Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  I called the relevant department and spoke to a secretary there.

  ‘Hello, it’s Dr Copperfield from Bleak House,’ I said. ‘I asked for my patient Mrs Dedlock to be seen urgently for an MRI and some tests. You’ve come back with 11.30am on May 15. Can you please explain to me how that fits the definition of “urgent”?’

  ‘Well, we are very busy, doctor,’ she said.

  ‘And Mrs Dedlock is very poorly,’ I said. ‘Potentially very poorly indeed. So I need her seeing pronto. Can you have a look in your diary and find me something quicker, please?’

  There was a sigh and the sound of fingers clicking on a keyboard. In the background, I could hear dozens of other office-dwellers merrily gossiping with each other. The secretary came back to me.

  ‘As I say, doctor, we really are very busy. But I have managed to find you an earlier appointment for the patient.’

  There was a pause. I think she was expecting me to prostrate myself telephonically before her and sob in gratitude.

  ‘Yes?’ I said. ‘What is it?’

  ‘It’s 11am on May 15,’ she said.

  ‘What?’

  ‘It’s 11am, May 15.’

  ‘Are you winding me up?’

  ‘Er, no. Why?’

  ‘I ring you with a very sick patient, a mother of three who I am pretty sure is about to be told she has multiple sclerosis. I point out that the appointment you have given her is more than four months in the future and ask for her to be seen sooner than that. And you give me an appointment half an hour earlier? Half a bloody hour?’

  ‘Well… ’

  ‘I’m ringing you in premium appointment time, here,’ I said, frothing slightly at the mouth. ‘I have patients waiting outside the door, and I’m on to you having a conversation like this? Are you mad?’

  We got Mrs Dedlock seen much quicker, but how much time and angst does this sort of thing take up?

  And if you think that’s an isolated case, think again. I could give you dozens of similar examples.

  Not long after that debacle, I was consulted by Mr Tulkinghorn, a man in his 40s, who was having chest pain. I referred him to hospital, the problem settled down and they allowed him to go home. I then got an email asking me to arrange for Mr Tulkinghorn to have a stress test on his heart, followed by an appointment with the consultant cardiologist so that the results could be evaluated. (Quite why the hospital cannot arrange this test and the appointment themselves I’m not sure – they used to, but nowadays it all comes back to us. Actually, scratch that: I am sure. In our pointlessly complex funding system, if it’s not arranged by the GP, the hospital doesn’t get funded for it, or not funded so much, or something like that, so everything they would have previously sorted themselves – obviously quicker and more sensible – gets bounced back to us.)

  With horrible inevitability, Mr Tulkinghorn was given his cardiology appointment before the stress test. I called the hospital to try to sort it out. They cancelled the appointment with the consultant, because there was no point in him being seen until he’d had the stress test. The patient then got a letter saying: ‘You did not attend for your appointment. You must go back to your GP to be re-referred.’

  By now, it was quite possible I’d be needing a cardiology appointment of my own: God knows what this mad, circular, bureaucratic nonsense does to the poor patients.

  Perhaps the best example of this insanity involved a 70-year-old patient with an iffy heart, arterial disease all over the place and one leg amputated as a result of his vascular problems. He was due to see the heart specialist when his health took a nosedive from ‘seriously ill’ to ‘just about dead’ and he was rushed in to have the other leg chopped off. As a result of this, he was going to miss his cardiology appointment. His wife rang Outpatients to apologise and ask if they could rearrange it. The response she received was: This is not sufficient excuse for missing his appointment. His GP must book another one.

  I know this sounds so surreal that Salvador Dali would have dismissed it as implausible, but I swear I’m not making it up.

  I was so angry that I actually sent a letter to the powers-that-be at the hospital.

  Dear X,

  I write with regard to my patient, Mr Young, and your recent conversation with his wife. Just for future reference, can you please tell me what criteria you think you might accept as ‘sufficient’ for missing an appointment? Because it seems to me that being rushed in to have your only remaining fucking leg cut off ought to score pretty high?

  After writing it, I started to worry that I was being too aggressive – a clear sign that I am losing it. I showed it to Sami Patel. ‘I’d take out the “fucking”,’ he said. ‘Otherwise, spot on.’

  I’LL TELL YOU WHY I DON’T LIKE MONDAYS

  TODAY WAS THE second Monday of the month, and that means it was our monthly partnership meeting.

  O joy of joys.

  These meetings involve the four partners (the Senior Partner, myself, Sami and Amy Daniels, struggling in from maternity leave) and the practice manager SS-Obersturmbannführer Jane Carstone. We kick off at around 8pm, we talk about the future of the practice and its staff, and we grind on until we are all either dead or prepared to concede anything to anyone, usually just in time for last orders.

  First item on the agenda was a complaint to Jane that I had spoken too sharply to one of the receptionists, Gordon.

  ‘Mrs Peggotty says you were rude to Gordon,’ she said. ‘Apparently, you said to him, and I quote: “Why don’t you just piss off, you are a bloody moron at times”.’

  ‘Well, to be honest I wouldn’t be distraught if he did leave,’ I said. ‘He’s hopeless. He loses paperwork, he irritates the sane patients and encourages the nutters and he consistently puts phone calls through to surgery when he knows he shouldn’t. All that said, I didn’t tell him to piss off. I may have been looking in his general direction, but I was talking to Dr Patel at the time. As he will confirm.’

  Sami nodded. ‘It’s true,’ he said.

  ‘Two things,’ said Jane, coolly. ‘Number one: I know Gordon has some performance issues, but if you have any problem with him there are procedures which must be followed…’

  ‘Und orders vhich vill be obeyed,’ said Sami Patel.

  ‘…and number two: do you really think that two partners should be talking to each other like that in front of the staff? And potentially patients?’

  ‘Fair point,’ I said. ‘But he is a moron.’

  ‘Fair point,’ nodded Sami.

  ‘Next,’ said Jane. ‘Just to note that the new registrar, Lucie Manette, joins in a fortnight.’ About one quarter of GP practices are approved for training, and ours is one of them. Trainee GPs in their final year are called registrars; most stay with you for a year, heavily supervised, with lots of tutorials and paperwork. A good one means you have, in effect, an extra partner for a year. A bad one means you have a nightmare. ‘She’ll initially work out of Amy’s room while she’s off on maternity, if that’s OK with you?’

  ‘Fine,’ said Amy.

  ‘Is she the tall blonde who was here last week?’ said Sami. ‘She looks as though she has bags of potential.’

  ‘She is tall and she is blonde, Dr Patel,’ said Jane. ‘Are you insinuating something?’

  Sami just grinned.

  ‘Next,’ said Jane. ‘The new Darzi Polyclinic opens in Skimpole Street this spring. We still have to decide what to do about that.’

  These Darzi’s Khazis were proposed by the former Health Minister Ara Darzi a while back. The basic idea is that you have everything – from primary care to minor surgery to dentistry to counselling – under one roof. We GPs don’t think they can do what we do as well as we do it, or what hospitals, dentists and head doctors do as well as they do it, and instead are a bit of a mess. There are arguments the other way, too, although most pander to the time-pressured worried well, rather than the elderly or chronically sick who have health ‘needs’ rather than ‘wants’. But one th
ing is certain, they do threaten the future of general practice, and are radically changing the way we work. For starters, they’re open from 8am until 8pm, seven days a week. Another issue is that you don’t have to register with them to be seen – you just walk in off the street. It’s not hard to see how patients might decide not to register with us, and with so much of a practice’s income linked to the size of its patient list, there are obvious risks here, both for us GPs and for patients: namely, the loss of fluffy things like continuity and personalised care, with the caring, friendly visage of the family doctor being replaced by some faceless unknown whose main concern is finishing his shift on time.

  ‘As I see it,’ said Sami, ‘we either open longer and all work longer hours, or we lose patients. And we don’t want to lose patients, do we?’

  ‘We could take on another salaried partner,’ said the Senior Partner.

  Salaried GPs earn around £60k or £70k a year and are the Ronnie Woods of medicine: they turn up, play guitar (or dish out scripts) and go home. They don’t attend partnership meetings, don’t have a say in how the place is run and generally act as a bum on a seat during the grotty late night and weekend shifts. Sometimes, they are docs who have no interest in a partnership for personal reasons – as with our current salaried employee, Dr Emma. (In her case, it’s because committing to the practice would mean getting involved in the admin and the non-clinical stuff which sends us bonkers, while interfering in her regular trips overseas to save whales, bond with the Inuit and harvest free trade knitwear in the favelas of São Paulo.) In other instances, they’d love a partnership but the partners won’t give them one because they turn out to be rubbish, or mad, or weird, or all three.

  ‘It might sound radical,’ I said, ‘but, actually, would it be such a nightmare to lose a few patients? Do we really want to hang on to the people who want to be seen at 8.30pm for a sore throat? Let them go down the Darzi, I say – 10% of our patients cause 90% of our workload, so if we lost the right 10% we’d be quids in, relatively-speaking. We could get rid of Dr Emma, never mind take on a new bod.’

  ‘You really are all heart, Tony,’ said Amy.

  ‘We’re not getting rid of Emma,’ said Sami. ‘What are you on about?’

  ‘We certainly don’t want to lose patients,’ said the Senior Partner. ‘Thin end of the wedge, that sort of thing.’

  ‘So are you going to up your hours? Or should we look at another salaried doctor?’ said Jane Carstone.

  ‘If we really don’t want to shed a few punters then maybe we should look at the salaried option to supply some extra hours,’ I said.

  ‘The only thing is, if we take someone else on… what if we rearrange all the rotas and then they don’t like it, or they don’t fit in?’ said Amy. ‘What with me being off at the moment…’

  ‘If they don’t fit in, we’ll get another,’ I said. ‘There’s an endless supply of them.’

  ‘Why don’t you knock up a bit of a plan and we’ll vote on it at the next meeting, Jane?’ said the Senior Partner, to general nods of agreement.

  ‘Next,’ said Jane. ‘Just to note that the insurance premiums are due for payment and are going up again.’

  There were groans around the table. Not that long ago, our profession was up in arms when annual premiums broke through the £1,000 mark. Now, thanks to ambulance-chasing lawyers, I pay £5,000 a year so that my arse is covered when I kill you because I supposedly didn’t tell you not to wash your warfarin down with a couple of bottles of wine.

  ‘A chap I know has just cut his week down to three days,’ said the Senior Partner. ‘His insurance premiums are down by a thousand pounds. He’s earning less, but with the new top rate tax thingy…’

  ‘He sounds like a very socially responsible bloke, your mate,’ said Sami.

  ‘You may very well be the first Hero of the Revolution to drive a Porsche Boxter,’ I said.

  The agenda moved on to our locum, Gavin. He’s been with us ever since Amy decided having another child was a sensible option. Although locums can earn very good money – £90 an hour, or around £175k a year, pro rata – he’s permanently broke, due to several failed marriages and a large number of squealing progeny.

  ‘Gavin’s been offered a partnership in Bristol,’ said Jane. ‘It’s near his kids by his second wife…’

  ‘Third,’ said Sami.

  ‘It’s near his kids by his third wife, so he’s accepted. He joins in three months, so there’s plenty of time to arrange another for the period before Amy comes back.’

  ‘And by then we’ll know what the new registrar’s like,’ I pointed out. ‘If she cuts the mustard, we might not need an extra pair of hands.’

  ‘Tony, I’m surprised to have to remind you that registrars are here to learn, not be exploited,’ said Jane. ‘Lucie certainly couldn’t be expected to do extended hours while the rest of you swan off.’

  ‘True,’ agreed Sami. ‘Nice idea, though. Be a shame to lose Gavin. I’ll miss lending him a tenner for his lunch three times a week.’

  The meeting rambled on in this style for the next hour or two, until Jane called for any other business.

  Sami stuck a hand up. ‘I’ve got something I want to raise,’ he said, looking at me. ‘I heard you talking to Nurse Susie the other day, Copperfield.’

  ‘And?’ I said.

  ‘And she was moaning about having to tick boxes and fill in forms to chase QOF points, and you said you knew how she felt, it was a pain in the arse.’

  QOF points are an expensive new bureaucratic way of paying us to do things we already did. I’ll explain them more fully in a moment.

  ‘It is a pain in the arse,’ I said. ‘I do object to having some highly-paid, chairbound biro-jockey hovering over my shoulder checking how many of our bloody diabetics we’ve tested for sodding micro-albuminuria in the last 15 months. Or worrying about whether we have a written policy for responding to requests for emergency contraception. Or docking us points for forgetting to tick a box which says there’s no issue outstanding if a patient is up for a medication review and there’s no fucking issue outstanding.’

  ‘Listen, you pillock,’ said Sami. ‘You can’t say stuff like that to the nurses. They should be filling out the forms, that’s how we make a living! How can we bollock them for not doing it if they hear you moaning about it?’

  ‘Who’s behind with his blood tests?’ I said. ‘Do I need to remind you of Hypothyroidism Indicator 2, “Ongoing Management: The percentage of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months”? You’ve got stacks of outstanding tests, and that’s six QOF points going begging unless you get your act together.’

  ‘They’re being sorted,’ he said. ‘I had a problem with my computer, as you well know.’

  ‘Children, children,’ said the Senior Partner. ‘Can we agree that QOF points equals profits, and since partners share profits we need to do all we can to ensure we harvest as many QOF points as possible? That means encouraging the staff to stick needles in anything which moves and make a note of so doing, and making sure we do the same.’

  That’s general practice: a constant tension between trying to get on with being a good professional and the distraction of proving that I’m doing so, just so I can pay the mortgage. Something I could have said, at this point. But I didn’t. Instead, I suggested we adjourn to the Red Lion.

  QOF POINTS

  I’M SORRY TO say that this explanation will be very tedious, and will contain lots of typically convoluted and labyrinthine NHS bureaucratese (‘…they are derived from the Quality Management Analysis System [QMAS], a national IT system developed by NHS Connecting for Health…’), and that at the end of it all you may be left scratching your head and wondering why they bothered. You’re not alone.

  The Quality and Outcomes Framework (QOF) is a national system introduced with the General Medical Services (GMS) contract on – fittingly enough – April Fool’s Day, 2004.

  Under
QOF, the idea is that each GP practice is measured in a variety of areas so that patients, PCTs and politicians can judge us against a mythical average standard, instead of trusting us, as professionals, to do a job that few of them actually understand.

  These areas are called ‘Domains’, and there are four of them: the ‘Clinical Domain’, the ‘Organisational Domain’, the ‘Patient Experience Domain’ and the ‘Additional Services Domain’. Each ‘Domain’ is split into ‘Areas’ (28 in total) which are themselves further sub-divided into 129 ‘Indicators’.

  We get awarded ‘QOF points’ for ticking the myriad boxes in these Domains, and we get money for each QOF point. There are a total of 1,000 QOF points on offer, and each point is worth £124.60 (adjusted for ‘prevalence’ and the ‘contractor population index’, which really are too boring to go into).

  As a for instance, the biggest of the ‘Areas’ in the ‘Clinical Domain’ is Coronary Heart Disease, which has 10 ‘Indicators’.

  To take one at random, ‘CHD 3’ is: ‘The percentage of patients with coronary heart disease, whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status need be recorded only once.’

  If we hit a target of 90% – i.e., 90% of patients have this box ticked in their medical notes – we earn seven QOF points.

  To take another, ‘BP 3’ is: ‘The percentage of patients with hypertension [high blood pressure] who smoke, whose notes contain a record that smoking cessation advice has been offered at least once.’

  If we hit 90% here, by telling smokers to give up, we earn ten more QOF points.

  In a way, it’s all rather insulting. The insinuation – perhaps even the accusation – is that we really don’t give a stuff about our patients and cannot be trusted to do the best for them, that if you attend my surgery as a 40-a-day man with a dodgy ticker or high blood pressure, without the government sitting on my back and, er, dangling QOF carrots in my face, I won’t bother telling you to stop tabbing.