Someone I work with is behaving atrociously. WWSTD

@thecaptain

My guess (and very much an outside look) is that they are just all flat-out firefighting and can’t afford the time to do anything other than the bare minimum for whatever happens to be the top of their heap at that moment in time.

I used to think that, but it’s actually gone beyond that now, and it doesn’t explain the poor attitude when we make them aware of the issue. I’m going to post later about some actual things that have happened, where it’s gone past firefighting into the realms of incompetence.

 Patients need to be advised that PALS are their point of contact for any hospital issues they can’t resolve through first attempts eg calling the secretary.

PALS are no help at our local hospital either unfortunately.

doing everything they can to avoid taking clinical responsibility for patients and so creating unnecessary workload for their colleagues.

At a recent visit to A&E my wife asked a hospital doctor’s advice regarding a heart issue that she has, and the response was “Discuss with your GP”. Here you are, an (admittedly junior) specialist in a hospital with all the tests you just done at your fingertips and access to all the machines that go ping, and that’s your response? Pointless.

I think Trust doctors know that they can get away with it, so they do. They have way more political clout than GPs.

I left the queue for Oasis tickets for this?

The last consultant I worked with in the community told me that “basically you do eighty percent of what I do, in twenty percent of the time” which I think is a fundamental truth of being a GP.

It’s a fundamental truth of being a good GP, which is what it seems you are.

It’s interesting that when someone from secondary care, who has doubtless spent hours ranting about how lazy, workshy and ignorant GPs are, pops into your surgery, they get a different picture. Would your depiction of hospital doctors as lazy, workshy and ignorant survive contact with reality?

It’s a broken, badly organised and under-resourced system, with a lot of individuals doing their best, and some who have probably mentally checked out and are doing as little as possible.

I can understand the frustration, though. Patients are being failed left, right and centre. I have numerous examples of excellent, and slipshod practice over the past decade involving relatives, some administrative, some via GPs, and some via secondary care.

Would your depiction of hospital doctors as lazy, workshy and ignorant survive contact with reality?

The difference between GPs and hospital doctors is that all GPs have worked in hospitals, very few of our hospital colleagues have any experience at all of General Practice, and even fewer a working understanding of what it is that we actually do.

But yes, I’ve had direct contact with my hospital colleagues, and whilst there’s always been a few who aren’t very good, IME they’re getting more common. It’s not so much laziness and being workshy, it’s the arrogance without the competence to back it up. And my friends who are senior hospital clinicians have commented on the same phenomenon.

This was the way last time i had to lean heavily on the NHS 20+ years ago.

The GP went above and beyond at every stage, contacting other services within the NHS and (eventually) a contracted third party provider when the NHS either gave me waiting times measured in years just for an initial consultation. Or simply didn’t respond.

At that point, all i needed to see him for was 20 minutes once a month for a general looksee and a renewal of my prescriptions.

I found out later that he was also dealing with the recent suicide of his son and a fairly serious illness of his own while trying to sort out my issues.

@kramer

I think all we can do is simply take a stand.

Although it’s tough intiially, it’s the only way change occurs.

I write about 3 letters per week simply refusing to take on additional work from hospitals, and tell them, in no simple terms, it’s not my job. it’s theirs. Or someone elses. But whoever’s job it is, THEY need to do it.
I then tell the patient.

From Private consultants asking me to refer back to THEMSELVES in teh NHS, to pre-op clinics asking me to request this, that, and the other scan. I just simply say No.

I’ve had paediatric clinics asking me to arrange 3 monthly ultrasound scans and review the result, and let THEM know if it’s abnormal (for a cyst or whatever. “no – you want the result, you do the test”.

I often get letters of annoyance back, but my mantra is “it’s ok for YOU to be annoyed. I’m still  not going to do it”.

No-one dies because it’s all slow paced out patient stuff.

Honestly, just do what we’re meant to do, and tell the hospital “no”.

I’ve given up going ‘above and beyond’ years ago, because, in the sad honest truth, “if you go the extra mile, you just end up a mile in the wrong direction”

DrP

True, but a lot of GPs haven’t worked in a hospital setting in decades. If you’re observing an attitudinal change, I’d suggest it’s probably something to do with the cumulative effect of everything that’s happened in the last 10-15 years affecting clinician behaviour. Also I’m pretty sure that many patients would say that their contacts with primary care feel different to 20 years ago, and not necessarily in a good way.

Sometimes it is hard to look at a vast, complex machine from a single point on the inside and get a reliable view as to where the points of failure actually are.

@martinhutch

I’d agree that it’s probably been a long time for most GP, but… we all know the basics..

• hospital DOCTORS can and SHOULD write a bloody prescription for a patient if they want them to start a drug there and them.. I’ve written letters to trusts and individual consultants telling them that it’s a complete waste of a GP appointment for a pateint to have seen consultant X, and then the next day book to see me because “consultant X wants me to have this drug ASAp. can you do that”. I promis you – if the pateint had to PAY (which i’m not saying they should, at all) for each contact with the health service, THEY would ask the consultant “erm, can YOU give me a script for this drug?”
• hospital doctors can and SHOULD give a poor scaffolder with a broken spine a bloody sick note. Why wouldn’t you. They exist, and are in the hospital.

It’s been years since i’ve been working IN a hospital, but I sure as heck know that the people in white coats with a stethoscope around their neck can and SHOULD be able to prescribe drugs and give advice on discharge..

DrP

Most patients view all doctors (except those who are obviously private) as working for the same NHS. It’s going to come as a bit of a shock to them when they learn that they are actually two warring tribes who hate each other 🙂

These are good examples of failures, but the telling thing is that a GP has no avenue by which to hold these NHS ‘colleagues’ accountable, and has to resort to venting their frustrations on a cryptic thread.

That’s the failure. The independent contractor status of GP partners is both helpful, and unhelpful when it comes to relationships with the wider NHS. Different parts of what the public views as a single organisation should have the means to hold each other accountable. Who do you speak to at an NHS Acute Trust when you want to change these kinds of behaviours? And who do consultants speak to when they want to influence all the primary care organisations in their area?

For all the many and varied reorganisations over the past 30 years, none has dealt with the fundamental disconnect between different parts of the NHS and social services.

Interestingly, in my 20 year career as a GP, every so often a hospital doctor gets a bee in their bonnet about that, and decides to come and audit/educate us about appropriate referrals. Every time they’ve stopped within a day or two because they’ve realised just how much we actually deal with ourselves and the level of clinical risk that we carry on a daily basis.

It’s a shame to hear this.

I don’t work in the NHS but I am currently working on clinical prioritisation criteria with specialists and GPs for the same referral system that NHS Wales also uses. It’s been quite enlightening because a lot of the work involves going to great effort to make things easier for primary care to refer.

We’re also working on the reverse process to try and introduce criteria for cardiologists to return patients safely to primary care rather than have years of pointless review appointments… I suspect that could be more contentious for reasons you have outlined.

When a new roundabout appears in a town centre, we ALL know it hasn’t just been a man with a digger going “oh, i’ll pop this up here today”.. there’s been years of planning and multiple teams deciding things in the background.

It’s the same in the NHS.

Multiple teams (in the CCGs, or whatever they are called) are tirelessly working out of the public eye to improve this.
There’s LMCs (local medical comittees) who are doctors and such employed full time to sort this out. They have “primary and secondary care interaction teams” to pin down all these details.

There’s high level meetings (of which I used to go to, but got bored of) where GPs, hospital trusts, psychiatric trusts, and ambulance trusts etc go to to comission and hash things out.

So it all goes on with an idea and an ideal. But then a new doctor joins a trust, or a registrar becomes a consultant, and the ‘old culture’ occurs again.

And @martinhutch is correct in stating that the general public just view the NHS as the NHS as the NHS… and (despite the media) your GP is the easiest person to see, so WE are seen as the “NHS whole and sundry”.. so I actually think my profession needs to stand up (to teh media, to the hospital, adn to the patients” and explain WHY what is beong asked of us is completely unreasonable. And then NOT DO IT!

DrP

The simple answer is that the NHS is screwed 🙂

What is clear is that all people on all sides of the coin are working , longer , harder , with less resources.

That’s the failure. The independent contractor status of GP partners is both helpful, and unhelpful when it comes to relationships with the wider NHS. Different parts of what the public views as a single organisation should have the means to hold each other accountable.

We have GPs employed within trusts specifically to liaise with primary care. For everyone’s benefit.

@roverpig

Most patients view all doctors (except those who are obviously private) as working for the same NHS.

Indeed, in fact many erroneously believe that we are junior to the hospital.

I don’t dispute there are some excellent initiatives to try to smooth the workflow between primary and secondary care, prevent inappropriate referrals and discharges, and liaising with social services to make sure patients are properly supported out of hospital. I wish they were more widely adopted.

But I still wonder whether the financial walled gardens of primary care and the little fiefdoms of consultants have historically made it much harder to develop proper (critical) relationships. There’s still a lot of tiptoeing around, not wanting to upset different clinical classes, setting up various committees etc.  And at a time when pretty much every marker of NHS health is in the redzone – waiting lists/time to first appt, A&E waits, ambulance response, NHS dentistry, GP routine appointment availability, staff vacancy rates – that’s a doubly tough thing to overcome.

I can understand why any incoming government takes a look at the whole mess of moving parts and thinks ‘this isn’t working, let’s REORGANISE!’. And why that never quite works. It’s like trying to reorganise a colander by moving around 10 rubber plugs.

But I still wonder whether the financial walled gardens of primary care and the little fiefdoms of consultants have historically made it much harder to develop proper (critical) relationships.

It’s not just primary care (and our independant contractor status) that are walled gardens… The trusts are all walled gardens..just bigger machines with a louder (and realistically, better organised) voice..

What goes against GPs (in my view) is that you could say there’s  60 GP practices (all individually ran) working alongside (or against, depending on teh situation!) ONE hospital trust, ran by ONE head chef…

As such, it’s ruddy hard to get ALL GP practices to agree on the right way of doing things, as opposed to ONE trust telling the employees how it’s ran..

If ALL GPs refused to do additional work, then the trust would simply have no way forward with the barrage of letters stating “this is odd you’re refusing my request DrP, because most GPs will hapily wash my car if I ask them to…”!!

We’re not so much the beast with 1000 heads, but simply 1000 beasts!

The BMA etc etc are trying to get us to align..

DrP

Sounds like an agency-principal problem writ large, with newer hospital doctors becoming imbued with their employers’ trend to try and limit liability and pushing work back onto GPs, who are the main point of contact for the majority of us..  Internally, I guess the fact that NHS staff are employees and GPs aren’t exacerbates the problem.

It’s a classic example of system failure.  As a commuter, I could vent  my anger at a member of Thameslink’s staff when the trains failed again, but the fact is was that over half of the reasons for failure lay with the train leasing company or Network Rail.  Each party sought to protect their own position and passed the problem on, with the issue surfacing at station employee’s level.

We’re not so much the beast with 1000 heads, but simply 1000 beasts!

The BMA etc etc are trying to get us to align..

If only there was an overarching local health authority which could liaise between GPs and acute hospitals where there are matters of dispute! OK, it probably wouldn’t bother, and would be stuffed with people trying to avoid clinical jobs, but still…

And there we were believing the NHS was a seamlessly integrated single entity focused solely on the betterment of patients health for the good of society…

Well, I guess it may be based on how you define ‘NHS’…

If you look at individual parts of the MASSIVE beast that is the NHS, then of course there is the need to maintain affordability and service delivery within those parts.

I don’t have access to every penny available to the NHS, thus need to ensure that my meagre pound of flesh is adequate to go round. Or you know what… I’ll just quit…’cos I’m not a charity..no one in teh NHS is.

DrP

It’s not so much laziness and being workshy, it’s the arrogance without the competence to back it up. And my friends who are senior hospital clinicians have commented on the same phenomenon.

Not read the whole thing but its far from my experience working in both hospitals and community and as a user of services.  In the time I was been working in healthcare most of the arrogance has gone ( due IMO to the influx of female consultants) and everyone hospital consultants included go the extra mile.  I suggest moving north of the border 🙂 as we don’t have all this nonsense with quasi independent trusts

My experience of the NHS of late, from my dying mother to a referral or two of my own, is it’s an exercise in moving problems around.

I’ll bleep past the former because it’s still a bit raw.  My own referral, they sent me a letter telling me that they were going to send me a letter.  WTF?  Aside from this just being massaging waiting list figures, why are you sticking bits of paper in envelopes when you have my email address?

Iron the soles of his feet and whip him with a car aerial?

Do it with one from a Ford Transit.  They’ll contract vanaerial disease.

 it’s an exercise in moving problems around.

Unfortunately very true. It’s also not specific to the NHS.

This week I’ve had a letter from a private consultant about an incidental finding on a scan on a patient, that the radiologist quite clearly states just needs a follow up scan in one year.

However the consultant says because it’s not his area of expertise the patient needs a referral to another specialist, please can I organise?

Well first of all, as is clearly stated in the scan that he commissioned, a referral isn’t warranted.

And second of all, if he wants to make a crap referral and waste everyone’s time, then he should make it himself, rather than fobbing the patient off by sending them to see me and putting pressure on me to make the crap referral, which is actually his responsibility.

I’ve also had two patients this week where the specialists are suggesting random referrals to other specialties even though the patient and their symptoms fall squarely within their own remit.

Sorry TJ, but I have to disagree about things being better north of the border. I hear the same complaints from the GPs at the practice I work for. A recent example was a diabetic patient who had become house bound was told they could no longer be seen at the diabetic clinic and the practice would now have to take this on. It was just once a year and there is patient transport freely available to take the patient to the clinic. Add in the private diagnosis of things like ADHD which patients are then advised to see their GP for prescriptions, or follow up bloods for other conditions and the work load quickly mounts up. This also on the background of people accessing their GPs more frequently. I was told the average used to be 3 times per year. It’s now something like 3-4 times as many but with no increase in funding.

This flows other ways too.

I work for n Pastoral Care in a Secondary school. We get contacted by parents who have taken a child who has been self harming to see the GP. The outcome of the appointment has been that the GP has said “Speak to the school. They can make a referral to Child and Adolescent Mental Health Services.”

While we can write a referral, we can go into no greater detail than the GP, and after will have less information. The GP will often have seen the result of the SH, while we often won’t.

It is appropriate for us to write referrals for condtions and behaviours that we see in school, and can gather useful contextual evidence for, such as ASD and ADHD.

However, we are not medically trained, and are outside of the NHS. Pushing the self-harm referrals to us feels like buck-passing, and just makes the referral chain longer and less efficient.

I totally accept that we are best placed for behaviour and developmental referrals, as we know the children involved far better, but once the GP is aware of the SH, they are best placed to do it.

Just my experience – the north of the border was a joke. 🙂

A recent example was a diabetic patient who had become house bound was told they could no longer be seen at the diabetic clinic and the practice would now have to take this on. It was just once a year and there is patient transport freely available to take the patient to the clinic

which is better for the patient?  Certainly not the ordeal of patient transport.

I get GPs are getting worked hard and have suffered under successive health ministers.

You want to try come working in community pharmacy and see the whole thing happening the other way around… “The surgery said come here and you’d sort it out.” Did they indeed.

(TBF, this appears mostly to be a problem with poorly trained surgery staff than GPs per se; the GP I was working with last year complained constantly about his own staff, too… I resisted pointing out the obvious, but ultimately their training, or lack thereof, has to come back to the partners.)

Aside from this just being massaging waiting list figures, why are you sticking bits of paper in envelopes when you have my email address?

Ah, that old chestnut.

No idea about NHS, but where I am the excuses include:

– the patient details are put into a system built in the early 90s and is still being used (!) – it doesn’t have a field for email addresses.

– uncertainties about sharing confidential information to external email accounts.

@TroutWrestler

While we can write a referral, we can go into no greater detail than the GP,

I’m interested why you think that GPs will have more information than the school?

Re emails – not everyone uses email, so you’d be replacing one modality with two.

I suggest a career change, Kramer. Think of your own health and well being. The best GP I’ve had quit when a member of his family and also a GP got cancer. He decided to live a bit.

I take it youve already weed in their shoes/ put laxatives in their coffee?

I’m sitting reading this with a morning coffee and thought the laxative effect was the whole point. I’m now wondering what I’ve done to upset someone, consistently, for pretty much my whole adult life.

I sometimes wonder if… actually hold that thought. Back in a few minutes.

@Edukator – thanks but funnily enough I enjoy my actual job, it’s just the presumption that I can (and should) do everyone else’s as well that I don’t enjoy.

My own referral, they sent me a letter telling me that they were going to send me a letter.

One of my family had a letter to say they were going to be put on ‘the list’ and that they would write to them when this was done. Two years in and he’s had three more letters saying he has moved from the waiting list for the waiting list to the pre list for the waiting list, and finally last month he is on the proper waiting list and will likely be seen in 18mths-2yrs….

We’re not even told how long waiting lists are these days.

One of my family had a letter to say they were going to be put on ‘the list’ and that they would write to them when this was done.

I was with my dad last week and he showed me a letter saying he had to present to General Surgery on Wednesday at 7am. What for he said? My hand or my bowel? I said I guess it must be the hand as there’s no mention of fasting etc. A few days later two more letters arrive. One saying he’s getting a phonecall on Monday the next saying he’s a  pre anaesthetic assessment on Tuesday. Still no reference to a specific procedure.