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.

Why am I not surprised?

As I am writing this Breaking News on twitter (@BreakingNews) has reported of the first few cases of Tamiflu resistant Swine Flu in the US. Seeing as we are giving Tamiflu out like smarties in UK I predict it will be a few weeks before we start seeing resistant cases in the UK too. Great.

Its debatable if Swine Flu will surge back again in the autumn/winter. Certainly all the preparations are based around a second more severe wave of infection. Will it be the same virus or will it have subtly mutated so no-one will be immune who can tell? Its all guesswork from what I have been reading.

I'm not going to rant on about Tamiflu being rubbish in children as you guys already know that. I will say that the recent study from Oxford was dismissed by the Department of Health as the research was done on Seasonal Flu, not Swine Flu. A couple of points worth considering;

1) The reason why we are giving out Tamiflu en masse is based on this study, which was done on, (you've guessed it) Seasonal Flu. So its ok to use one study done on seasonal flu to justify Tamiflu, but not another - huh?

2) Its hard to do studies on an emerging pandemic influenza as its new and not been around long! As we are no longer swabbing who knows what illness the children really have? Hopefully we'll get some decent studies coming out soon but don't hold your breath.

I've been asking people on Twitter if they would have the Swine Flu vaccine if offered. Mixed responses really but some people are now so distrustful of the Governments handling of the Pandemic they would decline. Others don't want to use an untested vaccine.

Please don't confuse the vaccine with Tamiflu. Tamiflu is rubbish. The vaccine isn't. I understand reasons why people are fearful of the vaccine but its manufactured in exactly the same way as the seasonal flu vaccine, just a couple of protein bits are altered. It will still have to meet the stringent requirements for using a vaccine on the public. The seasonal flu jab is only manufactured a couple of months before the flu season but people don't panic that its not tested properly. Seasonal flu kills 12000 people per year in the UK, it would be considerably higher if we didn't vaccinate.

There was a small outbreak of Swine Flu in the states in the 1970's. The vaccine produced then was with inferior technology and there were a number of reactions to it. Vaccine production nowadays is considerably more advanced and safer.

Swine Flu is H1N1, Spanish Flu was H1N1 too and that killed roughly 50 million people. Ok the Swine Flu virus is slightly different but it still has that potential to kill. I don't want people to be dismissive of the vaccine just because Tamiflu was a load of shit. Swine Flu so far has been a mild illness in most. It may, or may not, stay that way. Should you have the vaccine if offered? I think so. Its personal choice though so don't take my word for it. Don't base your decision on the rantings of an irate GPs blog. There may be a risk in taking the vaccine but there is a risk in everything we do in life. I suspect the risk of harm from the vaccine is considerably smaller than the risk of driving to work, using routine medicines or even just mowing the lawn. And if you smoke? Well the risk of harm from that far far outweighs any possible complication from the vaccine.

Later folks! Stay healthy!

Why not just put Tamiflu in the water..?

Hello again dear reader,

Been getting loads of feedback via twitter (@GPforhire) about my last posting. Apparently you didn't realise that Tamiflu isn't all its cracked up to be. Not surprising really as the negative side of tamiflu has had very little coverage. I could be paranoid and think that the government is suppressing reports of its lack of efficacy and side effects but is Labour capable of that?

Things are changing a little, there was this report in the Guardian today, and a previous one in May. I saw a young child last week that got a nasty rash from the drug. We've had multiple patients that couldn't tolerate the tamiflu due to vomiting and then phone us in a panic worried that they'd succumb to Swine Flu without their magic bullet drug.

Just so you know that I'm not making this up heres a few links that have looked at various bits of data.
You might have to be a BMA member to see the full articles

Tamiflu and anti-inflammatories (aspirin, ibuprofen or diclofenac) might be a nasty combo
GPs seeing lots of patients with side effects from Tamiflu
Tamiflu and neuropyschiatric side effects in teenagers - case not proven, caution recommended
Use of Tamiflu in children not supported by the evidence

So for the record, I wouldn't take Tamiflu, and neither would anyone in my family. Not for Swine flu anyway. For Avian flu I'd probably take it but resistance to it is growing.

Another worrying development:

Misdiagnosis.

I know of 3 deaths that have happened recently because they were thought to have Swine Flu but sadly had something much more serious which was missed until it was too late. This number will increase as the number of people assuming they have Swine Flu when they have something else will no doubt increase.

We run a simple problem clinic at our practice (see my earlier blog entry). Its been nearly empty this week. Summer holiday don't make that much difference to the numbers. I think its because these patients are confusing their symptoms with Swine Flu and using the Pandemic Line to get their tamiflu. These patients will probably turn up next week complaining of side effects from their treatment for their non-existent Swine Flu. I know some docs who have been swabbing patients still. Roughly 10% of the patients they thought had Swine flu actually had it on swabs. Thats experienced GPs seeing patients face to face and are still getting it wrong 90% of the time. God knows what the general public numbers would be like. Its madness frankly. Countless thousands of people taking Tamiflu (via the Pandemic line) for a mild self-limiting illness which they haven't even got!!


Quick link before I go. Heres a website run by the Medicines and Healthcare products Regulatory Agency MHRA. You can report any side effects from Tamiflu here. Tamiflu is a black triangle drug and so all side effects (even minor ones) should be reported. Its how we get to know if a drug is doing something odd. Anyone can report a side effect, doctor or patient.

Stay Healthy and see you again soon!

The Week that Was

So its the end of my first week back at work and the Swine Flu panic, er, I mean pandemic is in full swing. We are getting 30-40 patients a day worried they have it. Some do, some don't. Should we be giving them all Tamiflu? Well that depends on what guidelines you read and whether you are bothered by something called evidence-based medicine.

You're no doubt aware of the mountainous piles of Tamiflu the government has stockpiled. Let's get one thing straight. Tamiflu is an antiviral but this doesn't mean its a cure. Its not like taking an antibiotic for pneumonia. At best it will shorten the duration of symptoms by a day. The evidence so far has shown it has no impact on mortality (i.e taking it won't stop you from dying if thats your fate). Its use in a pandemic is unproven.

Lets not forget all the side effects. We are already seeing children who get quite nasty vomiting from it (1 in 10). Trouble is you tell the parents to stop the drug and they shit themselves, convinced that Tamiflu is the only thing stopping their child from knocking on heavens door. So the child vomits themself into dehydration and ends up needing admission.

Interestingly a large study of Tamiflu's potential neuropyschiatric side effects showed a possible increase in seriously abnormal behaviour (such as self-harm) in the under 19s. Its not meant to be used in Japan for this age group such is the number of cases they have had. Of course in this country we have no such qualms in giving it to our children. Tamiflu is classed as a black triangle drug in the UK- this means its a new drug, not all the side effects (or frequency of) are known, or the potential interactions.

One of the high risk groups for complications of Swine Flu is the under ones. The UK has a limited supply of liquid Tamiflu for this group. Guidelines state that all under 1's should be offered the drug. Trouble is is that it doesn't work, no evidence it works and I've been informed via a consultant Neonatologist that the under 1's lack the enzyme to activate it. Also the blood brain barrier hasn't fully formed yet meaning the drug that is known to cause hallucinations and confusion can easily pass into their developing brain. Brilliant. Is that in the press? Hell no, its not even in the Daily Mail which hates all things medical.

Now don't get me wrong. I'm not trying to scaremonger. I'm just letting you know that Tamiflu might make you quite sick, or worse. It lacks evidence of effectiveness and I'd think twice about giving it to anyone under 18.

One flu over the Swine nest

Good evening dear Reader,

I write this as I am watching Bear Grylls eat frozen squirrel brains in a Siberian forest. Still, if its a choice between that and Kendal Mint cake I know what I'll go for.

Work is vaguely interesting at the moment. We are all going to die from Swine Flu.

Or maybe not. In January of this year the RCGP published its Pandemic Flu guidelines which gave information about what do in the event of a new global flu pandemic. It was based on models from previous flu pandemics last century (that makes me feel old) with mortality rates etc... from Avian Flu. That was assumed to be the Big One. Its nasty, it kills a lot of people. Much to everyones surprise it was actually Swine Flu (H1N1) that swept the planet.

So far its killed a few hundred people and infected many tens of thousands (at least). Although these deaths are tragic, things should be put into perspective. Seasonal Flu (normal flu) kills 12000 per year in the UK. Does it get the same kind of hysterical coverage in the media? Not a chance. Mind you I can't be too tough on the media and the government (for once) as their projections were based on the far more deadly Avian flu.

How's things panning out now? Well I'm sure you are aware that Swine Flu is a lot milder than everyone was expecting. True it has killed people but the majority of these had other significant illness (not sure what exactly as no-one will tell us). One person died today of Swine Flu who was otherwise healthy. I am assuming they died from viral Pneumonia - v.nasty but rare, 40% mortality rate.

We've had a few cases through the doors where I work - despite advice to stay at home. I think currently the Staff are more scared then the patients. The difficulty is the guidance coming out from the PCT is mixed, frequent and far too wordy. I get 2-3 emails per day with 4-5 attachments. Each email supersedes the previous one - usually. Its a fucking mess. The Swine flu packs never turned up - not that they are needed now. Tamiflu guidance seems to change every few days. I'm still unsure if its for people presenting within 48hrs of symptoms, just the high risk groups, or everyone. Not that its any good. Government seems to think its a silver bullet but the evidence behind its use is not brilliant. Shortens the illness by hours, reduced viral load but its not without its side effects - including making all your skin fall off (rare but if everyone uses it we might see a case or two)!

Don't get me started on NHS Direct. Fucking waste of space that is. Masks are pointless too but good for scaring patients. I think a lot of the problems come from the original guidance which was based on Avian flu. Which is nasty and kills a lot of people. Where as Swine flu just makes you feel a bit poorly (usually). The guidance is slowly changing to take account of the fact that its not the End of humanity as we know it.

How you diagnose Swine flu? You guess. Thats right. We've been given a few symptoms that people will have but the trouble is is that the vast majority of viral infections we see in GP-land present with this. Even worse with children. Its only a matter of time before we miss a serious illness (meningitis, cancer, etc...) as we are so focused on believing everyone who is unwell has Swine Flu. And then the Daily Mail will have a field day. Whoop-de-fucking-doo.

Of course come winter the shit will hit the fan when Swine flu grows some balls and becomes the killer that we are all worried about. Oh well, such is life.

Why is hospital food so damned awful?

Apologies for the lack of blogging, I've been a bit pre-occupied when my next child made an unexpected appearance early when my wife's waters broke at 36 weeks. I won't bore you with all the details but thankfully baby Toby was born on the 29th May at 1030 weighing 5lb8oz. Mum and baby are doing well.

Anyway there were numerous things that caused problems, not least there being no beds on labour ward- a recurrent problem. You'd think with a Labour government in power they'd at least get that sorted ;)

I don't know if you've ever been to Leeds General Infirmary but its main car park is a bloody nightmare. It is, without any doubt, the worst designed car park in the UK. The angles on the approach to the ramp to go up each floor that you have to swing out wide to get around them. Newcomers to the car park regularly get it wrong and have to do a sort of 3-point turn to get up each level. The worst thing though, is the 1foot thick concrete miniwalls up each ramp. It seems they have designed these to jut out and rip up your wheel arch as you try and navigate the turn.

I've caught my car on it and so has my wife. In fact if you look at each ramp wall you can see a multi-coloured smear of car paint that is a testament to the number of cars that have had their wheel arches ruined on those damned stupid wall ramps. If you, like I did, wander about and look at the rear driver side wheel arch of most of the staff cars in the car park I would estimate approx 25-30% have been torn up by that stupid-ass designed car park. Let that be a warning to you if you ever park at the main car park in the LGI. Drive a small car.

Ok the other thing that I really don't understand is why is hospital food so bloody shit? I've been to multiple hospitals in the past and I have yet to go in one where the food they serve the patients is nutritious, edible and tasty. An adult male requires 2500 calories per day, 2000 for a female. This is higher if you are ill, recovering from surgery or breast feeding. Quite how you are meant meet these requirements on hospital food alone I do not know.

I remember doing my medicine for the elderly job and regularly we'd prescribe fortsips (calorie and protein dense milkshakes) to compensate for the utterly shit food that was served to patients. Honestly if you served this food to prisoners there would be riots. But as its a bunch of old crumblies who can't complain who gives a shit right?

Its no better on the adult wards for medicine and surgery. The portion sizes are pathetic, any salad consists of limp lettuce and a slice of anaemic tomato. Bread is hard, white and cardboard like. Butter is frozen solid. Everything is reheated and alarmingly whatever the ingredients it contains it all seems to taste and smell the same once it comes out of the reheater. Its a fact that the LGI cannot cook any fresh food on the premises for patients.

Get this, it is prepared in Wales and the transported via lorry to the hospital where it is reheated and then served. God alone knows why this is. Carbon footprint be damned I guess. If the swine flu pandemic kicks off and lorry drivers go off sick then I've no idea how they'll get the food to the LGI. I very much doubt relatives will bring it into a hospital full of swine flu patients.

One of the starters on the menu they gave to my wife was Orange Juice. Since when has a drink been a starter?! Oh yes, I remember now, when I did Home Economics when I was 13!! WTF? It that wasn't bad enough one of the main courses was Gravy. Thats right. Gravy. It can't possibly be a bowel of gravy could it? We weren't brave (or foolish?) enough to order it to find out. Needless to say my wife had all sorts of nice food bought in by me to supplement/replace the bloody awful shite the LGI had the audacity to serve to their patients.

So, if ever you have to go to the LGI for to visit a patient then make sure you come in a small car ( or park elsewhere) and for God's sake bring them some decent food (not grapes!).