Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  ‘Very good, Sami,’ I said. ‘Stick the kettle on.’

  Six quid to park at St George’s, I thought. Not to mention the fiver to pay some young scally to watch your car. No wonder so many patients abuse the ambulance service: it’s door-to-door, with no meter to feed. Gordon Brown promised to abolish car park charges at hospitals, but typically failed to suggest a realistic way of making up the resultant funding shortfall.

  With six minutes to go before my next patient was due, I ambled down the corridor to the common room. Sami was pouring boiling water into the cafetière.

  ‘Hmmm,’ I said, sniffing the air. ‘Hand-roasted Guatemalan, if I’m not mistaken?’

  He stopped stirring and stared at me. ‘How did you…?’

  ‘From Santa Ana la Huerta,’ I said. ‘Interlayered flavours, nuances of berries, honey and dark chocolate. A strong, yet elegant, bean.’

  He followed my eyes to the packet of Union Hand Roasted Guatemala Coffee (100% Arabica, £2.79 from Ocado, tastes like the contents of a specimen jar) lying next to the kettle, and groaned.

  He started pouring the coffee.

  ‘What I said about DNAs,’ he said. ‘To be fair, the government has a point. You’ve had one first thing this morning, there was my twisted ankle bloke on Friday, we had a dozen others that I can think of last week. We’re averaging 60 a month, in this practice alone. It’s tax-payers’ money, is this. Personally, I agree – DNAs ought to be fined.’

  ‘You must be mad,’ I said. ‘If we were to start fining them for not turning up, what do you think would happen?’

  ‘Well,’ he said, regarding me as though I were a simpleton. ‘A few more of the buggers might turn up.’

  ‘Precisely,’ I said. ‘Can you imagine what it would be like if everyone who booked an appointment at the surgery came in? When would we find the time to catch up on paperwork, check blood test results, write referrals? Not to mention coffee and Sudoku. The NHS would collapse overnight. Fine them? We should reward them.’

  ‘Hmmm,’ said Sami. ‘I hadn’t thought of it like that.’

  ‘That makes two of you,’ I said. ‘You and the Secretary of State for Health.’

  He meandered out, and I stood pondering awhile, safe in the knowledge that my own DNA afforded me a few minutes of precious peace, with nothing to concern me but a Hob Nob. If people don’t want to turn up, that’s their shout. I have far better things to do than checking Mr Harris’s ankle jerks, trying to look at the tympanic membranes of malevolent three-year-olds and listening to Mrs Mowcher’s description of her funny turns, the ones that only happen during Coronation Street on a Wednesday, for the 13th time to make sure I haven’t missed an obvious diagnostic clue the first dozen times around. Give me a surgery of 17 booked appointments with 15 DNAs, and that’s as near to heaven as I get.

  TEN MINUTES

  WE’RE SUPPOSED TO set aside 10 minutes for each consultation. It sounds a reasonable length of time, but there’s a lot more to factor in than just the obvious. We can’t physically eject patients while they’re still talking, and we can’t do much about those who turn up late and throw everything out of kilter. But even if every punter came in on time, sat down and spoke clearly and concisely about their precise symptoms for seven minutes, leaving me enough time to come up with a brilliant and incisive treatment strategy, or maybe just a quick prescription if I’m stretched, there’d still be calls to take from consultants, practice nurses and receptionists, hospital admissions to authorise, referrals to process, computer crashes and jammed printers to deal with, forms to fill in and QOF targets to hit.

  The NHS’s own online guidance to patients doesn’t help. It advises them to turn up with ‘a list of problems, starting with the most important’. ‘If you have a complicated problem,’ it says, ‘ask for a longer appointment when you book… Be clear about what you want the doctor to do… Be assertive if you need to. Ask the doctor to repeat and explain anything you don’t understand. If there are words you don’t understand, ask what they mean or get the doctor to write them down so that you can look them up later.’

  Which is all good advice to sensible folk like you and me and the people who wrote it, but in the real world not all patients are sensible. If a quarter of the people we see think they have complicated problems (when they haven’t), bring a list and require – assertively – that we repeat, explain and write down anything they don’t understand (i.e., everything), we’ll need 30 minute slots and 36-hour days.

  NEW YEAR, SAME STORY

  WITH IT BEING January, I knew my surgeries would be filled with two types of bloke – each of them claiming they had decided to ‘get healthy’ in the New Year.

  Mr Parkes fell into the first, more common category – those who have reluctantly decided that a diet of Quality Street, lager and Christmas pud, consumed while watching a loop of The Great Escape, is not the way forward.

  Or – as in his case – have had this decided for them by their partner.

  He’d brought Mrs Parkes with him, in the sense that a mouse brings a cat: it was clear his New Year’s resolution had been thrust on him by his glowering wife, and he wore it forlornly, like an unwanted festive woolly.

  ‘I’m a bit overweight,’ he mumbled. ‘I probably need more exercise and I should pack up the fags.’

  ‘Tell him about your drinking,’ prompted his other half, who had attended partly to hold his hand but mainly to make sure he didn’t fluff his lines.

  ‘I drink too much,’ he said, like a teenager caught with a porn mag.

  ‘And he can’t…’ said a voice from off-stage.

  He turned crimson. ‘And I can’t… er… get it up.’

  ‘That’s right, doctor,’ confirms Mrs Parkes. ‘And he has smelly feet.’

  It’s always tempting in these cases to suggest that the woman exchange her man for a sleeker, more vibrant, less pungent model. But I went through the motions and established that, yes, he was overweight, under-fit and led an unhealthy lifestyle. I gave him advice, unsurprisingly, about losing weight, dragging his ample arse down the gym and generally sorting himself out. Quite possibly he wasn’t listening, but Mrs Parkes certainly was.

  ‘Thanks, doctor,’ she said as they left. Her husband and I simply exchanged glances. He’d done his duty, but we both knew that our next significant encounter might well be when I sign his cremation forms.

  Mr Perker fell into the second category of January visitor.

  ‘I’ve come for a check-up,’ he announced.

  Further inquiry revealed that he jogs 20 miles a week, eats the recommended quota of fruit and veg, is a non-smoker with perfect body-mass index, subscribes to Men’s Health magazine and charts his own cholesterol and blood pressure stats on an Excel spreadsheet.

  The truth was, he was only attending for positive reinforcement, like a class swot eager for the teacher to mark his homework.

  Category two is far rarer than Category one – which is no bad thing because, while absurdly healthy, Perker’s sort make me feel sick.

  Both the seasonal polarities of male behaviour are the exceptions, though. For most men, January is just an arbitrary month on the calendar rather than a catalyst to a medical makeover. Maybe this is health negligence. Or perhaps it’s a simple desire to avoid wasting time on imponderables. After all, exactly what is health? Don’t expect the average doctor to provide an answer; we’re paralysed with doubt just deciding whether sore throats need antibiotics*.

  The World Health Organisation defines health as a ‘state of complete physical, mental and social wellbeing and not merely the absence of disease’. This definition is, for practical purposes, useless. For the average male, it would mean celebrating a major lottery win with a dyspepsia-free curry and waking up to find that his scrotal lump is not cancer, that he has moved to Barbados and that Cindy Crawford is downstairs cooking his brekkie. Oh, and that his team will stuff Man U eight-nil in the afternoon.

  Besides, it sidesteps the issue that health is
in the eye of the beholder.

  Mr Parkes would make the man from WHO’s toes curl, but may have happily reached his own limited personal physical, mental and social targets.

  Mr Perker appears super-fit but has an unhealthy preoccupation with his own physiology.

  So I’d suggest that health is feeling ‘fit for a purpose’, no matter how tiny or grand that purpose might be. Most blokes, I suspect, would accept this. Which means that they ought to spend January recovering from December, without having to make appointments they don’t need and resolutions they won’t keep.

  *The answer to this question is usually No. Whether or not to prescribe antibiotics for sore throats (and if so, which ones to dish out and for how long) has been the subject of hundreds of clinical trials. At the moment, the best that we can manage is to follow a set of guidelines that tell us whether a prescription is more likely to help than harm the patient.

  Of course there are more than one set of guidelines – in fact there are papers setting out guidelines on the use of guidelines – but most GPs will have heard of the ‘Centor criteria’. On this scale, patients score one point if they have a fever, one point if they have tender swellings in the part of their neck under the chin, another point if there’s a yellow gunky discharge over the tonsils and another point if they haven’t got a cough. A score of zero has an 80% ‘negative predictive value’ – translated into English, if you have none of the above markers (but still have a sore throat), the chance of penicillin helping you is less than 20%. If you score three or four marks out of four, you have about a 50:50 chance of having a bacterial sore throat and you should be offered antibiotics. That doesn’t mean you should take them. There are side-effects to taking antibiotics, and even if you score four points you’ll get better without them; it’s just that with them you might get better a day or so quicker.

  TRUE COST OF DRUGS

  JEFF BRICK was in to see me later on.

  He never bloody listens to a word I say, which often leads me to wonder why he bothers consulting me. Mainly, I suspect, it’s for his inhaler. After a lifetime working as an industrial welder on top of a 40-a-day Benson and Hedges habit, Jeff suffers, unsurprisingly, from dyspnoea (shortness of breath).

  Periodically he comes in for a check-up and a new puffer, and I carefully explain the importance of using it properly, and taking exercise, and quitting the fags, and he nods blankly as the words enter his left ear and exit the right without troubling the scorers within.

  Anyway, I printed off his prescription, signed it and handed it to him, and waited for him to get up and go. Instead, he sat there looking at it, his brow furrowed. Eventually, he said: ‘What’s this price thing by where it says about me inhaler, then?’

  I took the script back. Sure enough, it was there in black and white. I read it out: ‘Seretide 250 Evohaler. Use twice daily as directed. Supply 1 (one) inhaler. £59.48.’

  ‘Hmmm,’ I said. ‘Well, for some reason I can’t fathom, the computer has printed off the actual cost of the inhaler. It shouldn’t do, and as I say I’m not sure why it has, but there it is. That’s what they cost – nearly sixty quid.’

  ‘You’re taking the piss, mate,’ he said. ‘I ain’t payin’ that.’

  ‘You’re not,’ I said. ‘It’s just the usual seven quid-odd to you. The £59.48 is what it costs the NHS.’

  ‘You’re ’avin’ a larf!’

  ‘Er, no.’

  ‘You’re pullin’ my plonker!’

  ‘Look… no, I’m not. That really is what the NHS spends on the inhalers which you use like air fresheners because you can’t be bothered to read the instructions.’

  ‘Stone me.’

  I’d quite like to, I thought, as he shambled out, muttering to himself.

  I called through to reception. ‘For some reason, my PC is printing scripts off with the prices,’ I said.

  ‘Yes,’ said Mrs Peggotty, the reception manager. ‘I’ve just had Dr Emma call me to say the same thing. I’m ringing the IT people now doctor, don’t you worry.’

  The NHS IT infrastructure which helps me ‘Deal With Today’s Problems Today!’®, runs on vastly outdated software, so perhaps I ought to be thankful that it only crashes and burns every other fortnight. Still, it won’t surprise any reader with half an interest in government computer systems to learn that this particular problem persisted for a further five days.

  I say ‘problem’, but it was actually a blessing. In fact, it was brilliant and it ought to be a permanent feature of all prescriptions and medicine labels: if patients knew the real cost of their medication, maybe they’d be less cavalier about forgetting to take it, losing it or flushing it down the loo. Those who pay prescription charges and bitch about forking out £7.20 per item – pretty cheap for an inhaler costing nearly 60 quid – might change their tune, as would those who buy an annual ticket for £104 and act as though they’re taking out a second mortgage, rather than handing over the price of a second-hand Nintendo Wii.

  Conversations along similar lines peppered the next few days. Psoriasis sufferers couldn’t believe a month’s supply of scalp ointment ran to £108, a man on anticonvulsants had a fit – well, nearly – when he realised how much he was denting the NHS budget, and an old lady taking a cholesterol-lowering drug actually apologised when she found out that she was costing the NHS £80 every time she handed in her repeat prescription on the first of the month. And she was one of the ones where the money seemed well spent (I’m afraid that making value judgments about my patients goes with the territory).

  So by the time Yvonne Claypole rang I was well up for it.

  ‘Hello doc, listen, do me a favour, yeah?’ she said. ‘Only, I went over to Bristol to see my sister’s family at the weekend, yeah? I had the prescription you gave me last week for my migraines made up while I was there, yeah, and, d’you know what, I’ve only gone and left all me tablets down there. Leave another prescription with Mrs Peggotty in reception, there’s a love, and I’ll pick it up in the morning.’

  ‘Can you just hang on a mo?’ I said. ‘I just want to check something.’

  I laid the receiver down, printed a script off and looked at it.

  Imigran Radis tablets 100mg. Take one at onset of migraine. Supply 1 (one) pack of 12 (twelve) tablets. £85.80.

  Eighty. Five. Quid. On headache tablets for a woman who is so bothered about her problem that she has forgotten where she put the last lot of pills.

  I got on to Google. Then I picked the phone back up.

  ‘Listen, Yvonne,’ I said. ‘Can you get yourself to the coach station in town by 8pm? There’s a bus to Bristol leaving at half past. It’s £18.50 return. And do give my best wishes to your sister and her family.’

  DRUG BUDGETS

  GIVEN THE ABOVE, I suppose I ought to explain drug budgets. We don’t have one, as such – in the sense that you can’t run out of money, come November. What we do have is an Indicative Prescribing Budget (IPB) and a Prescribing Incentives Scheme (PIS).

  The IPB was introduced a while back and is an amount of money allocated to your practice on a computer at the PCT. It’s based on the number of patients on your list, some very basic and unsophisticated demographics (a GP in Eastbourne might get a little more money to reflect the fact that all his punters are OAPs), and also on historical prescribing patterns. (In the months before it came in, I’m told that some unscrupulous doctors were wildly prescribing everything they could to anyone they found near the surgery, on the basis that this would push their budget up. A nice idea – wish I’d thought of it.)

  The incentives scheme is a list of criteria; the more of these boxes you tick, the more money you earn for your practice. Among them are things like not prescribing expensive antibiotics, or not prescribing too many antibiotics, or keeping within your indicative budget, or not going more than 5% above it. Another revolves around the percentage of generic drugs you prescribe, as opposed to branded ones. When a drug is first released, it is patented. Once the patent runs
out, anyone can manufacture it – these ‘generics’ are cheaper than the original branded drug but generally have exactly the same properties.

  As I say, you can’t spend your ‘budget’ and run out of money, but if you bust it you’ll end up getting a visit from a Prescribing Advisor from the PCT asking why your prescribing costs were so high and refusing to pay your PIS money. (Unless, of course, you can justify your prescribing. Some years are busier than others.) None of this involves the really expensive blockbuster treatments, like the breast cancer superdrug Herceptin – if someone on your list needs something of this order, you write to the PCT and they will deal with it as an exceptional case.

  NHS IT EXPERT — MORON OR OXYMORON? DISCUSS

  WITHIN A WEEK or so, the PC doctors had finally fixed the computers and we returned to state normal, where no-one knows what his pills cost.

  Next week, something else will go wrong, of course.

  I can’t for the life of me understand why those in authority place so much faith in computers. This question occurred to me one morning as I attempted, with gritted teeth, to type in a prescription for Mr Snagsby, one of our frequent fliers.

  The latest ‘helpful update’ to the IT systems in our surgery is a program which interrupts me as I’m writing prescriptions for Drug X to inform me that a different drug, Drug Y, would work out 94p per month cheaper.