'. Nothing about reduced A+E attendance or measurably improved outcomes - nothing to suggest anything other than convenience - which as an aspiration is fair enough, but nothing to indicate it is actually needed.

An MP's Briefing Paper and PM's post election speech had no evidence either, apart from the generous reassurance that doctors weren't actually all going to have to work 7 days each week.

Then we get to the New Deal Speech where there are signs that JH is scrabbling around for something a bit more than the 'convenience' of the Manifesto, in belated recognition that actually yes there really does need to be a need, given the circumstances.

'The role and purpose of 7 day primary care is about much more than convenience – it is about making sure precious hospital capacity is kept clear for those who really need it. We have clear evidence from Imperial College London that a lack of access to GPs at weekends results in increases in urgent hospital admissions.'

At last a mention of something I can hold on to - alas no actual reference is given. A bit like my paranoid patient who says someone told him the neighbours were spying on him but then can't tell you who. Nor can Prof Majeed who co-authored some relevant papers but he kindly confirmed on Twitter 3 papers I had also found from Imperial that JH might be referring to.

The problem is none are about 7 day working or weekends specifically and only one is about hospital admissions... of children.

More dissonance.

One shows an association between patient reported difficulty accessing appointments 2 weekdays in advance when they rang in ordinary surgery hours and self referral to A+E followed by discharge (ie not admission). It concludes that better access might result in less self referred A+E attendances (maximum effect size possible I calculate is a 1% reduction in A+E attendance) but the effect is dwarfed by the effects of deprivation which are 4 times greater, which the paper does acknowledge. The evidence would suggest therefore that for maximum benefit we should be resourcing deprived area practices with more appointments in weekdays in usual hours to reduce A+E attendance (but the direct beneficiaries would probably not be Tory voters!). Oh yes that was what our PMS funding (now cut!) was for.

Another makes a rather speculative guess at the proportion of A+E attendances that were preceded by someone not being able to get a GP appointment at a time that suited them, based on the GP Patient survey. This again is an argument for resourcing in hours care properly as the Patient Survey was on patients who rang their practice in hours who presumably were looking for appointments in hours. It tells us nothing about routine GP access at weekends or emergency admissions.

This is consistent with the finding that there is a lack of demand for weekend appointments by many of the PM Challenge Fund pilots.

The last paper, which if you compare the original abstract which contains no mention of GP out-of -hours, with its summary, which does, bears the hallmark of being sexed up. But at least it looked at emergency admissions ..er in children even if it cannot draw any meaningful conclusions about 7 day working. The authors themselves say 'we cannot infer causation' and the fact that the increase in admissions was seen in chronic conditions but not infectious ones led the authors to conclude that the study 'may indicate an adverse impact of financial incentive schemes focusing on chronic conditions in adults' rather than it being due to a problem with GP out of hours availability. 

Even the RCGP felt the need to issue a press release.

So the evidence JH seems to be referring to for 7 day working is ..well ..NOT evidence... unless he can come up with a paper Imperial College themselves don't know they have written!

Well at least it's not me that's losing the plot.

So it seems that JH is systematically misrepresenting evidence for political gain, again. So given I already work 45-50hrs per week, some already at weekends (work email, research coding, GP trainee eportfolio, appraisal, reading CCG documents, private study etc), can find no evidence of benefit from 7 day working, would have to pay a high premium on medical defence cover, face hitting LTA and pension charges, won't be seeing my patients (yes 'real clinical responsibility' is about continuity over access), won't see friends and family and like any GP my age who has read the runes has made sure I don't need the money, will I be working weekends mainly for the convenience of Jeremy Hunt?