If I only had the time by John Locke

I have spent a lot of time trying to manage my time over 28 years as a GP and have probably wasted quite a lot of it in the process. The lessons are straightforward around priorities, lists, doing today’s work today, delegation and saying no to tasks which are not my responsibility or that I do not see as important. That would all be easy if I had more time and someone to whom I could delegate work. Our admin staff would probably leave and patients would wonder why I have become so grumpy or obstructive.

                                                                                                                                          

I am often asked by patients if I am busy, sometimes in a slightly sarcastic tone having just spent 30 minutes in a heaving waiting room. My answer depends on that tone. It may be ‘not really’ which makes them think I have been having a snooze or was determined to finish the sudoku puzzle or more often I reply that I start the day with a full timetable then see how many other tasks/patients I can squeeze in.

To prioritise work you can use a matrix of urgent and important boxes.

 

URGENT	NON-URGENT
1. Chest pain Haemorrhage	2. Cellulitis UTI, Patient worried	IMPORTANT
3. Rash Tracheitis	4. Queens score Weather	NON-IMPORTANT

 

Box 1 will be directed to 999 or NHS24.

Box 2 up to 2 weeks

Box 3 a letter to say the request is being considered

Box 4 sometime in the corridor

 

If I worked in an office with a door that shut firmly, fixed appointments daily and access electronically then I could fit all tasks into each box and respond with a timescale mainly determined by me. Medicine is not like that.

Most GP work starts in Box 3 driven by patient perception of urgency but should really be in Box 2. I would like more to move to Box 4 as that may be more important to me on different days such as when Rangers visit Palmerston. Most consultations will really end in Box 4 as there is no diagnosis to be made or it will be self-limiting. Box 1 has been moved to the ambulance service but those symptoms can easily be moved to any other box depending on the underlying cause. A 1 week old rash from a new perfume may be urgent due to patient concern but will heal whatever I do, so over to Box 4.   A reported rash which turns out to be a nasty cellulitis with rigors should be Box 1.

The problem is that to make these decisions I have already spoken or seen the person so the time has already gone. Our appointment systems cope with same-day demand to manage Box 3 when Box 2 could really be the starting point. The e-mail attachment has already been opened or the letter read before I can decide on the box. So I wondered how I could metaphorically shut the door without becoming totally unavailable and I realised that everyone else except me had worked it out years ago

– A PERSONAL REFERRAL TEMPLATE!

This would have the usual pre-amble about national guidelines, urgency, exclusions, links to other (more appropriate) services and a telephone ‘hot-line’ with 8 different pre-recorded messages, all spoken quite quickly so you would have to press 9 to repeat them.

As an aside, when I was a GP trainee the other GPs wondered why one partner had quieter nights than them. Then they listened to the message he left on the telephone and knew why.

The referral page would include examples of urgency and several mandatory boxes to complete, including, of course, some of which you would never have thought of asking such as weight, exercise tolerance and smoking status which are irrelevant to most requests but help me update QOF figures.

Exclusions would include tasks which should have been done by another clinician, prescription requests by in-patients or for the deceased (not kidding), urgent requests for medication needed for a holiday booked 2 months ago or anyone asking for a house visit having just flown back from Florida that day or specifying which time they will be in.. Similarly any replacement of sedatives or opiates even when the police have been informed.  These will all need a covering letter.

Important but non-urgent requests such as ongoing symptoms, medical reports, HGV exams, meeting requests and replacement certificates will be put on a waiting list. This will be within 4 weeks for sore knees and shoulders and 8 weeks for all other problems.

Ideally, of course, a period of consultation, staff communication and public awareness of this new system will be vital to its success. I will write a strategic document with an implementation timescale and financial projections which will be circulated but unfortunately I have been unable to assess any impact on other parts of the service…

 

……I don’t have the time.

John Locke is a General Practitioner

 

 

Two Decades of Change by Jean Robson

20 years ago I joined the Charlotte Street practice, working in what had previously been the coal cellar of a large sandstone house. My room was dark, with bars on the windows, but spacious. The waiting room was immediately outside my door, but had no windows.
19 years ago we started trying to build new premises, had plans drawn up 4 times, but each hit a hurdle. 8 years ago a fire made our building unsafe – we were “temporarily” accommodated in Nithbank – the building had originally been a nursing home – a gentleman patient attending my surgery was reminded of the time he scaled the walls to ‘illegally’ enter the first floor room of one of the nurses! I did not need to put a radio on to avoid patients in the waiting room overhearing my conversations, but plumbing was noisy, when hands were washed in the next room I had to abort a chest auscultation, waiting rooms were extremely cramped, and wheelchair access impossible upstairs, and difficult downstairs. We were continually hot-desking, and staff were working in cramped noisy environments, not conducive to accurate and confidential work.

The process of building new premises has been long and fraught, endless meetings, negotiations, contracts, delays, moves aborted, then finally 6 months ago we moved to spacious light airy premises. Waiting rooms are big, which has a positive impact on consultations, patients seem more relaxed when they walk, or easily use their wheelchair to access my room. Staff have space to do their work, the whole team is able to meet in one room, the atmosphere is far less fraught than I recall in 20 years. Of course there are snagging problems to be resolved, but on the whole life is better! The time committed to ensuring that the building would work for us was time well spent, the developer has built surgeries before, but they had never built one for us.

The practice of medicine has also changed substantially over the last 20 years, the Quality and Outcomes framework (QOF) came in, which aims to ensure the quality of care for patients with chronic diseases, or risk factors. I feel that the QOF has brought more advantages than disadvantages, we have a responsibility to the population of patients as well as to the individual in front of us, and therefore need robust recall systems, and reminders about aspects of care. I disagree with those who suggest that QOF “makes us treat…..”; it does not, the only requirement is to consider appropriateness of a range of evidence based interventions. Unfortunately some of more recent QOF criteria have less of an evidence base; the national enhanced services can be insufficiently sensitive to local issues, and annual contract changes result in change fatigue, frustration and disengagement. These issues need to be worked on, but on the whole I feel the population of Dumfries and Galloway is provided with much more reliable monitoring and management of chronic disease than we managed 20 years ago.

In medical education changes have also resulted in difficulties and challenges. 20 years ago doctors in training applied for posts, joined a team, learned from their mentors (who knew them well by the end of their post), but could be exhausted after long hours on call, and might have no structure to their training; we have moved to a situation where EWTD limits the hours our trainees work, undoubtedly safer in terms of inadvertent errors; and trainees enter training programmes which aim to build competences required by a doctor at the end of training. The fragmentation of supervision required to meet EWTD rules makes it difficult for a supervisor to know his/her trainees’ strengths and weaknesses, so structured assessments are required. We are only just getting to grips with the assessments, and acknowledging that to do these well takes time and skill, but when done well can result in a comprehensive assessment, learning and development to ensure that our trained doctors of the future meet the needs of the population.

In summary my environment, our service, and our training has improved; but we need to go on working to make the most of our situations to ensure that identified priorities are addressed, and the needs of our patients and trainees are effectively met. However I can do that in a light airy, spacious, comfortable surgery; for the other half of my week I am grateful to Chris Isles for his help in ensuring that the developers understand the needs of OUR new education centre, so in 2017 I will feel comfortable in the new hospital.

Dr Jean Robson is a GP and Director of Medical Education NHS Dumfries and Galloway

Next weeks blog will be ‘Who is Molly Case?’ by Alice Wilson, Associate Director of Nursing, NHS Dumfries and Galloway