A day in the life of a salaried GP

I am no longer a salaried GP, but I thought that you'd enjoy this article I wrote for Pulse magazine - it shows a day in my (old) life.



I could tell you about a normal day in the life of a salaried GP but it would be really rather dull.

This Monday, however, was a rather unusual day - the first day in our new building. The partners had been sweating bullets over it for the past few months and the big day was finally here. We had a sneak peek on the day before to find our way around and marvel at the nice new desks, smooth floors and curious locking mechanism on the doors. Keys are a thing of the past, instead we have a new little key fob that you wave at the handle and the door unlocks. The fob looks alarmingly rather like a shiny black suppository.

0800 I arrive half an hour early to set-up, and find out whats going on. I have the pleasure of doing our rapid access clinic on the first day. It’s a clinic with 5min slots designed to see all the minor complaints – like sore throats, colds, earache – so the complex stuff goes to the normal clinics. There is not much room for pausing or having chat, it’s a fast clinic and if one patient takes too long it very quickly over-runs. I predict problems, it’s in a new building that’s a bit maze-like and a doctor that doesn’t know where anything is.

0805 The trays we use to store our sick notes, forms and such like have quadrupled in size. I don’t have one or a name plate. Sadly I still have to work.

0810 First things first, time to check the most important room in the building. The tea point. So far so good.

0820 Receptionist informs me toilets are not flushing as the water hasn’t been switched on yet. Wish they had told me before I had a sit down session. Feel sorry for whomever uses it after me…

0830 Clinic starts! Patient is told they are my first patient in the new building, the patient doesn’t seem impressed and just wants their sick note.

0845 Hear the water has been switched back on. Run back to loo and flush the evidence.

0915 Need to weigh a patient. New scales not calibrated yet. Only one set of scales working, on other side of building. In a nurses room.

0950 First patient to complain about the car park being too small.

1000 Patient who doesn’t speak English tries to do consult with relative translating via mobile phone. No mobile reception in the new building. Oops.

1026 Notice that we have soft-close bins. Very nice. Patient feedback about new building generally positive

1030 Emergency case turns up needing my help and eventually an ambulance. Clinic running behind now.

1100 Total of 1 hour of urgent extras to see. Most are not urgent.

1215 1 home visit hasn’t been taken. Down to me to argue with doctors to see who is going to do it. Phone patient but they have gone out, informed they will be back from the shops soon.
Politely inform family that we will not be doing a home visit for them. Total of 24 visits today, split between 13 Doctors. Notice that a Partner did an early morning pre-booked clinic between 7-8am. Not a single patient turned up.

1250 On the phone and it starts ringing – it has more than 1 line! No idea how to swap calls so ignore ringing.

1256 Rapid access clinic finally finished. Just a mountain of paperwork to do now and script signing. Room is freezing so wear my coat.

1325 Paperwork finished. Should have been in a meeting that started at 1300. Turn up late, not missed much. Jealously spy the fancy new coffee machine in the corner of the meeting room. Can’t use it though as one of the Partners said it costs a small fortune to use. (Last week one of the Partners did get a coffee out of the machine. Shortly afterwards a sign appeared on it saying Out of Order – awaiting connection to water supply. To discourage anyone else from using it? Who knows.)

1400 Meeting finished. Got 30mins before afternoon clinic starts. Decide to walk to shops for sandwich as not sure I’ll get a parking space on my return.

1430 Afternoon clinic starts

1600 Angry email from reception manager moaning about the new tea point being dirty and no-one is washing their own mugs

1630 Feeling generous and see 2 patients who are both 20mins late each. Would normally ask them to rebook but as it’s the first day in the new building I let them off.

1700 Informed that last patient has gone to the old building. See them 10mins later

1715 Done. Leave after washing up my mug. Race across town to pick up daughter before nursery shuts at 6pm.

All in all the day went well, apart from the workload. Might try and get a cup of coffee out of the machine upstairs next week when no-one is looking.

Free at last!

By the time you read this I will be a free man. Free from the shackles of being a salaried GP! I will have stepped out into the big wide world and blinked at the bright sunshine. Much like the old chap, Brooks Hatlen, did in The Shawshank Redemption, (hopefully I won’t end up the same way he did). I will join the ranks of locum GPs and pimp my skills to any practice that wants me.

I think I have become a bit institutionalised at my current practice having been there since I gained my GP qualifications. It was actually a big shock to go to other practices to see how other doctors work. I was actually shocked to see that in some practices the doctors meet up regularly and talk, divide up visits fairly and seem happy. I forgot that there are better jobs out there. It is not as scary as you think. Being a locum gives you a lot of freedom and a set workload (a novelty indeed).

It also made me realise how hugely dependent some practices have become by relying on salaried GPs to do the bulk of the work. If more salarieds say no and get up and leave, or become locums then perhaps things will change as some Partners don’t seem to listen to our concerns unless it affects them where it hurts, in their pockets.

I’d like to claim that I got so fed up of being dumped on and taken advantage of, that I stormed into the practice managers office and slapped down my resignation letter on the desk and bellowed a few choice words at him. Sadly the somewhat unglamourous truth is that I was too cowardly to do the above. My fellow salaried colleague did actually do something similar to the above and I don’t think any of the partners forgave him and didn’t speak to him after that. I hid behind my wife’s career. We have to move so she can complete her training so that was my excuse for leaving. I didn’t want to make waves and I need decent references (my colleague didn’t as he became a Partner at another practice). Things have got quite strained at work – 4 salaried GPs leaving over the next few months – and I didn’t want to add to the shitstorm

Medication pic n mix?

(taken from Pulse magazine blog)

We have a number of non-English speaking patients and I’m not sure I’m really getting through to them about concordance with their medication. I’ve had several patients who happily take a prescription for their illness, then travel abroad and see a ‘doctor’ who gives them a variety of potentially dangerous treatments. They then pop back a month or two later and see me and complain they are not better, having stopped the original treatment and tried something else entirely. I’ve seen patients who have been given methotrexate, psoralins, roaccutane and a wide variety of topical super potent steroids without any supervision or monitoring whatsoever.

Do I decline to see them again until they do as they are told? What if they continue taking these treatments without any monitoring? Worse still, what if they give these treatments to their friends or children? I’ve had patients accuse me of being tight-fisted for not giving them the incorrect and dangerous treatment they have got from abroad. Warnings about potential serious side-effects fall on deaf ears.

It does make me wonder why they bothered seeing me in the first place if they won’t use what I gave them, but try some dodgy pills from a person with dubious qualifications. It is quite frightening what odd treatments patients can get hold off via a variety of means. Any time a patient sees me claiming a ‘special cream’ has cured them of their eczema or psoriasis I can be fairly confident the mystery ingredient is dermovate.

It’d be interesting to know how many patients use their medication for something other than what it’s prescribed for. I know of some elderly patients who have been sharing their medication, god knows what sort of interactions have been going on. I wonder if it’s a bit like pic 'n' mix?

What makes a perfect patient?

A quick bit on GP funding before we begin so you know what I am talking about in the future - QOF stands for Quality Outcomes Framework - its a points based system for GP funding. You get points for managing certain conditions, managerial activities and other things. For example for a patient with heart disease you would get points for checking they are not depressed, on certain medication, blood pressure is below a certain value etc... Its designed to increase the level of care a patient receives by ensuring certain targets are met. It does mean that there is a tendency to concentrate on getting the points and nothing else however. Also some points are based on dubious targets or near impossible to get (the recent biased and poorly designed patient questionnaire released by the government was a good example). We have a few nurses who's sole job is to go chasing QOF targets to make sure we score as many points as possible

In exchange for not doing out-of-hours care anymore GPs had a paycut of about £6000, QOF targets were also introduced. At the time there was a recruitment crisis in General Practice so the government hoped getting rid of Out-of-hours care for GPs would make it more family friendly and changing the funding would raise pay a bit. When the QOF targets first appeared the government assumed most GP practices would reach about 70-80% of the total. Infact most Practices got 100% so received a bumper amount of funding. This is why Partners salary went shooting up. It wasn't that they were greedy it was that they were doing their job well!

The government ever since has been trying to claw back some of this funding ever since by changing targets on a yearly basis or forcing GPs to do extended hours again without giving them back the original money they took from them. There has also been a smear campaign against GPs as the government was more than a little embarrassed at cocking up the GP contract negotiations and giving too much funding to General Practice. QOF targets have had negative and positive impacts on General Practice, I'll talk about them more in the coming months but that was just a brief run through to bring you up to speed. Any questions send me a tweet via @GPforhire on twitter.

(below is taken from my blog on Pulse)

Its fairly easy to find out what makes a good GP – for example the GMC has some good information on it, as does the RCGP. But what about patients? What makes a good, or even a perfect patient?
I guess it depends on you want out of them, at its most basic could the perfect patient be the one who is registered but never turns up and lives a happy healthy lifestyle with no need for a GPs input? Perhaps but with my QOF chasing hat on you can’t score that many points from them. Maybe a few points as they are a non-smoker, non-drinker and normotensive. But not many.
Perhaps if they had a few chronic diseases that would be better, could get a few more points out of them. What about if they are a depressed obese asthmatic with epilepsy, diabetes and heart disease? Could score a lot of points there! But to be a good patient they would, of course, have to turn up for regular review and take all the medication you throw at them. Ideally you want to be able to score as many points for as little work as possible I suppose. Maybe patients could be trained to chase their own QOF points? What if a cohort of diabetic patients touted their QOF point potential to low-scoring practices? Could they hire themselves out by registering with a different practice each year?
You could have some sort of QOF über-patient but it’s just a tad dehumanising to only view them for their QOF scoring potential. For me personally I like patients who turn up on time, don’t stink of fags, booze or sweat, don’t have a vast list for me to try and sort out in 10mins, do what they are told, and most importantly send me cards saying thank you so I can put them in my appraisal portfolio to show what a wonderful doctor I am as it seems nowadays if its not written down it doesn’t count.

Medicine by numbers?

I’ve noticed something with the GP Registrars I sometimes get to supervise. They almost always forget to chase the QOF points. Its not even on their radar. When I’ve asked them it almost invariably “too busy chatting to the patient”. They aren’t taught about ticking the boxes, or if they are then they willfully forget. Compare that to a salaried GP – QOF chasing has now become our raison d'être. But lets be honest, who doesn’t hate chasing all the QOF Points? Perhaps someone should make the equivalent of a Photo-me booth? We could call it a QOF-me Booth? I reckon it could score most of the clinical QOF points. Pee in here, put your arm in here, blow here. QOF-me booth could do it all. Hmm, hang on a sec, that will do me out of a job! Forget I ever told you…

Are we getting to the point where we are practicing Medicine by numbers? It does make me wonder what is a GPs role in the future? If all chronic diseases can be managed by nurse-led clinics, acute problems can go to the drop-in clinics what’s left for us? Insurance reports and cremation forms I guess.

Show salaried GPs some respect

Below is a reproduction of my new blog which is appearing in Pulse magazine. I will be posting other stuff on this blog aswell. The Pulse magazine blog is aimed at GPs so it might use the odd big of jargon that you might not understand. QOF points are the major way General Practice is funded. Essentially you get points for asking or doing certain things - eg asking someone who has diabetes if they are depressed, getting a blood pressure below 150/90, asking ex-smokers if they are still ex-smokers etc... Its meant that most consultations have now become QOF chasing exercises because if you don't get the points, the Practice doesn't get the cash. The GP partners get the cash, they decide where it goes and how much they get to keep, salaried GPs work for the partners - we cost 1/2 to 2/3's as much as a partner but do all the clinical work and none (usually) of the business side of things.

Simple really. Well it would be if the QOF points made sense - which they don't always, and a percentage of them change every year. So now you understand a bit about how General Practice is funded hopefully the rant below will make some sense!

What’s it like to be a salaried GP? Not much fun that’s what. I came into general practice with the rather foolish idea that I would eventually end up a Partner, help think up some innovative changes, improve patient care and be my own boss. I mistakenly thought that I’d be a Salaried GP for a year before finding a partnership. Now nearly 5 yrs later I’m still a Salaried and partnerships remain as rare as rocking horse droppings.

I’m getting really fed up with the barrage of emails reminding us of all the QOF points we have missed, a big chunk of which could be done by the receptionists but for whatever reason they can’t bring themselves to do it. Extra work to do? Down on the QOF points? Extra vists to see? Bounce it to the Salaried GPs! It’s the attitude of the partners that I find disrespectful. If it’s a choice between getting a Partner to do something or a Salaried it almost always gets bounced to the Salaried GP – after all you have to make sure you get your moneys worth out of them.

I know lots of Salaried GPs are sick to death of getting flogged by the Partners. The Partners can cancel clinics at the drop of a hat, go on courses, meetings, anything that takes their fancy. Salarieds? No such luck. If it doesn’t bring money into the ‘practice pot’ (partners pockets) they are not interested.

Work is meant to be distributed fairly but it’s laughable when the partners claim they do the same as the Salarieds. They don’t. Don’t kid yourself.

I know some salaried GPs have been given permission to pursue some management activity (QOF chasing) but with no extra pay or time to do it in. Why bother? It’s getting like that now at work. Why bother? – I’m paid to do my clinics, fill in some forms and do visits. If it is anything else then I am not interested. It is terribly sad that it’s getting this way. The goodwill of the salaried GPs is evaporating fast. Partners need to treat us with respect and have a radical rethink about how they use the increasing salaried GP workforce. That Darzi clinic down the road is starting to look quite appealing…

Choose and Book. What a massive waste of money.

Title says it all really. I'll explain why in a mo,

First apologies for not updating this blog sooner. 3 reasons
1) Been on holiday - very nice it was too
2) Couldn't decide on a topic
3) I'm lazy (main reason)

So much has happened since I last blogged. From Tamiflu being declared rubbish (we knew that already), CRB checks for all (we're all paedophiles til proven otherwise apparently), and the government keen to get rid of GP boundaries (did they actually talk to any GPs about this idea or did they, as a colleague suggested, simply run it past a Question Time audience to see if they clapped?). Thats just a start, there are other things but, er, I've forgotten.

Anyway, to the subject at hand, Choose and Book (CAB). Have you seen your GP and been referred to secondary care (hospital etc..)? What should happen is the GP asks you where you would like to go and then books the appointment for you. A short wait and then you are seen in the hospital of your choice. Sounds like a neat idea, you could pick a hospital near work for example rather than the run down portacabin round the corner. The idea ( I think) was to create a sort of marketplace where hospitals compete for your 'custom' which in turn drives up standards and improves care.

A nice idea you might think but the NHS being what it is its a complete and utter shambles. What used to happen before all this was you'd see the GP, (s)he would recommend referral, sort out a letter, it'd get sent and a few weeks (or more) later you'd get an appointment. The GP could even refer you to a specific consultant so you wouldn't have to see the dodgy crap one that every knows is shit but too scared to say anything about.

Simple. Doc ->letter->Consultant. Job done.

Now what happens is you see the GP and they recommend referral. Where I work the doc does the next step but I know in other areas its handled by a dedicated team. The doc explains to you that you now have a choice of where you go. In fact they mention the word choice several times. This is because the powers-that-be occasionally monitor patients to see if GPs have offered them choice. Next step is logging onto the Choose and Book website. (How much did that cost??). Whats been happening recently is that the screen freezes and the entire thing crashes so the GP mutters under their breath and sends a referral the old fashioned way (sort of).

Assuming the website works the GP types in what service they want to refer you to and then the computer returns a list of available hospitals and such like that offer this service. This list used to be 5-6 local services, its been changed now so it shows every place in the UK that offers the service. Quite why anyone would want to go somewhere that is hundreds of miles away is beyond me but you have that choice so the Government is happy. Rather cheekily it also lists at least 1 private provider. It also lists waiting times - where I work this is woefully inaccurate and out by weeks.

You ask to see a specific consultant but the GP tells you that you don't have that choice. (Infact if truth be known you'll probably end up with the dodgy shit consultant as they have the shortest list.) You pick a place, GP confirms, prints out a form with a password, reference number and telephone number (assuming the printer works). You then phone this number a few days later (to let the referral letter reach them first, otherwise they can't do anything) and confirm who you are with the password etc and you are given a date for your clinic. You have to phone them fairly soon, if you leave it more than a week or two the referral is returned back to the GP. Finally you get to see the consultant, only its not a consultant, its a nurse practitioner.

So the new pathway is GP->Choose and book website->patient phones booking system->booking system liase with hospital->appointment booked->seen in clinic (might not be the one the GP wanted though)

Ok problems.
1) Patients actually want to go to their local hospital and see a named consultant ->can't do that
2) Special referral pathways have been set up to triage referrals and make sure they go to the right place ->CAB overrides this so trivial stuff now takes up consultant clinics rather than more complex cases
3) GPs don't know much about all the different services on offer so can't offer advice as to whats best
4) Patients sometimes make wrong decisions about where they want to go
5)It assumes patients have a good reading level (not all do). Bit stuck if they can't read the info.
6)Some services are overrun and waiting list times have soared, other services are underbooked. No way of moving patients to these underbooked clinics which would save time
7)Try explaining CAB to elderly patients and they haven't a clue what you are talking about. Large numbers fail to attend hospital or referrals are bounced as they didn't phone to confirm
8)Try explaining CAB to patients where English isn't their first language and they haven't a clue what you are talking about. Large numbers fail to attend hospital or referrals are bounced as they didn't phone to confirm
9)Website crashes.
10)Hospital clinics are being filled inappropriately due to an inept booking centre
11)Services have got worse not better.
12)The amount of effort its taken to set up a service that, in my opinion, is actually worse than the old system is quite breath taking.

Neat huh? I have yet to meet a GP who thinks that CAB was a good idea that works well. Its a bad idea, that works badly. Genius.