Sign the petition.

*adapted from Gimpy

The Gatekeeper and the Wizard: a fairy tale

The Gatekeeper and the Wizard revisited

During the university application process I very nearly applied for a double degree in Mathematics and Music instead of Medicine.  I consider myself very lucky to be able to enjoy numbers and sounds whilst having a career as a GP so I think I made the right decision. I imagine having a mathematical or musical career, coming home from the day job and then getting out my doctors bag as a hobby would be illegal.

I do not feel I have suffered from Burnout but rather what I call being “Burnt In” – Being chopped and tailored as a malleable student throughout medical school to become a doctor, with further kneading and squashing as a junior doctor then GP registrar.

So, for anyone interested, I completed the abbreviated MBI and here are the results;

EMOTIONAL EXHAUSTION = 15

DEPERSONALISATION = 1

PERSONAL ACCOMPLISHMENT = 14

SATISFACTION WITH MEDICINE = 16

I was very careful not to read the scoring system before completing the table.

So it looks like I’m quite emotionally exhausted but have very little depersonalisation and am fortunate to have a great amount of personal satisfaction with the job. I wonder if decreasing my emotional exhaustion would cause the depersonalisation score to creep up?

align the interface, prime purpose, level of service

fragmentation and coalescence, fault-line, integration, tracking the benefits

emergent consortia, emerging policy documents, held to account, postcode lotteries

co-terminous, foster integrated working, clusters, strong emphasis

sole preserve, patient flows, early thinking

ANOTHER PARAGRAPH from the new White Paper.

“2.8 We will also encourage more widespread use of patient experience surveys and real-time feedback. We will enable patients to rate services and clinical departments according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong. We will also require that staff feedback around the quality of the patient care provided in organisations is publicly available. As in many other services, this feedback from patients, carers and families, and staff will help to inform other people with similar conditions to make the right choice of hospital or clinical department and will encourage providers to be more responsive.21 The Department will seek views on how best to ensure this approach is developed in a coherent way.”

Every GP practice in the land has an NHS Choices site where people can leave feedback under the heading “What patients say about this GP practice”. I subscribed to the comments because I was interested in what people were saying. Our surgery had no comments until about 3 months ago. We now have a few.

A couple of them are blank with no positive or negative comments. I am happy to say most of them are positive and interested to find out that 2 of them were negative. One towards our receptionists and one towards the doctors. A few days ago one of the negative comments disappeared from the site.

I do not think this site will “help to inform other people” and I do not believe that the site will “encourage providers to be more responsive”. Stop it.

Patient Comments .

NOVO NORDISK HAS announced the withdrawal of insulin Mixtard 30, and stock will cease to be available after 31 December 2010.

Diabetes UK has issued a list of alternatives.

Whichever option is chosen to replace Mixtard 30 it is likely to be at best an inconvenience to patients. It could increase the chance of hypoglycaemic episodes. Prescribing costs, referral costs and consultation times will increase.

Is this a purely commercial decision? Will Novo Nordisk recommend their more expensive option NovoMix 30?

The National Prescribing Centre is in discussions with the Department of Health on the implication of this company decision. Will they have any clout and be able to overturn the decision?

A PARAGRAPH from the new White Paper.

“2.7 Information generated by patients themselves will be critical to this process, and will include much wider use of effective tools like Patient-Reported Outcome Measures (PROMS), patient experience data, and real-time feedback. At present, PROMs, other outcome measures, patient experience surveys and national clinical audit are not used widely enough. We will expand their validity, collection and use. The Department will extend national clinical audit to support clinicians across a much wider range of treatments and conditions, and it will extend PROMs across the NHS wherever practicable.”

From April 2009, all providers of NHS funded care have collected PROMs in 4 clinical areas;

1. Hip relacements

2. Knee replacements

3. Inguinal (groin) hernias

4. Varicose veins

My interpretation of “wider use” in the paragraph above is that PROMs could be extended into chronic conditions and mental health.

PROMs are typically short self-completed questionnaires. They are subjective. The patients’ response relates to a single point in time. Typical content includes questions regarding;

1. Symptoms of illness e.g. pain

2. Function – personal e.g. mobility/dexterity - social e.g. leisure activities

I am unaware of any PROMs relating to hernias and have not used PROMs relating to varicose veins for several years.

I have used the Oxford Knee and Oxford Hip scores and found them very useful. It is difficult to order a radiograph of a hip or knee joint without including the relevant score. Scoring takes time and I seem to use it more when my surgery is running on time.

Other subjective patient-completed forms I use are the PHQ-9 and GAD-7 which aim to score depression and anxiety respectively. If I do not include a PHQ-9 and GAD-7 score with referrals to our local counselling and CBT service they will not be processed. There is plenty of information regarding the validity of these tools. This is irrelevant to me as if I do not complete them, my patients cannot access the service.

Another PROM I have used (without knowing it was a PROM) for a long time is the international prostate symptom score (IPSS). There is no pressure to use this as part of a urology referral but this is something I again find useful along with an examination and occasional PSA blood test.

The concern for GPs is the possibility of many more PROMs becoming compulsory to complete before any referral is accepted.

A recent Kings fund publication has mentioned (in a typical example of understatement);

DO HUMANS learn from past ideas and events?

I’m thinking about this question today because I attended a meeting last week. I do not attend many meetings and I do not think the meeting was a particularly good one. It did not have a clear agenda.

We talked about the rather abstract and nebulous concept of the possibility of a GP Federation that would hold a large budget and commission services for their patient population.

I asked whether anybody could explain the process of commissioning in a clear and simple way. After all, if GPs are to commission then understanding the process would be a good first step.

Nobody could answer the question. “It’s difficult to put down on paper”, “The process is different depending on what you are trying to commission” and “Commissioning is not contracting or purchasing” were some of the comments.

My  mind wandered to a few years ago when a large private company, United Health Europe, bid to run a local GP practice. The PCT awarded the contract to them. All hell broke loose as other bidders could not understand how the PCT had arrived at their decision. United Health Europe’s contact was cancelled and the contract put up for tender again.

This time the contract was awarded to ChilversMcCrea Healthcare (another private company). United Health Europe did not bid. A statement was released by the PCT stating (from memory) that as a result of having to carefully review their commissioning process, they felt that they now had a world-class system they could be proud of.

Can we learn from this? Should we be asking the PCT to provide us details of their commissioning process? Is it a good first step on the way to understanding commissioning? Is it useless?

Unless you have been in medical blogging darkness over the last few weeks you will be aware of a white paper now published regarding further change. I wonder what it will mean for General Practice.