The Crippen Diaries (Week 39)

Not quite Tannochbrae

Monday 25 September

Another partnership QoF meeting. They are so dull, so boring, and so lucrative. I thought you should know how the government is spending your hard earned money this year. Much the same as last year. We get paid for scoring points. And points mean prizes. There are a maximum of 980 “domain” points available to our practice and we have until March of next year to get them all. Each point is worth £373.80 to the practice. There are 980 points available, which means there is £366,324 up for grabs. The practice manager is worried that we are a little behind. We have only scored 676 points, giving us £252,689 to date, with a further £113,635 available.

Ker-ching...

How do we score points?

1. The government is keen for all GPs to offer ten minute appointments. You can solve all the problems in the world in ten minutes. Seven and a half minutes would not be long enough, and fifteen minutes would be excessive. We do ten minute appointments. We did last year. We will next year. So we fill in the form.

“Do you do ten minute appointments?”

"Yes."

That scores 33 points or, to put it in terms understandable to the taxpayer, £12,335.40. Ker-ching….

2. The practice will undertake a patient satisfication survey. Four hundred questionairres put out in the waiting room, just like last year. 25 points. £9345.00. Ker-ching…

3. The practice will reflect on the patient survey and produce an action plan. 20 points. £7476.00 Ker-ching…

4. Having done the survey and produced an action plan, the practice will describe how it will report the findings to the patients. 30 points. £11,241.00 Ker-ching…

I will not go on in such detail. But recording everyone’s BP - £31.025, monitoring diabetes £34,763, recording patients’ smoking status and telling them to stop - £25,416. Keeping good records - £32,521

It is all good stuff. I suppose. But we were doing most of this anyway. There will be some practices that were not. Maybe that will bring them up to scratch. Maybe they will cheat. I do not know. There is lots of scope for fudging data. I could write a macro that would enter a lot of this sort of data onto the computer even if I had not seen the patients. Do not get me wrong. Very few doctors will do that.

We will earn something in excess of £300, 000 from QoF this year, as we did last year. Some of the money would have come to us any in standard scheduled pay rises. Some would not.

This sort of money could have been used to improve health care. The impact of QoF on health care, and patient satisfaction, is trivial. And many GPs are now closing at lunchtime and on Wednesday afternoon to spend happy hours filling in the QoF forms. What happens to their patients in the meantime?

They go to the nurse-led walk in centres or are seen by the deputising service.

Crazy!

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Tuesday 26th September

A smoker’s day today.

First, I was told today that smoking a pipe makes you live longer, and that if I searched on Google I would find the data to prove that. Sounded like nonsense, but I was interested enough to spend two minutes searching. I failed. And the same patient told me that all the stuff about “passive smoking” was Nazi propaganda. I suggested that that may be putting the case against a little stronger than was necessary. No, no I was told. Hitler was rabidly anti-smoking and would not allow it in his presence. It was he who first started to campaign against passive smoking.

Second, a 23 year old girl with a dry irritating cough which had started after a cold two weeks ago, and “just won’t go away.” I asked her now many she smoked (not if she smoked: I could smell it). “Twenty a day, but it’s not that” she said. I told her that the last patient I saw had been complaining of persistent headaches and that I had asked him if he banged his head against a brick wall. Twenty times a day, he told me. I think both of them would feel better if they dropped their twenty a day habit.

++++++++++

A phone call from Mr Jones about his wife, Doris, who I sent into hospital yesterday.

Doris had a heart attack seven years ago, made a good recovery, and has been stable ever since. Doris is a bit of a worrier. When she arrived yesterday, she said that as she walked up to bed last night, she had got pain in her jaw and upper part of her neck, like toothache. It went of when she lay down, but during the night she was woken three times with further pains in her jaw, which lasted a few minutes then passed off. Finally, as she walked in from the car to the waiting room, she had yet another episode which, once again, had passed off. Nothing to find. On history this is angina and, because it is occurring at rest, it is unstable angina. So she needs admission. Immediately. I told her she would have to go to hospital. She was shocked.

I phoned the medical assessment unit. The consultant in charge, who I have never met, was wonderful. Just like the old days. “Right, send her straight up.”

Do you get an ambulance, or do you let Mr Jones take her? On the one hand, it is unstable angina, on the other hand they have just driven down to me and the hospital it not much further away. And Doris is a worrier. If I call an ambulance, words like “unstable angina” and “chest pains” will hit the protocol and the full para-medicarama will arrive, with loud noises and flashing lights. Which is of course is just what she needs if she has a heart attack, which she probably will have if we make all that fuss. So I let Mr Jones take her and told him not to drive at ninety miles an hour.

They arrived at the hospital and were seen within minutes by the Consultant. Nothing to find again. And Doris did not have any pain. So bloods taken for cardiac enzymes, and Mr & Mrs Jones told to wait outside the clinic. They had been waiting for fifteen minutes, when the clinic nurse said, “Look, these tests will be an hour or so, why don’t you go down to the cafeteria and have a coffee?” So they did.

As they sat down for the coffee in the cafeteria, Doris had her heart attack. Severe, crushing chest and jaw pain, and sweating. There was no one around in the cafeteria, so Mr Jones found a wheel chair and wheeled her, at speed, back to the consultant in the MAU. The consultant went ballistic and said Doris was supposed to be having an ECG not a coffee.

She was admitted to the CCU. She has had her clot-buster. Twenty-four hours later she is pain free and stable, and will be having an angiogram shortly. So all was well in the end.

If you are going to have a heart attack, try to have it in a hospital, though not, preferably, in the cafeteria.

My concern is that she could so easily have had the heart attack whilst she was in the car with her husband. Would I have been open to criticism for not sending her in in an ambulance? Possibly, I think. I don’t know. Decisions like this are never easy.

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Thursday 28th September

Linda is a 38 year old nurse, actually a Sister, working at the local hospital in ITU. Her husband is a Paramedic. One of the occupational hazards of nursing is the risk (inevitability?) of marrying a doctor, or a nurse, or a police officer. Which is best, I wonder.

Linda has two sons, aged 14 and 11.

She is having problems with Peter, the 11 year old. He gets recurrent abdominal pains, and has done for some years. It has been thoroughly checked out. The paediatricians have diagnosed “periodic abdomen” which is not too helpful. Is it, indeed, a diagnosis at all? He also still bed-wets. Again, no underlying pathology. It is not really abnormal. It is just difficult. And finally, of late, he has been very badly behaved at home. He is rude, often offensively so, to his brother. He is very consistently disobedient to his parents.

Linda is incredibly sensible. She is not too worried about any of the three problems in isolation, but is now beginning to wonder if all three together could be a sign of some more serious psychological problem.

Peter is a bright, like his mother. He is doing well at school. The teachers have no concerns. The parent-teacher evenings are always a joy to attend. Linda and her husband work shifts and there is a bit of “box and coxing” with child care, helped enormously by Linda’s mother who live down the road.

This is good jobbing family medicine. But how do you deal with it? The easy approach is the knee jerk “well, I will refer him to CAMHS” for an “assessment.” Problem about that is that the assessment will be done by someone who is not medically qualified and, frankly, may be a waste off time. Someone might slap an ADHD label on him, and I am sure he has not got that. Or, even worse, it might be ODD (Oppositional Defiant Disorder).

Peter has already told Linda that he will not go to “Brat Camp” and then said, “I don’t want any Anger Management” either. Good old reality TV.

Linda feels guilty because both she and her husband work full-time. But they are in low-paid jobs, particularly considering the expertise they have. If Linda gave up work, they could not afford the mortgage. So we talk about that, and we talk about the options.

The biggest question of all is whether we are going to “medicalise” these problems. Am I going to slip Peter into the CAMHS “system” where he will be bounced around by well meaning amateurs? On balance, I do not think this is a medical problem. What I would really like to do is get a one-off, thorough assessment by an experienced child psychiatrist who would, I am sure, conclude that there are no mental health issues.

The NHS no longer provides that. I could get it done in the private sector, but Linda cannot afford that, and why should she have to?

So, we compromise. Linda will discuss it further with her husband. I make them a long appointment two weeks ahead. It may be by then that things will have settled. Certainly, Linda seemed calmer when she left than she was when she arrived. Talking does help.

The lack of decent mental health resources is one of the biggest problems I face, and it is particularly hard when, as in this case, the parents themselves work within the NHS.

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Friday 29th September

The senior receptionist came in at the end of morning surgery with a written report from on of the staff about a difficult patient. When a member of staff feels she has to put it in writing, you know it is going to be serious.

First, some background. Allocated patients. All people in the UK, however difficult, or dangerous, are entitled to have a GP. All GPs are entitled to refuse to accept a patient who wishes to sign on. Lovers of logic will have spotted that these two statements are incompatible. What happens to someone whom no GP wishes to take? They are “allocated” to a practice. In other words, you are obliged to take them on. Allocated patients tend to be a pain. They tend to be patients who have been thrown out of all the other practices in the area for rudeness, for being difficult, or whatever.

There is some dispute about how long you are obliged to keep such patients. The tradition is that you have to keep them ninety days, and then you can remove them. Some practices do that automatically on point of principle. We do not. We are a very big practice, the biggest in the area, and if we chuck them out, they will only be back in a few months.

Shane was allocated to us six months ago. He is already known and recognised by all the staff. He signed on with one of our female partners, Judith. Judith is middle-aged, Jewish and giggly. She has three teenagers of her own. She is good with children. I dare say she makes the odd mistake, don’t we all, but probably not as many as I make.

On Thursday afternoon, Shane was second in the queue at the reception hatch. The patient at the front of the queue was making an appointment to see Judith. Judith and I were both doing surgeries. Shane was listening in and shouted out, “Jesus, I wouldn’t see her, she damn nearly killed my daughter, and don’t see bloody Crippen either, he is nearly as bad.”

The reception staff are protective off Judith. They were angry. Later on, I sat down with Judith and told her what had happened. She giggled. “I’m sure I didn’t TRY to kill Shane’s daughter” she said, and got the notes up on the screen. She had refused to prescribe antibiotics for the girl when she had a temperature and mild earache.” Shane had stormed out, effing and blinding, and gone straight to Casualty, where an inexperienced junior doctor had prescribed antibiotics. This sort of thing is driving Flea, the American Paediatrician, into an early grave.

We will all talk about it at our meeting next week. My view is that Shane has to go. Is there no duty on patients to be reasonably civil? In the absence of mental illness, are they entitled to medical care however rude or, indeed, however violent they may be towards doctors and other medical staff? Do some rights not come with responsibilities?