Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  Yes, I do – but a fat lot of good it did me or my patient.

  REFERRAL MANAGEMENT CENTRES

  IF THIS REFERRAL Management Centre business all sounds confusing, that’s because (like almost everything else in the NHS) it is. One of the problems in writing about this stuff is that the systems keep changing. Also, different systems operate in different areas of the country. (OK, that’s two problems).

  The RMCs are run by PCTs and are supposed to lead to a more streamlined service, but unfortunately when you insert a layer of non-medical pen-pushers into the process and allow them to interpret GP referrals as they see fit, the result is anything but. My patients are often sent to the wrong specialists, which obviously annoys everyone – me, the patients and the specialists. (Martha, my medical secretary, is forever dealing with complaints from hospital consultants that the wrong type of problem is ending up in the wrong type of clinic).

  It can be relatively minor – Charlie won’t be dying of tiredness – but it can be very serious. For instance, a friend of mine referred a 38-year-old man with protein and microscopic haematuria in his urine. As any medical fule kno, this man needs to see a renal physician, since this is likely to be an inherent renal problem – unlike where the problem is of microscopic blood in the urine alone, in which case he needs to see a urologist for a standard package of tests (ultrasound of the renal tract, cystoscopy to peer into his bladder) to exclude stones and tumours etc. My friend referred the patient (correctly) with the blood + protein scenario to renal; RMC sees ‘blood in urine’, so diverts the patient to urology. The patient was scheduled for cystoscopy – an invasive procedure he didn’t need which had the added effect of delaying the tests he did need. It’s bonkers and dangerous.

  For more on Referral Management Centres, see the NHS Institute for Innovation and Improvement website (and have a glass of whisky and a service revolver handy).

  CHARLIE DARNAY, ME AND CHOOSE AND BOOK

  WHAT IF CHARLIE hadn’t been quite as tired as he was, and had exercised his legal right to use the aforementioned ‘Choose and Book’ to arrange the time and place of his treatment?

  The government’s ‘Choice Agenda’ boast is that ‘service users’ like Charlie can make these decisions for themselves if they want to, as long as the place they choose meets NHS standards and costs. They can make this choice based on a large number of criteria, from the serious (clinical performance or waiting time) to the relatively trivial (parking facilities).

  This might sound like a great idea – it’s so much better than someone like me dictating to Charlie where he’s going, surely? And not only will he get a say in his care, but it will also improve that care: the modern NHS is funded under a system called ‘Payment by Results’, under which the money is supposed to follow the patient. Patient choice will provide hospitals with an incentive to improve the quality of their services to attract more patients. Or so the theory says.

  In reality, it isn’t that simple.

  How wide is Charlie’s choice?

  The Choose and Book website says: ‘Choose and Book is a service that lets you choose… any hospital in England funded by the NHS. You can choose the date and time of your appointment.’

  Pretty unequivocal. But later, it admits that it only promises that ‘in most cases’ he can choose the date and time of his appointment. There’s a good chance that actually the exact time and date he wants won’t be available. Is this a minor quibble, or a major get-out? You decide.

  Secondly, sure, he can choose his hospital by going onto the NHS Choices website. In the Brave New World of the joined-up NHS, the government thinks this is easy, but then the Secretary of State for Health won’t have to use the system. Here’s the reality.

  Charlie goes online and clears the first hurdle – the web browser he uses actually allows him to view the site. You’d think this would be a given, but the ‘Frequently Asked Questions’ for Choose and Book somehow manage to say both of the following:

  Why was I told my browser was not compatible when I tried to log into the Choose and Book service?

  Some browsers didn’t used to work (sic) with the Choose and Book service, but we have now made sure that all browsers will work with the service.

  and

  Why doesn’t Choose and Book work with my web browser?

  The Choose and Book patient application is compatible with all versions of Internet Explorer and with the latest version of Firefox. Whilst we accept that this does not make the site accessible to everybody at this time, we are working hard to ensure 100% accessibility as soon as possible.

  Go figure.

  So Charlie hits the button marked ‘Find and choose services – Hospitals’ and types in his home address.

  Whoooah! Up comes the following boast: ‘We found 299 hospitals within 50 miles of your address.’

  Well, this is all supposed to be about choice, and to get the best you may have to travel. So if he really wants to, Charlie can now start ploughing through this enormous list to find the hospital rated highest for the treatment he needs.

  This is by no means a simple task, as the site repeatedly admits: ‘We are aware of the treatment names on this page can be confusing.’ (sic)

  He chooses a hospital at random and finds himself enmeshed in a complex maze of Care Quality Commission jargon, downloadable .pdf files and click-throughs:

  Full details about which standards this organisation met in 2008/2009

  Read Clareshire NHS Trust’s declaration and the information we used to check it

  General statement by Clareshire NHS Trust

  Statement by the patient and public involvement forum

  Statement by overview and scrutiny committee

  Statement by the strategic health authority

  Trust’s response to the hygiene code

  Signatories

  Additional information

  More about how we assess whether organisations are meeting core standards

  See how Clareshire NHS Trust results compare with other healthcare organisations in England.

  Remember, these are just a small part of the data on one hospital.

  It’s a good job Charlie’s IT-savvy, because if you’re not, trust me, you could spend days wandering around here. As it is, realistically, it could take him hours. And hours.

  He clicks back out to the main directory. In some cases, it simply isn’t clear whether the hospitals listed do or do not offer the relevant service (‘We currently have no information on patient services for this hospital’); where they do, much of the information as to the quality of the service delivered is presented in confusing, multicoloured bar charts, with multiple click-throughs to detailed pages discussing whether the hospital is meeting things called ‘core standards’, ‘existing commitments’ and ‘national priorities’ which, I predict, mean very little to you. Care Quality Commission ratings from ‘excellent’ through ‘good’ and ‘fair’ to ‘weak’ litter his screen. Details as to car parking and whether the wards have pay TVs are sometimes easier to find than more important issues like the mortality rate or prevailing incidence of MRSA or C. diff (‘Data not available’).

  Charlie clicks back out to the original screen. Does he really want to spend the rest of the weekend selecting one of 299 hospitals to use? Does he want to travel 25 miles for treatment? Unlike many of my patients, he does have a car. But then, like a lot of people who need to go to hospital, he’s also knackered. He narrows the search down to a more manageable 10 miles from his home address.

  This produces a list of five hospitals. A bit more like it.

  However, of these, only one actually offers the services he requires – and, unsurprisingly, it’s the hospital I would have directed him to anyway.

  So much for ‘choice’.

  Using his ‘unique NHS reference number’ and a password, he can now book his appointment online or by telephone to a call centre halfway across the country.

  Well, you might say – apart from
the fact that the Choose and Book USP is a bit misleading (Charlie might not get the time he wants, and he’s basically chosen the nearest hospital to him, as most people do) and apart from the fact that it has taken him a long and frustrating time to get to this point – what’s the problem?

  The problem is this: while Charlie can choose the time and place of his treatment, what he has given up – without even realising it – is the chance to choose the specialist.

  OK, a Department of Health spokesperson will be quick to point out here that Charlie never literally had a choice of specialist in the past, either. Strictly speaking, this would be true. But I did, and I, as his advocate, would make the best choice I possibly could for him, based on my knowledge of who’s who, who’s interested in what and which consultant answers to ‘Two Brains’ rather than ‘Dumbo’.

  Remember, I know our friend Snitchey and his interest in CFS/ME, and I’d have sent him direct to Snitchey.

  But all Charlie can do is book to see someone in the rheumatology department, where there are a bunch of other doctors, who are all perfectly capable when it comes to crunchy joints and brittle bones, but none of whom share this interest in patients with chronic fatigue.

  Eventually, of course, one of them will direct him to Dr Snitchey, but only after months of wasted time.

  SHOULDERING THE BURDEN

  FUNNILY ENOUGH, the very next patient I had in had experienced similar problems.

  He was Mr Marley, he was favouring his right shoulder, and he wasn’t very bloody happy.

  ‘I’m on the mend, doctor,’ he said. ‘Finally. But I’m not very bloody happy.’

  I said I didn’t blame him, and that neither was I.

  Mr Marley first came to see me six months ago. He’s a keen veteran rugby player, and he’d knackered the shoulder while tackling a 20-stone behemoth on the hoof.

  ‘I’m way too old for this game, doc,’ he’d said, ruefully. ‘I reckon that’s my last match for the Old Stupidians.’

  I examined him. It looked like a pretty straightforward shoulder impingement – this is where the tendons around the shoulder blade and the humerus, or upper arm, are damaged and inflamed. It’s painful and quite debilitating, and, given that Mr Marley’s job as a courier involved driving, lifting and carrying, it was quite a problem for him.

  We put him in a sling, injected the inflamed area with cortisone and dosed him up with anti-inflammatories. Once the initial problem had started to subside, I sent him for some physiotherapy.

  Usually, all of this does the trick but in this case it didn’t. He got back some mobility, and could just about function in his day-to-day life, but he couldn’t work properly and was still in quite a lot of pain. I saw him again a month or so after the injury, re-examined him and decided that he needed a subacromial decompression.

  ‘Basically, that’s an operation to clear out the crap which has built up in the joint and is preventing it from healing properly,’ I said.

  ‘I don’t fancy going under the knife,’ he said.

  ‘I don’t blame you,’ I said. ‘Hospitals are dangerous. If the sleep-deprived junior doctor don’t get you, MRSA will.’

  I grinned, but it was only partially a joke. A while ago, a consultant chest physician called Professor Sherwood Burge was all over the papers when he admitted that his hospital was ‘not a terribly safe place to be’. Like this was news! In common with a lot of GPs, I do my best to keep my patients away from hospitals. All blood samples for routine tests are done at my surgery rather than at the pathology lab, and I send them over there for X-rays and scans only when there’s a real chance that the results might influence their treatment (more importantly, this helps to keep the place freed up for those who really need it). I go to great lengths to avoid showing my own face there, too.

  ‘Having said that,’ I went on, ‘it’s a fairly routine procedure – a keyhole thing. It doesn’t take too long, and you’ll be up and out of hospital in no time.’

  ‘Well,’ he said. ‘Anything to get this sorted, I suppose.’

  This is when the problems really started.

  In the old days, I’d have referred Mr Marley direct to my mate in orthopaedics who happens to have a special interest in shoulder problems, and Mr Marley would have been in the diary for the following Tuesday. (This would happen on the basis that I am a fairly good GP and I didn’t mess them around; bad GPs who consistently referred rubbish might tend to find their referrals delayed for a bit.)

  To refer someone nowadays, I have to fill in a stack of paperwork and fight my way through a dozen secretaries, managers and commissars. I duly did all of this, specifying quite clearly that Mr Marley needed this operation. I’ve been a general practitioner for 20 years, I’ve seen a lot of knackered shoulders and I don’t refer people for surgery willy-nilly. If I say he needs an op, he needs an op. You might assume, naively, that I was referring him to an orthopaedic surgeon for that op. Mr Marley certainly did.

  The bureaucrats thought otherwise. Instead, they diverted Mr Marley away to the ‘Consultant Upper Limb Nurse Practitioner’ – a stupid, aggrandised title which basically means ‘jumped-up physio’.

  The CULNP didn’t ’fess up to this when he saw Mr Marley, of course, and instead relied heavily on the word ‘Consultant’ in his job title, so the patient thought he was seeing a proper specialist, as per my directions. The CULNP spent the next two months fannying around doing more and more physio until he finally began to suspect what I already knew and had already requested: that Mr Marley needed a subacromial decompression. Brilliant.

  I only found this out when the CULNP wrote to me in a slightly high-handed way telling me to arrange a scan. Then I got a further letter which had me bouncing off the walls in rage.

  Dear Dr Copperfield, it said. The MRI scan has revealed that Mr Marley requires a surgical decompression. Would you please refer him for this procedure.

  Aaaarrrrggghh! I already effing have – last autumn.

  On Monday, six months, two weeks and three days after wandering off the rugby pitch in a daze, Mr Marley finally had the op he needed.

  When he came in to see me yesterday he wanted some co-codamol painkillers.

  ‘Bloody hell, doctor,’ he said. ‘I’ve been off work for ages. I’m lucky I ain’t been fired. What the hell was that all about?’

  That’s a very good question.

  WHAT WAS IT ALL ABOUT?

  WHAT IT WAS all about was waiting lists and money.

  The hospitals will say that it isn’t, and that it’s all down to GPs for sending them crap referrals which could have been dealt with without surgery. Sure, there are some of those. But the fact is most of us know what we’re doing and we don’t ask them to cut our patients open unless they really need it.

  Politically, the Health Minister wants to be able to stand up in Parliament – or put out a press release – saying that he will ensure that you will see a consultant inside 18 weeks.

  The hospitals and Trusts need to hit that target, because there are all sorts of bonuses and promotions tied up with doing so, and lots of bad headlines and sackings (well, bad headlines) if they don’t.

  The problem is, consultant surgeons cost lots of money and in the real world there aren’t enough of them to cover everything.

  We ought to be able to explain this to people. ‘I’m really sorry, I know you’re supposed to see Mr Mulberry-Hawk within 18 weeks, but there’s been a rash of broken wrists thanks to the cold winter and the system’s creaking a bit… can you wait a bit longer?’

  But for some reason we don’t, so when Mr Marley arrives at the hospital, they shunt him off to the ‘Consultant Upper Limb Nurse Practitioner’ and tick a box on the computer saying that he was seen within the 18 week limit.

  The treatment he needs – and which we’ve always known he needs – actually takes forever, and he may lose his job while waiting for it, but at least the Health Minister can’t be embarrassed in the press.

  This isn’t the only
way they game* the system. You can’t have surgery if your blood pressure’s high, so when you attend for your pre-operative assessment clinic, don’t be surprised if the nurse starts telling you all about the possible complications of your aortic aneurysm – like death, to name but one. It’s only fair, after all, that you are properly informed, and if the side effect of that is that it terrifies you so much that your BP shoots up to two points over normal for the first time in your life, so you can’t have the op because the protocol says you can’t, and the waiting list clock starts all over again, tough. Sorry, you’ll just have to go back to your GP and get him to re-refer you when your blood pressure’s OK. And by the way, here’s a letter to your GP telling him he’s pretty useless for referring you with high blood pressure in the first place.

  It was fine until you walked up behind him and went BOO! you bastard.

  *OK, it may not actually be gaming – though part of me thinks it just might be – but it is bloody stupid, thoughtless, protocol-driven medicine which drives me and the punters mad.

  KAFKAESQUE

  I’M REALLY NOT saying everything was better years ago and that it’s all rubbish now, because it wasn’t and it isn’t, but try this one on for size.

  I had a patient recently who I was pretty sure had developed multiple sclerosis. I wanted her seen urgently for an MRI scan and a lumbar puncture to test her cerebrospinal fluid for certain MS markers.

  The hospital came back to me with an appointment: 11.30am on May 15. Given that this was, at that point, more than four months away, I felt they were stretching the definition of ‘urgent’ somewhat.