Life as a GP practice manager

[maz]

Fortunately as yet we are allowed to see any GP for non urgent appointments, if we can get an appointment that is. I don't even know who my named GP is. I only want to see my regular one. Well I have seen my named GP's name, but have forgotten . John feels just the same. Whenever we have to fill a form out, hospital, Dentist whatever, we always give this GP's name, not our named on(which we can't remember) . Unfortunately it seems the whole practice also likes to see this one GP, so prior to the virus you might have had to book your appointment 6 weeks out Who knows what it is going to be like when they get back up and running. I know seeing a regular GP doesn't mean they will remember us particularly, but it only takes a few minutes for them to know it was them who did treat us and understand what they did in the past and why. I don't trust that a new one will look at things the same way etc. Plus I might not just 'get on' with them.

I did have to deal with a new GP over the phone last month though. She sounded about 15 years old which didn't help my nerves which were already slightly shredded. She wasn't on our practice staff list so I guess she is/was a locum or maybe a new GP like you have just hired Jane. She seemed fine and dealt with me okay too. Maybe one of the staff GP's was off isolating or poorly. We always seem to have a locum working anyway though. Well a GP who isn't on the staff list that is.

So I completely understand your patients' concern about being moved like that. Particularly if they are in the older age range.

[Janey Dal]

Hi Marilyn and believe me so do we all, but we have to move some patients that’s the long and short of it.

And we can’t just give the young patients to the new GP because she would have an unbalanced list if we did. All we are asking is that they meet the new GP and if they still remain unhappy we will reconsider. The problem is that we have to be fair so if we move one then we have to move the others or not move any that request it.

Like I said as well,we have two GPs due to retire in the next couple of years so they will have to get a new GP then! I wouldn’t mind I get letters asking me to change their usual GP for lots of reasons, some sensible,some not! It just proves that you can’t please all of the people all of the time.

[maz]

I do understand Jane, just trying to be on the patients' side a bit. I just hate when things are taken out of our hands like this. But in the end, it is only a GP visit, why worry.

[Janey Dal]

And I appreciate that Marilyn! Believe me a get a very skewed view of patients in my job because the only ones I get to speak to are usually complaining or making a nuisance of themselves! I genuinely do find it helpful to hear the other side from nice genuine people!

As an example I had a phone call from a very annoyed patient who was complaining that the GP had told her she was pregnant via a telephone conversation and she wasn’t pregnant. I know very well that GPs would NEVER say that a patient was pregnant without a positive test. I listened to the phone call and indeed the patient had told the doctor that she was pregnant but the test was negative. The GP had said the patient certainly had classic pregnancy symptoms but that without a test nobody could say for sure. The doctor gave her medication for her constant nausea and asked her to do another pregnancy test and/or come back if the symptoms persisted. It transpired that the patient wanted a test done by the practice so she didn’t have to pay for it . She also wasn’t very bright but I probably didn’t need to add that bit!

And then unbelievably a patient came to our foyer and asked via the Receptionist via our intercom what the name of the pharmacy next door was. The pharmacy he could clearly see from where he was standing . There are some days....

We have also put bright red and yellow stickers on the floor (beautifully measured) which are completely ignored!

And one patient who was bringing her baby in for its immunisations who we nearly had a stand up fight with because she was refusing to wear a mask because she had asthma. Her records showed it was very mild asthma and equally we get them into the appointment and straight out within minutes. It is difficult because we cannot refuse to treat a patient but I need to protect the staff.

So yes! You can see that I need to hear the other side!

[maz]

So yes! You can see that I need to hear the other side!

I'll give you that one Jane

[Janey Dal]

So it’s all political at the moment. There are serious discussions going on at high level between the BMA (British Medical Association) and NHS England.

NHS England want us to start adhering to local and national income-generating contracts; the BMA say no way! These contracts require practices to hit certain targets in order to pull income into the practice. The contracts and targets are annual and start in April. So we have all lost the first three months of any potential achievements because we have been firefighting, obviously.

We are starting to see a few more patients face to face but nowhere near the numbers we did before. Partially because many patients are still very nervous of attending and also because the appointments slots are longer to allow a full clean of the surfaces between patients. Due to the nature of the virus we have to assume that every patient is potentially COVID positive.

Many of the income generating contracts are to monitor patients with long term conditions like diabetes or asthma and therefore require things like blood tests or blood pressure. This cannot be done via the phone obviously so the targets are totally unachievable this year. The NHS doesn’t appear to like to give money for nothing to GP practices which is interesting because they do it all the time for NHS corporate .

However, for your information, practices will continue to work to best clinical practice for the foreseeable future but most consultations will continue to be via phone. If you need to be seen face to face you will be and the GP or nurse will be in full PPE and also expect that you have a face covering, preferably your own, but if not the practice will provide one.

I cannot see this changing much until either there is a reliable vaccine or we start to understand the virus better and are able to contain it.

Preventative initiatives like smear tests, childhood immunisations and catch up immunisations (eg shingles and MMR for patients who have not completed the course) are at the forefront for next financial year. This, I suspect, to ensure that everybody is in the best possible health to endure what may be a long haul.

[Janey Dal]

And the constant joy of working to government guidelines continues......

Boris Johnson has announced that everybody who needs a flu jab this year will be able to get them early. Excellent! Except all the deliveries this year to GP practices and the pharmacies are later than normal . So we are already getting patients on the phone asking for a flu jab because Boris has said they can get them early.

We get our first delivery at the beginning of October so it’s going to be a long, long summer dealing with irritated patients . The uptake this year will be phenomenal due to COVID, but Public Health England have insisted they will encourage patients to get the flu jab but advise them that it won’t work for COVID. Sorry Public Health! With the patient demographic at my practice that simply won’t work.

I can envisage patients getting the flu jab, catching COVID and then threatening to sue the practice . And I'm not kidding!

And NHS England has also said that practices who offer minor surgery (skin tag removal, mole removal, small cyst removal, steroid joint injections etc) should start from 1st July to offer this service again .

A) they didn’t tell of this until 14th July
B) how can we justify offering appointments to patients for non urgent conditions when we are trying to avoid patient footfall into the practice?
C) for minor surgery it needs a GP, a Health Care Assistant and the patient in the same room for up to half an hour - that is not safe!
D) the jury is out on the risks for joint injections as they could potentially compromise a patient’s ability to deal with COVID if they catch it

We could of course refuse, but it generates extra income into the practice. Up until the end of June, NHSE paid us the same income for minor surgery as they did for the previous year at the same time because we obviously couldn’t offer the service and we rely on the income. So if we refuse we don’t earn the money. If we do it we are putting staff and patients at risk.

Oh yes! The lunatics are running the asylum as ever in the NHS.

[Janey Dal]

And the fun continues .......

I had to complete a survey for the CCG to advise how many COVID risk assessments had been offered to staff and how many had taken up the offer. We have to offer COVID risk assessments to all staff. They do not have to accept the offer. I advised that 100% of staff had been offered a risk assessment but only 24% had taken up the offer.

The CCG rang me to say that the figure for risk assessments should be 100%. I said no! 100% were offered but only 24% had accepted. They asked me if they could change the figure to 100%. I said no! If they are going to fudge the bloody figures why don’t they fill the survey in themselves? All for a tick in a governmental box. .

And we have mandated the wearing of masks in the surgery for all patients who visit. Oh dear! Some of them don’t like it! They all have conditions that preclude them from wearing masks apparently, but we are entitled to have our own policy that mandates wearing masks.

I had a row with a patient who was getting her bloods taken. She had COPD and ‘couldn’t wear a mask’. I said she couldn’t have the bloods taken at the surgery then. I offered to give her the blood forms so she could go to the hospital to have her bloods taken - where they would make her wear a mask! She gave in. She was only in for about 5 minutes and was fine. What really made my blood boil was that I could tell from her voice that she was a smoker so I had very little sympathy. She has COPD and continues to smoke but won’t wear a mask to protect other people?

Nobody likes wearing masks and I understand that. Our argument at the surgery is that if you have a condition (like severe asthma or severe COPD) that makes it difficult to wear a mask then you shouldn’t be out and about without a mask because you are at a higher risk level.

We get the (very few) patients who have to visit the surgery in and out very quickly to minimise contact. I also have a duty to protect the staff as well as the patients, so masks are mandatory.

And then in the middle of all this crisis I had a patient complain that she had had her bloods taken and the label had fallen off so she had been asked to come in and have them repeated. Apparently this was ‘scandalous’ and she wanted to take it further, “up to the highest authority”. The Phlebotomists are not employed by us anyway so she would have to complain to the hospital, but really? I understand it’s annoying but as she was retired and in good health, hardly the end of the world.

[maz]

Oh my goodness Jane, what you have to put up with. People make such a to do about wearing a mask ,even for a short period. Like you said, 5 minutes was all that woman needed to wear one for. Sigh...

[paul..m]

I see so many when I get a paper in mornings without a mask

[Janey Dal]

So this week has brought the excitement of the advent of flu season. This is always a big event in GP practices because there are so many patients who are in a risk group who are advised to have the flu jab. It is also a big income stream.

Last year was dire. We couldn’t give them away, nobody wanted them. This year we will be inundated. Not because they have any impact on COVID but because the patients think it will . However we have the added problem of not being able to allow huge numbers of patients into the practice all at once. So we have had to create a ‘patient flow’ by moving all the chairs around in one of the waiting rooms and sticking huge arrows on the floor. Only 3 patients in at a time, appointments only, no drop in. They’ll still ignore it .

To keep things safe and efficient will take 3 staff: 1 to administer the jab, the other to record it on the computer and the 3rd one to organise the patients. Normally only one nurse is required to administer the vaccine but that won’t work because we have to ensure that the length of time the nurse spends with the patient is minimal. So it will literally be that they present the arm to the nurse for jabbing and then leave. It’s taking a great deal of planning.

Meanwhile we are getting increasing complaints about patients having to wait for some time on the phone to get through to the practice to make a telephone appointment. We KNOW!

We have 14 lines into the surgery but at the moment we have up to 9 GPs ringing out so that takes up a huge number of lines. We are going to get a further 2 lines but that is at a cost of nearly £1,000.

One man complained that he’d been trying to get through for 3 months . I was so tempted to say “You must be better now then”. And another who was on the phone to the receptionist for 20 minutes complaining that he had had to wait 16 minutes to get through. And he wondered why? One patient insisted we should be quieter now that there was a pandemic.

I know it’s frustrating to have to wait so long, I know it is irritating. However we are in a bloody pandemic in case they hadn’t noticed.

[maz]

Our practice seems to have a different system every year, so it is going to be interesting this year.

[Janey Dal]

The trouble is that the government are making promises they can’t keep -no surprises there then!

They promised jabs for everybody in the 50–64 age group except they have no idea if there will be enough to do that. Guess who will get the flak if there aren’t enough jabs? We are reliant on the manufacturers who ask for us to order in January every year so they know how many to manufacturer. Well obviously that was before COVID wasn’t it? So unless the manufacturers get their fingers out and produce more there will be a shortage.

So the delight this week of a patient who came into our Reception and said she had an appointment. The Receptionist asked her name and couldn’t find her on the computer. She then asked for her date of birth in case she had a strange spelling of her name and of course those masks make it difficult to hear. No record of her at all.

“Are you registered here?” Asked the Receptionist

“No” said the patient “I’m registered at the practice next door but their door is shut”. There are no words!

And another joyful patient: He was having dressings put on his leg ulcers 3 times per week. They are so complex it takes a half an hour appointment and 2 nurses. They are as a direct result of his drug habit and general chaotic lifestyle. He is 45. His mother has been on the phone to complain we are not looking after him.

He has missed the last 6 of his appointments thereby costing the surgery for 6 hours of nurse time and 6 hours of appointments that could have been used for someone else. He then had the temerity to ring 111 and when they sent out the paramedics he told them that he was having regular dressings on his legs so the paramedics rang one of our nurse practitioners to tell her off for the state of his legs .

He then didn’t attend his next appointment made for him by the paramedics. He has been removed from the list. Goodness’ knows how much he has cost the practice but he obviously has no conscience.

Grrrr!

[Janey Dal]

A full moon this week! And I kid you not. It definitely makes a difference to patients' behaviour.

I have spent the whole week having arguments with patients who 'can't' wear a face mask. They all apparently have COPD! I suspect if I asked them what COPD was they wouldn't have a clue .

I actually had a stand up row with a patient in the waiting room . She needed her ear swabbing because she had repeated ear infections which antibiotics weren't touching. She was asked over the phone to come down for an ear swab but told that she had to wear a mask. She refused and demanded to speak to me. I told her in no uncertain terms that she could not have a procedure that had her and the nurse practitioner in such close facial proximity without wearing a mask. She told me that that was 'bullshit' and put the phone down on me.

She still turned up wearing a visor (not sufficient protection for an ENT procedure as per national guidance) and refused to wear a mask. I said I would compromise with her: she could go into the nurse's room, put the mask on, the nurse would come in and do the swab and leave. She could then take the mask off and leave the surgery. Well apparently I was refusing her treatment and she left saying she would take it further . She had no medical conditions that precluded her from wearing a mask but apparently she got so anxious she would 'fall over' .

The whole thing is a minefield! We accept that there are some people where wearing a mask would be very distressing (patients with autism for example) and we try to be as fair as we can. Sadly there are some who just think it's 'clever' to be different and want to make a point.

Apart from the example above, all the other patients have accepted the rules (somewhat reluctantly), worn the mask and do you know what? Had no problems doing so!

I have a duty of care for the staff as well as the patients. The nurse who was seeing the really difficult patient has asthma and could easily refuse to see patients face to face at all. She has chosen to see patients at risk to herself, but we need to ensure she is safe.

Hopefully with the full moon gone, next week will be quieter .

[maz]

Hopefully with the full moon gone, next week will be quieter .

Ever hopeful Jane