General practitioner

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Sock marks and suspected sickies

Research shows that many GPs find their workload unmanageable, with inappropriate referrals from other agencies and patients attending for trivial reasons. Caroline Winter-Jones reports

'Doctor, my six-year-old is peeing a lot. I’m giving him four times the recommended dose of a supplement I got on the internet — it has frequent peeing listed as a side-effect — do you think I should stop it?’

These few lines amount to one of the biggest challenges facing general practice today — what is a GP really for?

This is just one example sent to us in response to a BMA News request to GPs.

It is to the ‘free-at-the-point-of-abuse’ family doctor that every paranoid parent, downtrodden worker and stretched social agency seems to turn.


'Risk sink'

‘People’s expectations are continually raised by the politicians about what the NHS is for and there seems to be no appetite to discuss what the NHS shouldn’t be for,’ says Sussex GP Russell Brown, founder of Resilient GP, a 3,500-strong Facebook group of like-minded practitioners.

General practice, says Dr Brown, is the ‘risk sink’ of the NHS: ‘For example, an old lady has fallen over at home. Paramedics have visited and got her back up.

'[There are] no obvious injuries, so they can’t see any reason to take her to hospital, but they phone us and say “GP to check”.

‘Well, she’s either injured or she isn’t. If she isn’t, she doesn’t need me and if she is, she doesn’t need me because she needs to go to hospital.’

Other agencies are equally guilty, Dr Brown adds: ‘Housing issues almost never have anything to do with the GP, but we often get someone asking for a letter to get them a larger flat, or their flat’s damp, or they want to move somewhere else because they are asthmatic.

‘If I write a letter, it will get filed in the notes by the housing association and they won’t take any notice of it. But patients are told by somebody in the office they need a letter from their doctor — I suspect it is to get them out the way.’


Persistent culprits

Big employers are persistent culprits too, asking their workers to get forms signed confirming fitness to work, a requirement that was stopped several years ago.

Gill Beck, a GP principal for 30 years who now works as a locum, describes the issue: ‘A generally fit 30-something who had strained a calf muscle presented me with a note from his employers demanding I assess his fitness to undertake his job delivering supermarket orders.

'He had felt back to normal and returned to work himself, but was not allowed to work by the company until the GP had completed this occupational health assessment.

‘It took 15 minutes to explain to the patient that the NHS does not provide an occupational health service for companies.

'I wrote to the company explaining the rules. They sent a further two employees to the same practice in the next two weeks trying the same thing.’


Quirks and qualms

A snapshot survey carried out among its members by Resilient GP in March this year uncovered 200 examples of inappropriate consultations, ranging from rashes that turn out to be sock marks and blue tongues caused by cheap sweets, to parachute jump sign-off forms and sick notes to cover holidays, to prescription requests for pet guinea pigs.

It says a lot about the precious relationship between GP and patient that they will bring every quirk and qualm to this trusted figure’s door. Raising the issue of wasting limited appointment time, however, leaves many GPs feeling uneasy.

Making a mockery of patients, not keeping confidentiality and breaking the contract that says a GP will see all who are ill or perceive themselves to be ill are some of the concerns GPs share about tackling inappropriate consultations.

‘There is a cohort of GPs who think we should be anything and everything for our patients,’ says Dr Brown, who is also a member of the BMA GPs committee and chair of East Sussex LMC.

‘I have some sympathy with that view, but if we say no to the things we don’t need to do, it means we are more likely to be there and not be burnt out for the people who do need us,’ he adds.


Generation game

Educating the public on this is not straightforward; there is the risk of the wrong people getting the wrong message.

The (often) younger generation, who have a tendency to over-consult, will only hear ‘go and see your GP if you are worried’ even when they only have a cold. And the (often) older generation, who tend to under-consult, will not want to bother their family doctor.

Toni Hazell, a salaried GP in north London, describes an episode she remembers from her experience in an emergency department: ‘We had someone come in by ambulance with a trivial cut finger while an hour later an old woman who was having a heart attack struggled in on the bus.’

Hospital colleagues can contribute to the problem, says Dr Hazell, but she has a way to deal with it: ‘I always bounce it back. It is inappropriate for us to be asked to chase up the results of a test requested in secondary care.

'So when I get a discharge summary saying “GP to kindly chase cultures”, I email the consultant and say we haven’t got the resources to do that — 100 per cent of the time I get an apologetic email back.’


TImely triage

Dr Hazell’s practice, in a deprived area of Tottenham, has introduced telephone triage to counter the unsustainable demands.

She describes how it works: ‘When I get in in the morning, I have almost no patients booked and I have a list of telephone calls.

'The only things we book in advance are things like coil and implant fittings, postnatal appointments and exceptions such as deaf patients who can’t phone.

‘Patients speak to a receptionist, who asks what the problem is. Most are happy to give a bit of an idea. Less than 5 per cent will just say personal. Either we phone back or they get put straight through.’

'Social matters are diverted to the correct agencies or tests are ordered so the patient can have an appointment when the results are in.

'People with toothache are sent to the dentist.'


Improved access

Dr Hazell says the system has hugely improved their access and is beginning to go down better with the patients.

‘It’s really nice when someone rings up and it is clear they need to be seen, and you say, "How about 11 o’clock?" Then there is a stunned silence and they go, “What, today?”’

It also stops people booking an appointment on the first day of their child’s illness ‘just in case’ they don’t get better in a few days.

When patients know they can get a same-day appointment, they are more prepared to wait and see.

In East Sussex, where they are three whole-time equivalent GPs for a growing practice of 6,800 patients, Dr Brown has worked with his CCG (clinical commissioning group) to take on a common sick note (or, as they are now called, fit note) issue: ‘If a woman has had a hysterectomy and is expected to be off for six weeks, historically the hospital would have given them two weeks and said "go and see your GP", which is nonsense because if she is going to need six weeks, give her a fit note for six weeks.

‘I began writing to the consultant every single time and encouraged other colleagues locally to write every single time.

'I wrote a presentation that was designed to educate hospital doctors and emailed it to several departments. Now it is uncommon for fit notes after surgery to be done by me.

‘There is a better understanding among the consultant body, which filters down every six months when the juniors change. This has saved me between four and six appointments a week.’

If any requests trickle through, Dr Brown refers them to PALS (patient advisory liaison service), which sorts it out between the patient and the hospital.


Useful advice

The GPC has done a lot of work to help GPs deal with ill-advised requests without feeling they are leaving patients and colleagues short. Quality First: Managing Workload to Deliver Safe Patient Care, published by the GPC in January 2015, sets out guidance.

Part 1 is dedicated to inappropriate demand and lists examples where GPs should just say no. It advises GPs to contact the source of the referral and request that their CCG addresses the issues. Additionally — and crucially — it also provides template information leaflets and letters to make this process easier.

With the BMA Future of General Practice survey of 15,000 GPs finding in February this year that 93 per cent of GPs say their heavy workload has had a negative impact on the quality of patient services, there is a feeling in general practice that something has to give.

GPC deputy chair Richard Vautrey underlines the work the BMA has been doing to support GPs.

He says: ’We have recently been encouraging NHS England to implement proposals to stop hospitals unnecessarily referring patients back to their GP when they could sort the problem out directly with the patient themselves.’

NHS England acknowledged the problems in its 2014 strategy paper Five Year Forward View and proposed ways of relieving pressure on GPs by encouraging patients to see other appropriate professionals such as pharmacists.

It has even nominally thrown some money at the situation with many of the Five Year Forward View’s first- and second-wave schemes set up under the prime minister’s GP Access Fund addressing demand issues in direct and indirect ways.

Whereas decades ago the population might have relied on their extended family to reassure them about some of their minor health woes and worries, nowadays, with the mantra of seven-day services repeated by the Government, it is difficult to fight the tide.

Dr Hazell sums it up: ‘Patients need to understand that while they have rights, they have responsibilities as well.

'At the moment, it very much feels that GPs have all the responsibilities and none of the rights, and patients have all the rights and none of the responsibilities.’

Which takes us back to the heart of the matter — the one-to-one consultation in which confidences are created and maladies ministered to.

It is there that patients can be taught, little by little, to care for their NHS and not take for granted their beleaguered GP.

Read Quality First: Managing Workload to Deliver Safe Patient Care

Find out more about Resilient GP



The story so far