Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  That said, our situation is a lot more complex than that of your average self-employed worker. (Years ago, one of the very first things I wrote for money was a guide to the payments system to which newly-qualified GPs could refer. It took me eight weeks to complete.)

  After 1948, when the Minister of Health Aneurin Bevan opted to ‘stuff GPs’ mouths with gold’ to get them to abandon their private practices and sign up to the newly introduced National Health Service, the monster that was the payment system grew and grew into a labyrinthine behemoth of bewildering complexity. The instruction manual known as the ‘Red Book’ ran to hundreds of pages.

  GPs were paid a Basic Practice Allowance, just for setting up in practice, and then a sum of money per patient.

  Some of their expenses – such as building costs, heating and lighting – were reimbursed, and bundled on top of that there was a complicated ‘piece work’ system where GPs got paid for performing some additional tasks known as ‘Items of Service’, like offering contraceptive advice and doing so-called ‘minor’ operations, which didn’t form part of the ‘traditional’ GP provision.

  They also received ‘Seniority Payments’ for getting older (or, some would say, surviving at least seven years in the job), ‘Night Visit fees’ for getting out of bed after 10pm (but not if all they did was answer the phone at four in the morning and give the standard, ‘take two aspirins and call me again in the morning’ advice – that was unpaid) and money for performing check-ups on elderly patients and new patients to their practices.

  All of this changed in 2004 when a new contract was negotiated – although some GPs prefer to use the slightly more accurate term ‘imposed’.

  GPs are now contracted to offer ‘General Medical Services’ in exchange for a share of the total amount of money available to provide GP services across the NHS, a figure known as ‘The Global Sum’.

  The size of the share is determined by taking into account, among other things, the number and ages of the patients on the practice’s list, the number of patients who join or leave the practice each year, the cost of hiring nurses and receptionists, and the number of ‘deprived’ patients in the area.

  For most GPs, this contract left them better off than they had been before, with the intended average income rising from around £60,000 to nearer £90,000 per annum.

  The minority who would be worse off were supported by a safety net known as M-PIG, the Minimum Practice Income Guarantee.

  Are you with me so far? Good.

  No sooner had the government agreed the Global Sum than it took a large chunk of it back again to fund the Quality & Outcome Framework (QOF) incentive scheme discussed earlier. As I said, there are a thousand QOF brownie points on offer, and because of a major miscalculation on the government’s part almost every GP in the country gets almost all of them, just by doing all the stuff we previously did unpaid for years (often stuff we’d have to be on the edge of negligence to miss).

  The General Medical Services thing and the QOF system are negotiated nationally. Larger practices can negotiate directly with their Primary Care Trust and enter into a contract to provide ‘Personal Medical Services’. These contracts cover aspects of medical care that aren’t included in the GMS contract but are still do-able by GPs and are needed in their area. For instance, one of my mates works in South East London and has about 2,000 Nigerians on his list, who all need travel vaccinations every time they go home, which is two or three times every year. So, travel vaccinations form part of his PMS contract.

  The unintentionally generous QOF package – which saw GP earnings reach a peak in 2005 – resulted in an outcry, and the outcry resulted in pay cuts for GPs in 2006 (of 2.1%) and 2007 (of 1.5%). I’m not much of a betting man, but I don’t expect to see another rise for quite some time.

  OUT OF HOURS

  THE OTHER KEY thing to talk about when discussing the New Contract and governmental cock-ups is out of hours (OOH) care.

  When I was a boy (cue Dvorak’s New World), GPs provided OOH care in emergencies.

  By the time I began what I’ve laughingly come to call my ‘career’ in General Practice, the definition of an ‘emergency’ was showing real signs of slippage.

  I started out young, keen and willing to visit patients anytime, day or night, but that feeling was soon knocked out of me by calls for, among other things, the morning-after pill at midnight. (The clue’s in the name, girls.)

  By 2004, politicians were promising that GPs would not only see genuinely ill people within 48 hours (neglecting to provide the space age technology by which it would be possible to ascertain before the fact who was and who was not ‘genuinely ill’), but also people who merely ‘believed themselves to be ill’. In my practice, this sometimes seems to equal the entire population. As a result, the government made it virtually impossible for patients who really needed to book regular appointments about long-term illnesses to get to see the same doctor each time – and it was clear that the concept of ‘urgent’ or ‘emergency’ care had vanished.

  We were expected to provide instant access for even the most trivial conditions 24 hours a day, seven days a week – and, to a man and woman, we all hated it.

  GPs were retiring early or leaving the NHS to work abroad, and far too few newly-qualified doctors wanted to replace them, opting instead for the greasy pole-climbing world of hospital medicine – which merely reinforces my point about how crappy a GP’s working life had become.

  Out of a clear blue sky, and to ease the passage of QOF, the government’s crack team of world-class hagglers (I’m sorry, I am trying to keep a straight face, I really am) offered to allow GPs to ‘opt out’ of providing OOH care and make it the Primary Care Trust’s problem.

  Imagine the GPs’ negotiators when faced with this offer. The thought process would have been along these lines:

  Blimey! They’re going to let us off OOH! OK – must think straight, here. How much will the government want to take out of our wages in exchange for this massive, massive concession? Ten grand? Fifteen? Still, it’ll be worth it. Sleep! And weekends off!

  The government actually asked for £6,000 per GP. But don’t worry, they said, we’ll put a system in place that allows you to claim some OOH money in respect of the admin involved in opting out.

  Back to the GP negotiation team:

  YAAAAAHHHHH-BLOODY-HOOOOOOO!!!!!!!! A HUBBA-HUBBA-HUBBA!!! GET DOWN!!! GET RIGHT DOWN!!! YEAH!!! YEAH!!! YEEEEE-HAAAAH!!! THE GUYS BACK AT BMA HOUSE ARE NEVER, NEVER, NEVER GONNA BELIEVE THIS!

  Actually, their response was probably more like, ‘You drive a hard bargain, but in the interests of continuing dialogue, we’re prepared to accept,’ before excusing themselves, running to the nearest toilets and corpsing like a bunch of school kids who’ve just stuck a ‘KICK MY SORRY ASS’ note on the back of the Headmaster’s jacket.

  Meanwhile, entirely predictably, the national papers are now full of horror stories resulting from PCTs’ attempts to provide OOH care for roughly £4 per patient, per year.

  BURN OUT

  I FOUND MYSELF in the Red Lion with the Senior Partner the other night. We’d escaped intact from a practice meeting and were slowly sinking a couple of pints and putting the world to rights, when he suddenly let out a heartfelt sigh.

  ‘I dunno, Tony,’ he said. ‘I never thought I’d say this, but I’m starting to think about retirement. Charlie’s away at uni now, so there’s nothing keeping us here any more. D’you know, I’ve always fancied sailing round the world.’

  ‘You haven’t got a boat,’ I said, ‘and you don’t know how to sail. Other than that, it’s a great idea.’

  ‘It’s just, I’ve had enough of all the crap,’ he said. ‘When I began my career in general practice, I had an idea it could get pretty crappy. But I had no idea just how crappy. You’d have thought that, by now, with all my experience, I’d have reached some sort of crap plateau – but no, it continues to be an uphill struggle up the never-ending north face of Mount Crap, as I disc
over, thanks to life-long learning, new and exciting forms of crap piled on the old. And the really galling thing is how much of this faeculent matter is generated by bloody doctors, not bureaucrats. I mean, these bloody “quality care” sacred cows...’

  ‘Tell me about it,’ I said, hoping he wouldn’t. Unfortunately, he didn’t take the hint.

  ‘This morning,’ he said, ‘I had a consultation with an asthmatic. The poor bloke had gone through the rigmarole of phoning up, booking an appointment, taking time off work and sitting in our waiting room, next to all the coughing, wheezing viral sponges, just because our “quality” repeat prescribing system recalled him. For what? A consultation which was basically, “How’s it going?” / “Fine, thanks.” I gave him a peak flow test to pad things out, but I don’t care what the NSFs or the Clinical Governance Gestapo say, it was an outrageous waste of my time, and his.’

  The Senior Partner took a swig of his ale, and stared into the glass.

  ‘I will enumerate my objections,’ he said. This was my cue to get another round in, quick. It was obviously going to be a long night. ‘First, most treatment reviews are unnecessary. Why do I need to check a thyroxine or analgesia regime annually? Can’t we rely on the punters to let us know if there’s a problem? They already have a fairly low threshold for attending and they really don’t need any more encouragement from me.

  ‘Second, patients can usually monitor their own diseases these days: they have peak flow meters, BP monitors, pharmacy-based cholesterol tests and so on. We’re potentially redundant, which can’t come a moment too soon for me.

  ‘Third, treatment reviews inevitably create work. Nine times out of ten, people who come in for clinical reviews always find something else to bloody mention while they’re there. I don’t actually blame them – who’s going to make the effort to come in to the surgery just to have their repeat prescription card rubber-stamped? So a “Therapy Update” turns into a “While I’m here”, and more time is wasted.

  ‘And fourth, this is a classic case of doctors over-valuing illness. When will we learn that diseases like asthma or hypertension aren’t as important to people as we’d like to believe, not when there’s shopping to be done, giros to collect, cars to nick and so on? It’s absurd expecting patients to take time off from their busy schedules just so that we can pretend we’re providing a quality service. We should realign our values with the punters – in other words, we should care less. I mean to say, the only patients who attend religiously for treatment reviews are the obsessive basket cases who bring a year’s worth of computer print-outs depicting their twice daily peak flow readings and these people shouldn’t be encouraged to get to the doctor, they should be encouraged to get a life.’

  ‘You forgot the fifth point,’ I said. ‘Treatment review consultations are bloody boring. Which is why I usually delegate them to Nurse Susie.’

  JARGON

  AS MUST BE clear by now, the NHS is a world-leader in jargon creation, and there isn’t the space, or the will, for me to explain it all here. Some things are in the glossary at the end of the book, others you’ll have to Google or have a guess at, but here’s a rough translation of what the SP is on about in the passage above.

  ‘Life-long learning’, part of the ‘Working Together, Learning Together’ ‘framework’ introduced in 2001, is the result of a truly brilliant epiphany experienced by someone in an office somewhere. In a moment of genius, he or she realised that medicine is constantly evolving and doctors ought to ensure that they keep on top of this. Thank God s/he did so, because prior to that, everyone I knew was obviously relying on what they learned in medical school 30 years ago.

  ‘Quality care’ is another similar load of guff which is supposed to ‘put quality at the heart of the NHS’ but, as the Senior Partner is discovering, often has exactly the opposite effect.

  ‘NSFs’ (National Service Frameworks) are a set of dictatorial rules imposed on a group of people in surgeries who know what they’re doing by a group of people in offices who don’t know what they’re doing.

  The ‘Clinical Governance Gestapo’ are the people who check up on you to make sure you’re doing these unnecessary things.

  TRACEY’S RASH JUDGMENT

  I COULD TELL Tracey was trouble from the moment she walked in.

  She was straight out of the Fat Slags: leggings, a tight white top that barely contained her fulsome person and an expression somewhere between rage and disbelief.

  She sat down and started gabbling at 90 miles per hour.

  ‘So I’ve got this rash, yeah? So I seen that Dr Gavin about it…’

  ‘Gavin Hall? He’s actually a locum, but carry on.’

  ‘What? He ain’t even a real doctor?’

  ‘No, a locum is… look, we trust him on rashes.’

  ‘Whatever.’ She hoiked up her top: there was, indeed, a red smear across her midriff. ‘So I seen him, right, and he just calls it a fancy name and says it’s nuffink serious, yeah? I mean, look at that! Nuffink serious?! He says if it itches to rub some of that Caroline lotion in…’

  ‘Calamine?’

  ‘Whatever. To rub some of that in if it itches, and otherwise it’ll just go away of its own afford. So I says to him, I ain’t being funny, yeah, but I’m going to Jamaica for Christmas in three bleeding weeks and I ain’t going looking like this. So he says, “Well, I’m sorry, madam, right, but there’s really nuffink else I can do, yeah?” So I said I wanted someone else to have a look, which is why I’m here.’

  ‘Oh dear.’

  I really dislike having to provide an instant ‘second opinion’ for disgruntled punters with minor ailments. It puts me in an impossible situation. I’m sure that Gavin will have examined Tracey far more meticulously than I would have bothered to, and will have spent precious NHS time explaining the likely benign nature of her problem before advising her down the calamine lotion route. The truth is, there’s probably nothing else I can do, either. But people like Tracey don’t want the truth.

  As she carried on yattering away, I turned over the possibilities in my mind.

  Scenario A (most likely): Gavin’s assessment is perfectly accurate. It’s Pityriasis rosea, and it really is nothing to worry about. As far as we know, it’s a viral infection producing a characteristic skin eruption that fades after six weeks or so, and you’re unlikely to get it again.

  Scenario B (not impossible): Gavin has done all the right things but has diagnosed as viral Pityriasis rosea a rash which to my slightly more experienced eye looks more typical of a fungal skin infection called Pityriasis versicolor. An easy mistake to make that leaves me with a dilemma: P. rosea will burn itself out; P. versicolor won’t. In fact, it will become even more apparent in sun. If my hunch is right, and Tracey wants to look good on the beach, she ought to be using antifungal treatment from tomorrow.

  If I stick up for Gavin and it turns out he was right, great.

  If I stick up for him and it turns out he was mistaken, it makes us both look stupid.

  If I say that he might be wrong and offer an alternative diagnosis, that makes him look stupid and me a smart arse.

  And if I say that he was wrong and it turns out that he was right, I’m the berk who prescribed an unnecessary antifungal treatment.

  Time for the ‘lab test as delaying tactic’ approach.

  ‘Tracey, it’s almost certain that Dr Hall is correct but if you’d like me to organise a couple of investigations... perhaps I could take some skin scrapings from the rash?’

  Moments later, and after some self-righteous harrumphing, she was happily queuing for a blood test with the practice nurse.

  Which was when I heard another eruption, this time more volcanic than cutaneous, as she deciphered my handwriting on the request form: ‘Rash of unknown cause. Possible secondary syphylis.’

  Ah yes, Scenario C. Perhaps I should have mentioned that earlier.

  HOW TO SAVE THE NHS BILLIONS WITHOUT ANYONE NOTICING

  I’M NOT USUALLY one
to agree with management consultants, but they recently suggested the NHS workforce should be cut by 10% to save money. This surely merits further consideration. In fact, I’d like to make some suggestions of my own about NHS staff who we could sack tomorrow and who wouldn’t exactly be sorely missed – largely because we wouldn’t notice, or care:

  Health visitors: they’re supposed to have a ‘special role’ in the care of new mothers and new babies. It’s so special, in fact, that no one really knows what it is. What I do know is that they create unnecessary anxiety in parents by suggesting that an umbilical polyp might be something rare and serious (wrong and wrong) or unnecessary work for me by misdiagnosing sticky eye as conjunctivitis and sending mother/child to my emergency clinic.

  Counsellors: ‘talking treatments’ are seen as a panacea these days. In a way, they are – for the GP rather than the patient. Because they enable us to tell the emotionally incontinent to go away, but nicely. Like the rest of us, counsellors are 70% water; unlike the rest of us, the other 30% is fluff. I believe they make good tea, though.

  Anyone involved with: Choose and Book, Referral Management Centres, NHS Direct and the Summary Care Record: all obscene wastes of time and money.

  Pre-op assessment nurses: these are nurses who check you over before you have surgery. All they do is measure your blood pressure and dipstick your urine, yet they manage to screw both up. A slight blip in your BP when they’ve just outlined the possible complications of your op (eg death) does not constitute hypertension, it constitutes being scared. And minor abnormalities in your wee are of no interest to anyone, least of all me. Yet somehow these irrelevances might lead to the cancellation of your surgery until I ‘sort it all out’.