Ah well, you say, you’re a big boy, Copperfield – you can live with the odd mild insult here and there from whoever is Health Secretary this week
That’s true, but what do you think the outcome of QOF was?
When the QOF target-setting team asked GPs how much preventive medicine we already practised, we told them and they didn’t believe us. They set the average QOF score at 700 out of a possible 1,050 points a year (it was later reduced to the current 1,000), and decreed that any GP scoring more than 700 points would get a proportional pay rise. Most doctors immediately scored over 800 with minimal extra effort, simply by using the first few minutes of each consultation to tick the boxes on their screens which confirmed what they already did: ‘Patient has been advised to stop smoking; use condoms; eat fruit; lose weight; exercise more; drink less.’
In fact, across the piece, we managed to earn 90% of the available points, and now we all drive Maseratis.
The Maserati bit is a joke, although we do earn more than they thought we would, but it is true that all that has really happened is I now spend my time filling in forms which an NHS bureaucrat employed in an office somewhere spends time auditing, before another NHS bureaucrat in another office somewhere spends time collating, before another NHS bureaucrat in another office somewhere sends me some money for doing what I already did but perhaps didn’t always write down in a prescribed format.
It’s always nice earning more, but when you add up the cost of QOF and QMAS and NHS Connecting for Health, I can’t help wondering whether it was all either necessary, or good value for taxpayers’ money, or made any significant difference to actual patients.
GOING POSTAL
I ARRIVED AT work at 7.15am to see Mrs Peggotty struggling manfully to heft two big black bags into one of the large trolley bins in the car park.
I’d have offered to help, but it was raining cats and dogs and I didn’t want to put my back out, so I ducked down below the dashboard – to re-tie my shoelace, you understand, not so that she wouldn’t see me – and waited. It took her ages, mostly using the clean-and-jerk technique, but eventually she managed to shoulder them into the bins. I sprang from the Nissan and got to the entrance door just in time to hold it open for her.
‘After you, Mrs Peggotty,’ I said. ‘Terrible weather, isn’t it?’
‘I saw you in your car there, Dr Copperfield,’ she said. ‘I was thinking perhaps you’d give me a hand. Those bags were awful heavy, like. All that junk mail.’
‘I’m awfully sorry, Mrs Peggotty, but I didn’t… my lace… oh, crumbs, is that the time? Surgery starts in… I must…’
Safely ensconced at my desk with a mug of coffee, I found myself confronted by a pile of letters approximately six inches thick. It’s like this most mornings, and a week from now plucky old Mrs Peggotty will be back out by the trolley bins, girding her loins for another struggle with 100 kilos of pointless paper.
The first seven or eight envelopes were franked with pharmaceutical company logos, which at least saved me the trouble of opening them. Such letters are always either trying to market a drug I won’t use, or inviting me to an educational event (with free meal) to teach me about a drug I don’t want to know about, or informing me that either of the aforementioned two drugs have been withdrawn due to unforeseen problems (but that’s OK, because I won’t have prescribed them anyway).
There was a pile of casualty slips telling me that patient X attended our local A&E with Y and had Z done to him. Obviously, I read these, though they often can leave you more confused than if you hadn’t. They’re produced on a computer proforma and because the diagnosis often isn’t clear and the staff are in such a hurry, they often make no sense at all. For example, the first one read:
Patient attended with: Head.
Diagnosis: Other.
Management: Returned to GP.
Er, thanks.
There were one or two letters from the hospital telling me about patients who have had recent clinic appointments or in-patient stays. These are read – or at least scanned (and sometimes laughed at, for similar reasons to the A&E reports).
A quick slurp of now-lukewarm coffee, and I moved on to the requests for reports for life insurance or assurance, allowances, disabled parking stickers, and fitness to appear on television game shows (yes, really).
My eye strayed to the clock on my wall: 7.45am. Fifteen more minutes, and then the first patient of the day would be bashing down my door.
I finished the coffee and returned to the now-smaller pile of mail.
A fat brown envelope (‘All our junk is printed on recycled paper originally sourced from environmentally sustainable forests tended by lone parents in Sweden’) containing the latest National Institute for Clinical Excellence (NICE) guidance was next. These always seem to concern things we’ve been managing perfectly well all these years, but which suddenly need managing in a completely different way because a load of academics who’ve never spent a day in general practice say so.
In this particular case, it was the latest diabetes guidance.
The Standard Operating Procedure for this used to be:
Diet
Then drug A
Then drug B
Then drug A+B
Then insulin.
Job done.
Admittedly, things have got a little more complicated since the pharma companies have had the audacity to develop new drugs. But now we’re left with this low-sugar dog’s breakfast:
It makes my eyes bleed just to look at it.
Bear in mind this is just one of 19 pages in the document, and that this document is – no kidding – the ‘Quick reference guide’. The full guide is the size of a telephone directory.
Will I read it? No.
Will it matter? No, because by the time I do, it will all have changed again, anyway.
Now, what’s this? A postcard from Kelly Jupe who is on holiday in Marbella with her boyfriend:
Dear Doc Cop!! Having a gr8 time (and using plenty of Factor 30 and watching my units lol!!!!!)
Just a quick note to say that I done what you said and took them pills but I’ve still got that like irritating pain in my neck???
Kelly xxx
Thanks, Kelly – I know exactly how you feel.
A complaint from a patient about something or other – not quite mad enough to warrant a place on the common room notice board, though – and some stuff from the PCT about my prescribing data and my ‘balanced scorecard’.* I frowned: most of the PCT crud gets diverted to the practice manager, Jane Carstone. I put it to one side, looking forward to passing it on later with my broadest smile.
Some guff from the Benefits Agency, a few requests for information from employers and charitable institutions and a solicitor’s letter:
‘Further to our previous correspondence, Mrs Grimwig has informed our office that the flat immediately below hers is currently occupied by a drug dealer. Can you confirm that this would have a detrimental effect on her health ?’
No. In fact it might even save the NHS some money if she were to deal direct. (And that will be £37.50, thanks.)
Finally, the usual survey – this week’s came from BigPharmCo and invited me to indicate whether I would consider using a ‘new but not yet established’ drug for the treatment of patients with something or other. The survey will be followed up with invitations to ‘educational’ meetings at ritzy restaurants at BigPharmCo’s expense. But I don’t much like surveys, or ritzy restaurants, so I scrunched it up in a ball and aimed it at the wastepaper bin on the other side of the room; it bounced off the rim and joined the other thirty or so which were lying at various distances from the target.
I looked at the clock: 7:59am. Just time to clear them all up before I opened the door to Mrs Chuffey and her terrible thrush.
*You might be wondering what a ‘balanced scorecard’ is, and what relevance it has to my performance as a doctor. Me too. The BS is an intensely bureaucratic and obsessively box-ticking way of
ranking GP practices in order that those where the doctors are trying to kill you/discriminating against you/generally failing to comply with Department of Health diktats can be identified and punished. A fuller explanation, running to around 10,000 words of jargon, can be found at the NHS primary care commissioning website (if you are at all interested).
CANCER WAITING LISTS
OUR local graffiti artistes had been hard at it when I arrived for work at the virus/human interface yesterday, after a pleasant weekend away in the honeyed charm of the Cotswolds.
The following conversation had taken place on our building, in alternate and indelible black and silver marker pen.
Fuck u TOO, Knobhead! Chuzzlewit rulez
Who YOU callin a Nobhead?
U no hoo I mean, knobface!
Kyle Chuzlewit is a knobhead
Fuk u knob breath
KYLE CHUZLEWIT = GAYYYYY!!!!!
Most invigorating: Banksy, eat your vandalising little heart out.
Inside, I met a distressed young mum, Ms Pinch.
She was 22 and had been suffering for a while with bloody diarrhoea.
By that I don’t mean simply that she was exasperated by it; I mean it really was bloody. The problem had been continuing on and off for some time, was getting worse, and now she was losing weight. She was embarrassed and she was frightened – not least because she’d read in some magazine that this was among the symptoms of bowel cancer.
I didn’t think for a moment she had bowel cancer. What I did think she had was inflammatory bowel disease – specifically, either ulcerative colitis or Crohn’s disease, both unpleasant, both of ‘idiopathic’ or unknown cause and both quite capable of making a patient feel pretty ill.
She needed to be seen at the hospital quickly to confirm my diagnosis in order that treatment – industrial doses of steroids – could begin as soon as possible. She’d already left it a while before coming to see me, and this is one of those things which really shouldn’t be left.
As with Charlie Darnay and his ME, and Mr Marley and his dodgy shoulder, there was a time when I could simply have phoned my favourite gastroenterologist, had a quick chat about Ms Pinch, and she’d have been seen within a day or two.
Now? Oh, dear me, no – that would never do. She has to enter the ‘system’.
That was when the problems started, and they were caused by the government’s famous cancer waiting list pledge.
A while back, Labour announced that ‘cancer patients’ would be referred to a specialist within two weeks of presenting to their GP.
Well, it made a great headline (headlines plural, actually – the pledge has been regularly wheeled out and repeated over the years).
At first glance it doesn’t look a bad idea. People with cancer will be seen within a fortnight – who’d be against a target like that?
Me, for starters.
The trouble with things like this is that they are motivated entirely by sound bite politics – its only useful purpose was that it allowed Gordon Brown to stand up at a podium, make a pledge and then dare the Tories not to support it.
What people like Mr Brown either don’t understand or pretend not to know is that we hardly ever send ‘people with cancer’ to a specialist.
Sometimes we do, sure – and in those cases, we could do with having our patients seen that day, never mind a fortnight hence.
But mostly we send people up with symptoms which might be compatible with cancer but might be lots of others things as well. The fact is, they often don’t need to be seen within two weeks – in some cases, it might surprise you to know, even if they are cancers.
Since the two week rule was decreed by the bureaucrats in Whitehall, the hospital clinics are stuffed with query cancers which don’t really need seeing quickly and the knock-on effect of this is there are lots of patients with non-cancerous problems who do need seeing quickly – people like Ms Pinch – whom we can’t get seen quickly because, you guessed it, all the clinics are full of query cancers.
What to do?
I could be dishonest and claim that I thought she might have cancer, but I didn’t think she had so it wouldn’t have been professional (some GPs do play games like this and they get found out very quickly).
It was tempting to send her up as an ‘acute admission’ – an ‘emergency’, in other words. Then she’d get sorted out in two shakes of a colonoscope. But, again, I’d get a bollocking for ‘abusing the system’.
So instead of a nice natter on the phone with the gastroenterologist, I had to resort to pleading, cajoling and shouting to get anything done – knowing full well that the appointment I eventually secured would probably be cancelled anyway.
The other side of this invidious coin is that once you trumpet these pledges at your political rallies, you create expectations in people. Sometimes, you create expectations in people who ought to know better. Recently, I read that GPs are ‘complacent’ about cancer referrals. Says who? Professor Steve Field – the generally excellent chairman of the Royal College of General Practitioners, no less. Apparently, a new report has found GPs fail to refer a significant number of cancers under the two week rule. To which my response is, if you take the number of GPs in the country (around 41,000), multiply by the numbers of patient interactions and divide by the fact that cancer doesn’t always look like or act as the textbooks say it should, then of course some will be missed (and some things that turn out not to be cancer will be referred).
Complacency, though? I don’t think so. We all live in fear of missing the Big C, but that doesn’t make it any easier to sift the pathological needle from the polysymptomatic haystack.
The simple stats hide the complex truth. Politicians and journalists could be forgiven for thinking that medicine is black and white. They can’t understand the nuances which we have to agonise over – the patient diagnosed with diverticular disease who presents a year later with more diarrhoea, the bloating woman whose chronic anxiety would reach breakdown point if she’s investigated, the elderly patient unwilling to pursue the rectal bleed which is probably just piles anyway… plus there’s the fact that cancer doesn’t always oblige with text-book symptoms because the mitotic process – by which cancer cells divide and grow – hates GPs, too, and wants to make us look lazy and incompetent. This is real life practice and it has the potential to screw up patient lives and our referral stats. Being a GP, Prof Field understands this. And being our figurehead, you’d like to think he’d point it out.
Of course, we could all take the easy route and refer urgently any patient with even the slightest hint of a whiff of a suspicion of something vaguely neoplastic. That way, our arses would be covered, and all the GP-knockers would presumably be happy. Until they discover that the two week wait has morphed into two years – which would result in accusations of defensive medicine. At least that would make a change from complacency!
REBECCA BAGNET, AGAIN
I WAS TOYING WITH the idea of checking my favourite searches on eBay during my coffee break when the phone rang. It was Gordon, receptionist extraordinaire. Even as he spoke I heard the voice of Jilted John in my head.
‘Er, Tony...’
Memo to self: Ask Jane to remind Reception staff to refer to us as ‘Doctor This’ and ‘Doctor That’ when patients are within earshot.
‘Er, Gordon...?’
‘Er, Tony, would you be all right about seeing a 15-year-old girl without her parents as a Book on the Day walk-in and wait thingy? She says she’s run out of insulin.’
‘Who is it?’
‘Er, Becca Bagnet.’
Around half an hour later, she shambled into my office in full-on emo regalia. Dyed black asymmetric hair, enough eyeliner to sink the ocean-going variety and a selection of Oxfam shop bangles adorning a pair of painfully thin forearms.
‘Rebecca.’
‘Doc.’
‘How are things?’
‘Crap. Same as always.’
‘Mum and dad OK?’
&
nbsp; ‘Guess so.’
‘What’s with the diabetes thing?’
‘S’alright.’
‘That’s not what I’ve been hearing.’
‘Like what?’
‘Like you’ve been waking up in Casualty rather a lot recently. Is there something particularly tasty about hospital sugar lumps these days?’
‘They don’t do sugar lumps. They do injections.’
‘I know. It was a joke.’
‘Ha ha.’
‘And these injections… you usually end up needing them after your friends have tried the sugar lump and/or glucose liquid thing, and you haven’t come round.’
I pulled a random selection of her casualty cards onto the PC screen... blood glucose levels less than 3mmol/litre, brought in by paramedics or by concerned friends, drifting in and out of consciousness, revived by an injection of glucagon (the hormone the body uses to release stored glucose from the liver into the bloodstream). One A&E report mentioned vodka, another mentioned Bacardi and a third referred to a possible seizure en route in the ambulance.
‘Do your mum and dad know that you’re here?’
‘I can look after myself can’t I?’
‘Well, judging by these hospital reports, no, you can’t.’
‘You’re as bad as they are. Do I get my Lantus and Humalog or not?’
Lantus and Humalog are types of insulin, obviously.
‘What about some finger-prickers and testing sticks to check your blood sugar?’
‘Got plenty.’
Which meant that she wasn’t using them. Type 1 diabetics like Rebecca are people whose insulin-producing cells have been destroyed; they are treated by delivering replacement insulin via injections or a pump, and ensuring they eat a healthy diet and take plenty of exercise. They need to adjust their insulin doses in line with their blood glucose level, and this is determined by pricking a finger to obtain blood, checking the reading and then dosing according to the size of the next meal, the amount of exercise planned etc etc.
Sick Notes: True Stories from the GP's Surgery Page 6
