Monday, 10 September 2012

NHS Rules of Engagement

Today I attended my local GP surgery to test my fasting cholesterol after several months on non-pharmaceutical treatment of my high cholesterol (Benecol daily smoothie drinks). While sitting in the waiting room, I was pleasantly surprised to see a notice read: REMEMBER: ONE PERSON, ONE PROBLEM = ONE APPOINTMENT.

As a NHS GP, I have always wondered why the NHS expects NHS GPs to spend 10 minutes dealing with one patient's problem, yet patients feel free to come with a list of ailments for GPs to magically resolve all in 10 minutes; some parents asks their GP to also see their children in the same 10-minute consultation; medical defence organisations keep reminding GPs to document all the positives and negatives (ie type up a full consultation report during this same 10-minute consultation); the Department of Health expects GPs to also ask about QOF (Quality Outcome Framework) markers during the same 10 minutes (ie smoking history, weight, smear reminder, drinking history, asthma review, vaccination reminder) and now I hear that even GP locums will be performance managed and may be referred to the revalidation officer, if they fall behind in documenting QOF markers, do not complete a full audit cycle or return patient satisfaction surveys (hard to get a good satisfaction report from a patient, if a GP has just asked a patient to pick only one item on his or her list of 5!).

Here we have the crux of the matter. How do patients know that it is one person, one problem = one (10 minute) appointment, unless they are told? I asked Dr Andrew Wilson (a GP trainer, Deanery course facilitator and former convenor of the RCGP panel of examiners) on the London Deanery GP trainer's course, 'what should I say to a patient who comes in with a list of problems for one consultation?' I was attending the GP trainer's course several years ago, and he replied to a group of us, attendees, 'This is a 10-minute consultation. What is on your list? What is the most important item to you for us to deal with today?' We GPs can then hear the entire list and see if some symptoms are related to the same condition or if they are all separate. Often times the patient's priority may not be the urgent red flag serious sign so we listen and check.

Why do we have to put the patient in this awkward position of  'Doc, I saved up all my problems for you?' The patient thinks he or she is doing the GP a favour by making only one appointment when actually the converse is true. The NHS pays surgeries based on an assumption that a patient attends on average 3 times a year with 3 problems, ie rationed care. This government assumption seems unrealistic especially during a recession when more patients rely on their family GP for support than a church priest or in the context of hospitals now offloading secondary care into the community and directly into GPs' laps. Some patients attend more frequently and are named 'frequent attenders'. Surgeries rely on others attending less than 3 times a year to create a balance but do not inform the 'frequent attenders' that the NHS rules of engagement are based on an average of 3 visits a year per person.

We GPs have to be wary of patients with lists as we fear the red flag crushing chest pain symptom hidden within the list or the 'by the way, doc, I have chest pain,' upon exiting the room. This requires a full 10 minutes if not more to decide whether an ambulance is required or a rapid access chest pain clinic referral.

What happens to GPs who are inundated with patients with lists/ multiple problems to treat every 10 minutes in 3-hour sessions without a break? Follow this by doing yet another non-stop 3-hour session with patients booked back to back (some arriving 10 minutes late for a 10-minute appintment), after spending the lunch hour grabbing a sandwich on the way to doing  a list of home visits. Burnout, stress and suicide. Having worked with GPs who have either intimated or attempted suicide, I am extremely keen to raise awareness of how much stress the NHS GP is being put under and think of ways to make this a win:win for both patients and his or her GP. GPs are only human. Why do we expect superhuman ability? Who can treat 3 medical problems (take a history that will pass the medicolegal test in court, examine, prescribe or type a referral letter or complete a blood form or print a leaflet and talk through management options, and then type up a full report x 3 all in 10 minutes?).

Perhaps the easiest way, is an electronic announcement letting patients know the 'NHS Rules of Engagement' in the waiting room. GP surgeries work so hard to please their patients and mine even offers a daily walk-in emergency clinic every afternoon for 2 hours with 5-minute appointments. Yes, GPs have 5 minutes to see an emergency patient, treat and document. So please do your NHS GP a favour and limit to one person, one problem = one appointment. You may ask for a 'double appointment' for 2 problems or just schedule 2 appointments. Communication should be 2-way and shared. Patients need to know the NHS Rules of Engagement! And more GP surgeries are informing patients.