Steady as she goes...

Its been nearly five months since the launch of the access component of our New Model of General Practice. In that time we have learned a great deal about some of the theories and practicalities involved in meeting population needs for primary care. Heres a quick dissection of the learning so far on one theory. 

• Theory One.
  Stream work to ensure that productivity remains high. This concept involves separation of acute and routine work so clinicians remain in one mode of operation nd improve efficiency. 
• Learning Point
  Streaming work by clinicians reduces access to routine appointments and can stretch individuals performance to concerning levels. e.g. we learned that after 24 phone consultations we stopped making good decisions in terms of when to see or not see patients. 
• Answer one
  Limit number of phone calls per session to a safe, comfortable sixteen. Encourage clinicians to be aware of their own decision making processes. "Mindful consultations".

Its been a while.

If you have followed the various trains of thought on my blog you will know that I'm looking to make a difference to the care of patients in the system we call the NHS. 

I've not given up looking, but now the time has come to make some changes. 

My practice has embarked on a new model of general practice. We had to, we had no choice. General Practice UK has been a model which was once everything that was required by the population. Free access to a resource that was valued by the population and used only when needed. 

Although the NHS is valued as a brand, years of prodding and media bait have reduced value in General Practice to a position of under investment and increasing demand. Average yearly consultation rates have gone from 2.5 to 6 per annum and money has decreased. 

Our partnership has a big ambition, to generate the value and ownership required from the local population in a way that means the relationship shifts from a professional/ customer relationship to a partnership of care. 

Now, I know that such is the way of the NHS that multiple colleagues will now say "but we always engage our patients in decisions"  and "we've been doing it for years" and they may be right, in their own way but our system is changing in ways which are unique to us. 

Inside out, outside in.

Organisational structures are a major barrier to good care.

This is the premise behind integrated care. The organisations do not have to merge or cease to exist, but simply to recognise the barrier exists and deal with the problem.

Simply re defining discharges as transfers to primary care will change attitudes about how a "transfer" to primary care is performed.

However beneath this simplicity lies a complex issue, the knowledge and relationship of the competencies possessed by each of the parties is on both sides limited.

GPs who used to work in hospitals will remember how it used to be, Consultants who have never worked in primary care will imagine the jungle, the savages, the fear that returning the patient to the wild will see it lost forever.

How then to make visible those who provide safe passage and care through the jungle of primary care and the urban landscape of secondary care.

Choose and Book did much to separate individuals from communicating directly. Perhaps now is the time to pervert the Choose and Book directory of services into the tool to put those networked around the patient into a system which allows all participants to recognise each other and communicate.

Do the basics

If you've checked out my linkspage you will know I'm a fan of TED.com, recently listening to a talk by Abraham Verghese on the importance of touch as examination, ritual and therapy I was reminded of another passion of mine which has consumed weekends in the last month- rugby.

The good Doctors call to arms was to treat patients well, to treat them as people, to use touch rather than data as the means to interface with a patient. He gave the case of a woman with breast cancer who had four opportunities go by before someone took the opportunity to do a physical exam and found the tumours.

What has this to do with Rugby?

Well, the English team has left the world cup, only Wales remains of the home nations. How can this be? What was their secret?

In both diagnosis and sport there are certain set pieces, certain formalities which comprise the basis, the essentials of the craft. For both Dr verghese and Wales the secret of success is simple:

Do the basics well

If the basics are all present be it , kick off, line out, ruck, scrum or, introduction, history, examination, explanation and treatment then what follows will be a firm foundation for a successful performance.

It's not a rocket science insight, but given the plethora of discharge letters without a given diagnosis, or the patients perception that they were told nothing about their diagnosis perhaps is is time to make sure we do simply "get the basics right"

Irreconcilable Differences?

Writing in his book Blink, Malcolm Gladwell tells the story of a marriage guidance counsellor who is able to predict success or failure of a couple after only a few minutes of interview time. The key he believes is contempt, if couples show contempt then all is lost, the relationship is doomed.

This week I have been speaking to people in primary care and secondary care.

In truth there were times when it did feel like being a marriage guidance counsellor.

All the red flags for relationship arguments were being waved in to the debate. The sin of absolute generalisation-"You always (then insert the apparent sin) in primary/secondary care" - really?- We always send out letters late? We always fail to refer appropriately? The sin of dragging in the in-laws "social care doesn't do its job and that's your responsibility to commission" is guaranteed to raise hackles.

Once absolute generalisation is used it tends to suggest that a fight is on the cards and that ignorance of each others feelings and functions is the underlying cause.

The main tragedy this week is that there is starting be be a little hint of contempt. "I never take my child to the GP he's rubbish- I don't know why any parent would."

Really? All GPs are rubbish?

Perhaps we should take a leaf out of the marriage guidance book and concentrate of creating a conversation in every health community which might just avert contempt, otherwise we will really find Irreconcilable Differences

Shift your paradigm please, I'm trying to get home.

What would happen if we discharged people from primary care to hospital and readmitted them back to primary care?
Just take a moment to consider what that simple shift in thinking would mean.
Yes the discharging practitioner would need to prepare the patient for their brief exit from the wrap around support of primary care, but also it would not be possible for patients to slip out of primary care and in to the hospital without it being sanctioned by a primary care physician.
Similarly on readmission to primary care the appropriate information would need to flow but the decision about readmission to primary care would again be controlled by the primary care physician.
I know some of us will argue that that's how it already is- but ask yourself honestly- do primary care physicians get consulted or have knowledge a priori of admission?
What would happen if we worked like this? I suspect reassurance that Mabel is always like that, and "yes, I'll see her in the morning" might, in many cases, prevent Mabel entering the hospital walls.

In a similar way when it came to the return of Mabel to primary care, her re-admission as it were, the checks on availability of a primary care bed, the required systems, and of course the information, would ensure that Mabel was not admitted to primary care unnecessarily and that since her readmission would be the default, the Hospital would need to find daily justification to keep the patient.

Perhaps Primary care physicians would like to consider doing the ward rounds in the hospital in order to decide who must stay behind in secondary care and who can leave to be readmitted into primary care.

If we all adopted this simple mind shift I'm sure less people would end up in hospital, they would spend less time in hospital and ultimately remain longer where they wish to be- at home in primary care

What kind of bike do you ride?

Do you ride a bike? What kind of cyclist are you? If you ride a bike you know what I mean, generally there are two tribes, the roadies and the MTBers. Although the are different demographic features of the two groups, certainly different appearances and features in the various bits of mechanics they employ in their leisure pursuits, I would like to suggest that there is a more fundamental difference in the way you think in the two pursuits. As a Roadie the Tarmac is endless, your body settles in to the rhythm, the pace line, the drafting and, odd pot hole aside, the Zen. The mental quiet, conversation and interaction in the group is the reward and in many cases reason to be a roadie.

MTBers on the other hand are always physically interacting with the bike, the terrain, the changing challenge, conversation is impossible especially on the "gnarly bits". The impact is that MTBers focus on the here and now, no chance to think beyond the next rock, dip or bend.

Neither group is superior to the other, no one is wrong or right. They are just very different in how the same activity is performed and the thought processes which the activity requires and generates in it's performance.

Medicine is like that, we have at the moment two tribes, the generalists and the specialists, each performing and to a certain extent thinking in different ways. 

Neither is "better" than the other and both are required to deliver a functional healthcare system. 

My issue at point is that there are a group of cyclists who are happy to wear Lycra, ride the road, accept the zen of the racing bike on a Sunday morning. Those same cyclists will have been out on the Saturday morning attacking the trails, making the jumps and wearing the baggy shorts of the MTBers. 

Where are those who straddle both primary and secondary care? The GPWSI is one breed, but the Consultant with interest in primary care is not yet on the map.

Should it be? Isn't there a piece missing from the landscape? Perhaps consultants in intermediate care are the closest we have at present but their value needs to be recognised and we all need to recognise the beauty inherent in each others craft. 

Trust me I'm a Doctor!

A key part of being a leader is to be trusted by those we lead. many of us think that trust is something which has to be earned, takes time and either happens or not. 

Oddly enough I used to think that until I came across an article in Harvard Business Review which outlines the factors on which trust can be built. Of the ten or so listed there are three which are entirely dependant on the individual who needs to develop trust in someone else. The remaining factors are all able to be influenced by the person who wants to be trusted. 

These factors include obvious features such as consistency of action, perceived risk, having similar goals and ambitions, as well as some less obvious factors. If someone asks you to trust them you need to know they actually care about you, not in a romantic way but in a benevolent way, considering your interests as pat of their value set. 

Our emerging clinical leaders in primary care will need followers who trust them to lead. These leaders need to be able to communicate, be predictable, be capable, care for their colleagues, be transparent in their goals and strategy and build on the common agenda of all clinicians. 

There is obviously a significant trust gap within primary care, small practices, GP providers and self aggrandising leaders will all contribute to the trust gap. However that gap is nothing in comparison to the gap in trust between secondary and primary care.