GP question (no spoilers)

just got a questionnaire from my GP surgery.  The last question states:

NHS England requires all GP practices to have a senior member of the team reviewing all requests for appointments. This is likely to be a GP. Are you in favour of this change?

I don’t bloody know if I’m in favour of it, I only just heard about it. Presumably the pro’s are that the GP could filter out some stuff that doesn’t need to be handled by a GP, and the cons are that this takes said GP away from actually providing primary care.

What do our resident doctors think?

I dunno, I’m not a Dr.

But the only way to get an appointment with mine is to gross out the receptionists when they ask why you need one.

I get that they need to weed out the colds and flu’s from the “my right testicle is about 3x the size it’s supposed to be” cases. But it might also make more sense if that was someone with some medical training that could screen between a cough that needs some investigation and a cold.  Or spot the difference between hypochondria and immuno-compromised.

It’s a difficult one. There’s some evidence from EDs that triaging is best done by the most senior clinician available but as you say, that means taking a GP away from actually seeing patients.

What’s really needed is more recruitment and (particularly) retention but that means more money…

That’s utterly insane.  Doctors are thin enough on the ground as it is without turning them into admin staff.

Every tech support department in the country these days has a front line service, often hidden behind an IVR system, who can walk through a script before passing you to someone technical.  It’s frustrating as a customer for sure, but it’s efficient as a department for weeding out the sorts of people who ring 999 because their local KFC ran out of chicken.  I’d want GPs to be P’ing rather than spending two hours of their working day buggering about with a scheduling system.

Who performs similar triaging at A&E? (Genuine question).

Usually a senior nurse. However in a Majax it’s likely to be one of the consultants.

Who performs similar triaging at A&E? (Genuine question).

There is no standard approach to this. Some places it is consultant led, other Nurse/Health professional.

Many studies showed best benefit when its consultant led, but that doesnt get favour with management because consultants are expensive, and I guess with consultants because they like to look after people and there are not already enough of them in ED.

As to GPs I would hope good practices will have regular management meetings where they review clinic utilisation.

I think it’s a false economy.

Time and time again, the research tells us that GPs add value (twice as much as the rest of the NHS) by continuity of care with experienced trained generalist physicians.

The idea that cases can be diverted to other, cheaper practitioners to save money is fallacious, because the alternative practitioners tend to take longer, and be too thorough, leading to extra investigations and referrals.

At the same time, by fragmenting primary care like this, we lose continuity of care, which costs us in the long run.

It is absolute **** madness.

I don’t bloody know if I’m in favour of it, I only just heard about it. Presumably the pro’s are that the GP could filter out some stuff that doesn’t need to be handled by a GP, and the cons are that this takes said GP away from actually providing primary care.

the statement does not say a GP it says “a senior member of the team”.  That rules out someone on work experience – but wouldn’t exclude a nurse practitioner, or even a “senior receptionist”.

I get that they need to weed out the colds and flu’s from the “my right testicle is about 3x the size it’s supposed to be” cases. But it might also make more sense if that was someone with some medical training that could screen between a cough that needs some investigation and a cold.  Or spot the difference between hypochondria and immuno-compromised.

but actually a receptionist who has answered the phone to worried patients every day for the last 3 years might actually be just as well placed to help the patient find the right care.  I’ve found that on all but one occasion that by giving a proper account of why I want an appointment I was able to get the advice I needed for me or my family in a timescale that seemed appropriate for the severity.  On the one occasion I did have to get assertive it was a lack of appointments not a lack of knowledge or willingness – she thought I should call again tomorrow but two days in a row I’d been on redial from 0800 and they had no appointments less than 3 weeks when I got through.  When I expressed concern, a GP called me later that morning and asked me to come in and see him that afternoon.

Every tech support department in the country these days has a front line service, often hidden behind an IVR system, who can walk through a script before passing you to someone technical.  It’s frustrating as a customer for sure, but it’s efficient as a department for weeding out the sorts of people who ring 999 because their local KFC ran out of chicken.

but people quickly learn how to game those systems, because in healthcare their will be keywords that get you an appointment quicker because the consequences are life threatening rather than not being able to checkout on Amazon…   Want an appointment today “you are having difficulty breathing” or “have chest pain”.

I’d want GPs to be P’ing rather than spending two hours of their working day buggering about with a scheduling system.

it may actually be the best way to get a case dealt with – a 2 minute phone call where you speak to a voice you trust who directs to Nurse, Physio, Phlebotemy, Pharmacy etc would potentially be better for 5x as many people as one 10 minute appointment where they innevitably refer you to one of the above. There will be a lot of GP appointments that would be far better if someone had been able to say at the booking time – right there’s no point talking to the GP without a blood test or urine sample so let’s book that first.

A triage element in general practice is very worthwhile, but only if it is staffed by someone who can immediately pick up on the red flags which demand attention despite the issues raised perhaps seeming relatively trivial or non-threatening. Sometimes that takes someone with experience, be it in primary care nursing or general practice, rather than someone like the new ‘physician assistants’, or receptionists.

Then again, the GP might be rubbish at that. I can think of a couple of recent GP contacts involving relatives in which obvious red flags were ignored or brushed aside. Sometimes the receptionists are better than the GPs at spotting this stuff.

Ultimately, you need the patient to be directed to the person who is the most effective at dealing with their issues quickly, and for that person to have the time to do it properly. At some point we’re going to have to fund and staff general practice properly to deal with the pressures that are mounting up year on year.

I actually think, at least in my practice, for the most part patients are decent enough in their requests for appointments.

And despite the varying ‘other people’ you can see who aren’t me, patients STILL want me (or my GP colleagues).

I think, as in all systems, there’s a degree of waste. However, in my practice at least, the effort that would be involved in reducing the waste (of appointments) far outweighs any benefit.

We’re too small to have a specific triage GP. But that’s the beauty of general practice – we meet the need of the local community.

Wheras the government want all GPs to be identikit practices. This won’t work.

A huge city practice would benefit from a full time GP triage. My sleepy village one less so.

The key…let the effing practice decide!

DrP

rather than someone like the new ‘physician assistants’, or receptionists.

Then again, the GP might be rubbish at that.

be careful you don’t fall into the trap of assuming all Physician Associates are crap.  There are issues with their regulation.  There are possibly issues with them being a cheap substitute, but they are neither automatically crap, nor are all all doctors automatically good.  Its likely that some sort of well regulated, well managed PA approach is actually part of the long term solution, whether that’s for triage or freeing up GPs to do the triage.

And despite the varying ‘other people’ you can see who aren’t me, patients STILL want me (or my GP colleagues).

Thats the interesting thing – people place an awful lot of faith in their GP!  I’ve always wondered if GPs were aware of the people in their practice who have a better reputation than others? Whether that’s a reputation for really listening (a skill that is often lacking) or for dishing out tablets easily…

NHS England requires all GP practices to have a senior member of the team reviewing all requests for appointments

That’s a new one on me. I think the ‘beauty’ of our GP system is there’s not one size fits all, taking my own practice, we triage all pat enquires every day, each GP gets about 25 to look at after reception team have filtered out the admin and obviously not for us (“My tooth hurts” kinda gig). We can get through more pat enquiries this way that we could with blind booking, we have a rough idea what’s going on, and we can select the appropriate appt for pats, same day, 1-2 days and routine. We let pats book their own routine slots (technology’s great for that shit)

If folks don’t have internet, they can come down to the practice and fill it out here, or we can do it for them, both in person and over the phone. Our pats have been doing this for 4 years now, and after some teething troubles most wouldn’t go back to queuing on the phone. And neither would our reception team. After doing this it’s gone from 16 mins to get through on the phone to a minute and half on average – Although the pats still say they can’t get through, there’s just no pleasing some folks.

We have a system that proactively monitors the heath of some of vulnerable pats and for a few we even call them our selves (or their carer in some instances) in case they need us for something.

Each practice has to do what they think is the best for their own patients, there’s no “right or wrong” way of doing it.

the statement does not say a GP it says “a senior member of the team”

It does. In the next sentence.

The way I’m reading it….that’s the statement from the GP practice, not the one from NHS England.

NHS might have said the first bit  – we require a senior member of the team to review all appointment requests.

GP surgery are not in favour – so send out a survey adding…This is likely to be a GP.

It’s a skewed survey, to drive the responses they want. They could have said, ‘This is likely to be a GP meaning we will have less appointments to offer overall’ to drive an even worse response

Or they could have said ‘this is likely to be a trained senior member of the nursing staff to make sure that the most urgent appointments are prioritised for GP visits’ – what response would the survey then get?

There are three main problems with General Practice:

• To the uninitiated, what we do looks easy, we deal with relatively minor problems, don’t do things properly (scans, tests, ignoring protocols ) and just spend our time chatting to patients. Therefore people think we’re easily replaced.
• Our funding keeps on getting cut in favour of hospitals. This is despite General Practice productivity and cost effectiveness being much higher than hospitals – because, as alluded to above, we work in different ways to hospital doctors.
• We are woefully under-represented in leadership positions in the NHS, instead having specialists and academics who don’t really understand what goes on in General Practice in leadership positions.

This means we repeatedly get hare-brained initiatives to replace us with something “cheaper”, or to get us working in ways that are closer to hospital doctors which actually makes us less cost effective.

Another issue is the idea that demand and access can somehow be fixed. It can’t, because of induced demand, in exactly the way that building more roads doesn’t make it easier to get to places.

The last point to make is there is absolutely zero correlation between patient satisfaction and better outcomes in General Practice. Yet we keep on chasing patient satisfaction because it’s easier to measure and for political reasons.

One of my favourite tales of “chasing patient satisfaction” was what happens here locally, with the patient transport service.

Patients didn’t like having

A-wait for a mini bus to pick them up on it’s rounds

B-be on a mini bus with other patients

And c – wait for the mini bus to take them home on it’s rounds.

So as it went, OF COURSE the patient feedback suggested that EVERY PATIENT HAVING THEIR OWN VEHICLE (car or taxi) was the best option. The option the commissions opted for.

And can you guess AT WHAT POINT IN THE YEAR THE BUDGET WAS BLOWN…. Clue… It was VERY early on 🤣🤣🤣🤣🤣

I’m not even joking… The Simpsons (where homer becomes trash commissioner) was foreshadowing!

Anyway…the point reflects Kramer’s above… Id you let people who don’t really understand something, decide on THAT thing, it’ll go wrong very quickly.

DrP