Because it is a computer system commissioned, designed and implemented by imbeciles, it does not take into account the fact that I know full well that Drug Y is cheaper, but that I have already tried that drug on the patient without success, or have discovered that the patient is dangerously allergic to it, or that I’ve thought about it but have considered it unsuitable in my professional, that is to say medical, opinion.
Unless I push three different buttons to confirm my original choice, the patient gets switched by a process called ValuScrip to the cheaper version, which is annoying enough.
Worse, though, the PCT are monitoring how many of ValuScrip’s recommendations I act on (almost none, as it happens) and they reserve the right to penalise my drug budget by withholding PIS payments if I don’t accept a certain proportion of them.
Musing on the difference between a Secretary of State for Health and a GP’s computer – chiefly, that you ought only need to punch the information into a Secretary of State once – I eventually achieved the desired result and sent Mr Snagsby on his way with a chit for drugs that may be slightly more expensive than the bean counters would ideally like, but will at least work and have the added benefit of being unlikely to kill him via anaphylactic shock.
It’s all of a piece with the ‘Connecting for Health’ NHS computer system, the black hole that will have swallowed up around £7 billion of our hard-earned tax by the end of 2010. Doctors have been banging on for years about the inadequacies of this programme, with its twilight language of ‘Clinical Dashboards Toolkits’, ‘NHS Interoperability Toolkits’ and ‘Enterprise-wide Arrangements’.
One aspect of the software is supposed to speed up the process of booking an appointment for a patient to see a consultant. This particular facility is so awful that most GPs refuse to use it, even though patients referred with an old-fashioned letter are theoretically forced to wait longer for their first appointment at the hospital.
The white-coat-and-bow-tie merchants are just as cross about this as GPs, ploughing through clinics full of bunions while little old ladies with painfully crunchy hips are bounced back down the waiting list because their GP sent them along with a handwritten note.
Then there is the issue of security. I’ve had many patients ask dubiously whether their health records are safe once they are loaded on to the centralised ‘NHS spine’. My response: I very much doubt it. The IT nerds insist that electronic records will be more secure than paper-based notes. I look at the almost weekly incidents of thousands of computerised records being left in pubs, emailed to the wrong place or outsourced to India, and then point out that my filing cabinets are locked and I know who has the keys.
The geeks are trying to persuade us that their new systems will improve communication between GPs and hospitals. This is rubbish. My local pathology laboratory installed the latest hideously expensive software a while ago, and the system crashed before the engineer had left the building. For several days, thousands of results had to be faxed or couriered to surgeries while some intensive head-scratching, chocolate-digestive munching and rebooting went on at the lab. When the computer lurched back into action, it sent seven copies of every test result in its memory into GPs’ inboxes, including tests that had been requested by, and should have been reported to, hospital doctors. Then everything crashed again.
The letter of apology that followed was addressed to 67 local GP practices. That’s 200 doctors, give or take, who had been repeatedly switching their PCs on and off again after phoning Tech Support.
Still, the technophiles won’t give up. Another pilot project allowed patients to see their records and download their test results via the internet. Brilliant – if the scheme is ever rolled out across the country, my patients will be able to discover that they have an inoperable brain tumour from the comfort of their own home. At least that will save me the trouble of my breaking it gently to them.
Why wait? Show up at the surgery with some ID and a few quid and the Data Protection Act ensures that you’ll get a printout of your entire computer record: every diagnosis, every prescription, every blood-pressure reading, to do with as you please.
I wonder what you’ll make of this:
‘TATT 2/52 FH ↓T4 O/E NAD TFT+FBC 2CMA’
Try, ‘Tired all The Time, for two weeks, has a Family History of Hypothyroidism, On Examination Nothing Abnormal was Detected, lab rats asked to do some Thyroid Function Tests and a Full Blood Count simply To Cover My Arse.’
MEET REBECCA BAGNET (OR HER DAD, ANYWAY)
AFTER A NOURISHING breakfast of paracetamol on toast and a slug of pholcodine linctus BP, I dragged myself into the surgery today.
You might think that doctors would be good at judging when we’re fit for work, considering that a large part of our working day is spent assessing our patients’ ability to do jobs we know next to nothing about. Ironically, it isn’t so. It’s a macho thing: ‘proper’ doctors don’t take sick leave.
First out of the morning’s traps was Matthew Bagnet, who had blagged my 8am slot for a prescription review. As he came in he was treated to an exhibition of world class expectoration as I tried to get a particularly stubborn gobbet of phlegm to shift from the back of my throat.
‘Blimey, you ought to see a doctor yourself,’ he said, as he plonked himself down in the patient’s chair and rolled his sleeve up for the ritual blood pressure check.
Wordlessly, I reached into my desk drawer and pulled out a sheet of A4 paper bearing the legend ‘YOU SHOULD SEE A DOCTOR’. I crossed out the number 23 and wrote in ‘24’.
‘Ah,’ he said. ‘You’ve heard that one before, then.’
It was when we wrapped up his BP check and 12,000 mile service that he hit me with his, ‘While I’m here, doc.’
But it wasn’t about himself, it was about his daughter, Rebecca. I’ve seen Rebecca grow up from shy toddler, through highly-strung schoolgirl and into troublesome adolescent.
‘It’s her diabetes,’ he said. ‘She’s just not taking it seriously.’
He wasn’t telling me anything I didn’t already know. I’d had a succession of letters from the local Diabetic Day Care Centre, ranging from the straightforward, ‘We were sorry that Rebecca couldn’t make it in for her assessment today,’ to the more recent, ‘We really wonder whether it’s worth sending this girl any further appointments,’ after she failed to attend for the fifth or sixth time.
Along with these there were copies of attendance alerts from A&E departments round and about, all following the same pattern: ‘Known insulin-dependant diabetic, low blood sugar, treated and streeted. GP to follow up.’
‘OK, Matthew,’ I said. ‘No more Mr Nice Guy.’
I pulled Rebecca’s repeat prescription chart up on the screen, selected ‘All Items’ and hit the delete button. ‘I’m not putting my name to any more insulin scripts until I see some blood numbers, a body mass index and a BP reading on Becca’s record. Get her over here before her current supply runs out.’
IMAGINEERING SOLUTIONS FOR SHIFTING PARADIGMS
SAMI AND I HAD a meeting with the PCT suits later.
It all started about a year previously, with a squeal and an expletive from my medical secretary Martha Bardell, both of which were audible from the common room. Such displays of exasperation are unusual from the highly professional and controlled super-sec, so I immediately went to investigate.
I found her hunched over in her chair, slowly banging her head against the desk and moaning.
‘Everything alright?’ I said, casually.
She looked up and almost growled. ‘I don’t believe it!’ she said. ‘It’s another bloody form!’
More swearing. Blimey! This was serious.
She handed it over. It was, indeed, another bloody form. This time, for microscopic haematuria – invisible amounts of blood in your urine. The form – which needed completion by the GP to get the patient referred to a urologist – required around 25 separate pieces of information. Name of patient, obviously. Any a
bnormal findings on examination, also obviously. But, rather less obviously, questions like, ‘Any recent travel?’ – perhaps because (and I confess I’m guessing here) obscure tropical diseases can sometimes cause microscopic haematuria.
Anyway. Big deal, you might think. It’s just a form. Bite the bullet, fill it in, move on. Fair enough. But then, there’s a form for chest pain. And one for indigestion. And another for rectal bleeding. And yet another for headache. And for heavy periods, and infertility, and breathlessness, and memory loss… In fact, no matter what your symptom is, there’s a form for it (admittedly, I haven’t yet tested this out for the most obscure symptom I can think of, pilimiction – the passage of hairs in your urinary stream – but I have a feeling I wouldn’t be disappointed).
There are lots of symptoms, so that’s lots of forms. And they need keeping track of, filing and updating, and, of course, the hospital keeps producing new ones and updates on old ones every five minutes. This upsets Martha.
Each form is completely different, each needs tracking down and each needs laborious completion with information that either seems irrelevant or which the hospital doctor is going to get from the patient anyway. And this upsets all of us, because it’s a pointless waste of time, effort and, in these recessionary times, money.
Over the following few days, phrases like ‘bureaucratic nightmare’ and ‘unbelievable levels of bullshit’ were bandied about, increasingly loudly and vehemently, until, at the next practice meeting, we decided that enough was enough. We would make a stand and stop using those sodding forms. Instead, we reverted to what we’d always done: writing a sensible, courteous referral letter, providing all the information relevant to the particular case but none of the nonsensical frippery.
Brilliant.
Except that, on day three of our brave, form-free world, the first referral bounced back. The next day, a couple were returned. The next, a handful. And then it became apparent that all of our referrals were boomeranging back to us.
Why? To quote the message sent to a molar-grinding Martha, ‘These referrals have been refused because your doctors have not used the correct forms.’
This was sorted out by a few choice words directed to some jobsworth on the end of the phone.
‘We have a contractual obligation to refer patients to hospital as appropriate,’ our Senior Partner told the jobsworth, ‘but we are under no obligation whatsoever to use any particular form, any more than we are to fill it in in illuminated script. Which means that, should any patient suffer harm because of your refusal of our referral, medicolegal liability will be held by you.’
This solved the problem. But we’d created such a stir with our policy of non co-operation that the PCT suits weren’t happy, which is why Sami and I found ourselves sitting opposite a couple of them this morning.
The meeting went well. Sami explained our position from the outset. He’s good at this type of thing: he hates management jargon, but he has a weird talent for it, too.
‘The thing is,’ he said, ‘we don’t want our stance to get in the way of a seamless patient journey.’
The suits looked impressed.
‘Nor do we want it to reflect badly on our aspiration to Total Quality Management. We’d hate to see a dip in the dials on our Clinical Dashboard.’
The suits glanced approvingly at each other.
‘So we’ve had an idea shower. And, going forward – bear with me – we’ve come up with a paradigm shift. We’d like to give you the heads up, run it up the flagpole et cetera.’
He pulled a piece of paper from his pocket. The suits were obviously intrigued, leaning forward slightly, waiting expectantly for Sami to unveil our masterpiece.
‘Clearly,’ he continued, ‘the status quo isn’t a strategic fit for World Class Referring. So we’ve imagineered a solution.’
Bugger me, he’s good. He unfolded the paper.
‘We’re calling it a “Universal Referral Form”, or URF. It’s a one-size-fits-all solution. We’ve cascaded it to local practices and they’ve all confirmed they think the idea is…’
For the first time, he faltered, searching for the right buzzword. I took this as my cue to chip in.
‘They think it’s empowering,’ I said.
‘Exactly!’ said Sami. ‘They think it’s empowering.’
The suits could barely contain their excitement.
‘We think we can work synergistically with you to facilitate this across all practices,’ said Sami, recovering his poise and handing over our meisterwork. ‘It’s kind of a win-win-win. You, us and the patients.’
The suits looked blank. As did the piece of paper they were holding.
‘This is a piece of headed notepaper?’ said Suit one, slowly.
‘With nothing on it?’ said Suit two.
‘That’s right,’ beamed Sami. ‘On which we write a referral letter. A Universal Referral Form, like I said. We’d like to enter it for the Strategic Health Authority’s annual awards. The “Innovation” section. If you could just sign our entry here?’
‘Are you sure you’ve used the right entry form, Sami?’ I said.
CHARLIE DARNAY AND ME
TWO MONTHS AGO, Charlie Darnay, a bright bloke in his mid 20s who was studying hard for a challenging IT qualification, came to see me. He complained of a variety of things – inter alia, that he couldn’t sleep, he had aches and pains in his joints, a persistent sore throat, problems concentrating, short-term memory lapses and occasional dizziness and nausea. If he did any exercise, such as the weekly game of squash that he used to enjoy, things got worse rather than better. His performance at college was suffering and he was worried sick that he’d fail his next set of exams.
I ran some blood tests to check for various possibilities, such as anaemia, diabetes and thyroid trouble, and they all came up blank.
I had him in again to decide where to go next.
‘The results were all inconclusive,’ I said. ‘We can rule out anything really serious, I think, but…’
‘Could it be ME, doctor?’ he said. ‘My girlfriend was reading about it in one of her magazines and it sounds like what I’ve got.’
‘Hmmm,’ I said. ‘Well, your symptoms certainly fit the diagnostic criteria.’
ME – short for myalgic encephalomyelitis, and also known as chronic fatigue syndrome (CFS) – is a controversial condition, with attitudes ranging from those who doubt its very existence to those for whom it seems to be their raison d’être. Things get surprisingly heated in both camps, especially considering that we’re dealing with people who say they’re suffering from very low levels of energy. Whatever. There’s a bloke in the Rheumatology Department at the local hospital – Dr Snitchey – for whom it’s a special interest. Not long back, I attended a lecture he gave about the issue and he seemed a good sort; the obvious thing to do was to get Charlie and Dr Snitchey together.
You may have heard of the new NHS system called Choose and Book which – in theory – entitles patients to choose when and where they go for treatment. The thing is, it’s a pretty complicated and exhausting process, and since Charlie was already exhausted he asked me to sort it out for him.
This is where it gets irritating.
‘So, can you arrange for me to see this Dr Snitchey, then?’ said Charlie.
‘I’d like to send you to see him,’ I said, ‘but I… er… can’t.’
‘You can’t?’ said Charlie. ‘But I thought you said he was an expert in the field?’
‘He is,’ I said. ‘Not that long ago – I mean, only five or ten years back – it would all have been very straightforward. I would have written a letter directly to Dr Snitchey via his secretary, and you would have toddled off to see him in his clinic. Job done. Unfortunately, we’re not allowed to book like this any more.’
‘You’re not?’
‘No.’
‘So what do you do?’
‘These days, I have to write a general referral letter to the hospital. All I can
really do is address it to Dr Snitchey, with strict instructions that only he or his secretary opens it, making it plain that you need to see him, and hope for the best.’
‘Well, surely if it’s addressed to him he’ll open it and they’ll just book me in with him?’ said Charlie.
‘I wish it were that simple,’ I said, ‘but, in my experience, what will probably happen is that the letter will find its way to the Referral Management Centre.’
‘What’s that?’
‘It’s a room somewhere with a lot of computer screens and telephones where they collect all the hospital referrals sent up by GPs and decide who the patients get to see.’
‘Right,’ said Charlie, looking puzzled. ‘So surely they’ll send me on to Dr Snitchey then?’
‘Hmmm,’ I said. ‘You’d like to think so, wouldn’t you? Unfortunately, they don’t take much notice of what we write in our letters. They tend to make up their own minds as to what treatment you need.’
‘But at least they’re doctors, right? The people in this Referral Management Centre?’
‘Er, no. They’re just bodies sat in front of computers, ticking boxes and pushing paper. The chances are they will see that the letter has been addressed to a consultant in the rheumatology department, so you’ll end up being sent to a consultant in that department, but not necessarily Dr Snitchey.’
Which is exactly what happened.
Charlie entered the twilight world of the Referral Management Centre, they ignored my request and arranged instead for him to see Dr Snitchey’s colleague, Dr Craggs. Craggs is perfectly capable when it comes to arthritis and systemic lupus erythematosus, but has no interest or expertise whatsoever in chronic fatigue syndrome.
This morning I received notice from the hospital telling me that Dr Craggs had examined Charlie and that he felt, on reflection, that he would have been better off seeing his recently-appointed colleague Dr Snitchey who works just down the corridor. Snitchey has special expertise in the management of these cases, don’tcha know?
Sick Notes: True Stories from the GP's Surgery Page 3
