Life as a GP practice manager

[refandy]

Hi Jane

I've got to pick you up on one point, specifically

We are not a hotel! We cannot say "and what time and day would you like your appointment?". If you need to see a doctor then you will find the time to do so. It may not be convenient but if you are ill then you make it. This may sound harsh but honestly the number of patients who are offered appointments and say they can't make that one. We offer up to three and if they have refused three then tough.

First, let me say I understand where you are coming from but there has to be a degree of flexibility.

This attitude does not reflect how the world works now. As someone who does not work close to the surgery, being offered appointments at 11am or 2.30pm means at least a half day off work for what could be a 5 minute conversation. As you say, ok if you are 'ill ill' and not able to go into work but not if you are just 'ill' or need to talk things through with the GP? How about something which could be nothing if seen and dealt with early but becomes serious if left untreated all because the surgery does not have any flexibility around appointments? What if it is someone suffering mentally and the one and only time they build up the courage to phone and book an appointment with their GP they are offered unsuitable appointments - they may never phone again.

I'm having building work done at the moment and one of the builders has been complaining of a problem for ages but hasn't seen his GP because he cannot get an appointment at a time that suits him. He cannot afford to miss half a day or days work because he needs the money and fears being sacked if he takes the time off. It could be nothing but it could be something serious developing.

My old surgery had commuter clinics where they would fill appointment backwards from 8am to 7am. Early enough to see the GP and then get into work on time. My current one doesn't. My old surgery offered telephone appointments for those occasions , my current one doesn't.

It's about being reasonable and flexible - on both sides.

Andy

[maz]

That's a good point Andy.

[Janey Dal]

And I agree Andy!

I have to say that I am talking about the extremes here. The vast majority of patients are brilliant and we accommodate them easily. There are certain ones who really think they can book an appointment more or less when they want eg they ring up and want an appointment at 20 past 4 because they are going to the hairdressers and then to pick the kids up from school. Or they are going on holiday the next day and have forgotten to order extra medication so need to be seen immediately. They are the ones to whom I am referring.

We do offer a great deal of flexibility in our appointment system including telephone appointments in the morning with free slots for the GP to book a patient in at the end of the morning if, following the telephone consultation, the GP need to actually see and examine the patient.

We offer late nights, same day urgent and routine appointments up to 2 weeks in advance as well as telephone appointments. Patients can book appointments on-line. It is as flexible as we can make it. Sadly there are always the ones for whom it isn't flexible enough.

If your builder rang our surgery we would fit him in. He may have to wait up to a week for an appointment but we would accommodate him because we have appointments available after 6.30 every day.

We never, ever refuse to see a child who is ill, no matter whether there are appointments or not. We also run a Pool which means that even if all the appointments are filled, we will still see patients who ring up with a genuinely urgent complaint the same day.

We also have embargoed appointments that are released every day so that if you phone up one day and there are no suitable appointments, you can phone again the next day and some more have been released. So genuinely we do our very best to accommodate patients but even with all that on offer some patients are not happy.

Sadly as ever some patients abuse the system. We had the mum of a 18 month old child who booked an urgent same day appointment for her child who she thought was not walking or talking as she should be. This is NOT an urgent same day appointment. Of course we have every sympathy with her concerns, but it would have waited a few days for a routine appointment.

The frustration is that if patients abuse the system like this, there are fewer appointments for patients who really do need to see the doctor that day.

I hope that reassures you that there really is as much flexibility in the system as it is possible to make, but nevertheless some patients don't give a flying doo-dah about anybody else, they just want to be seen when it suits them.

[refandy]

I'm reassured !

[Janey Dal]

Good!

An interesting week this week having had a Windows 10 upgrade on all our pcs. This has caused various problems as I'm sure you can imagine. Often you don't realise a certain piece of software isn't working since the upgrade until you need it, and that may be at a critical time.

We have had real problems with the nurses' computers because they use a lot of third party software for spirometry, ECGs, blood pressure etc. The software was was working in some rooms and not in others, different nurses had different bits of software working or not and the poor nurses spent the week dashing in and out of each others' rooms with patients. IT kept 'fixing' it remotely only for it to crash again.

On Friday I had had enough and escalated the problem to the project manager saying I wanted an engineer out on-site to sort out ALL the problems at once.

"I haven't got an engineer I can send" he said via email

"Well I suggest you find one" I said

"I realise" he said "that it isn't ideal but I have added it to my learning log for my next project"

"I am absolutely delighted for you that you have added it to your learning log" I replied "however, with the greatest of respect that doesn't help my situation does it? Do you suggest I advise the nurses and the patients of your professional progress when they complain that they are running late and all the patients are complaining?".

They are sending an IT engineer out on Monday . This is probably just as well because my next step was to escalate it as a complaint.

The Nurse Manager has been given strict instructions that the IT engineer does not leave the premises until all the software is working.

[maz]

Jane gets things done! Every business needs a Jane.

[Janey Dal]

Only because I'm a stroppy mare!

I still cannot get over the fact that the eejit project manager thought I would be assuaged with his telling me of his learning curve .

Sometimes words fail even me .

[Janey Dal]

Yesterday I got an instant computer message from our pharmacist who had an appointment with a female patient to discuss her medication. The patient's husband had turned up in her stead and there were Safeguarding markers all over his record saying he was violent, and he was sitting in a room on his own with a female member of staff!

So I ran to her room and knocked on the door and opened it. Normally you would never interrupt a consultation but this was potentially serious. I said to her "Sorry to interrupt but I need to speak to you!".

She came out of the consultation and we had a quick catch up in the corridor. She was really concerned about sitting in with him so I advised her to say to the patient that she had an emergency situation and had to leave. I waited outside the consultation room just in case and he did leave although wasn't particularly happy about it.

My rationale was that as he had turned up instead of his wife the pharmacist could not discuss his wife's medication with him without her permission so having the consultation cancelled was not detrimental to anyone.

But such is the decision-making required at times. It transpired that he was only violent to his wife (oh that's okay then ) and not a danger to anyone else, but nevertheless I have a duty to ensure the staff are safe at all times.

I rang him later to explain that he couldn't turn up to discuss his wife's medication without her permission and he was in a right strop with me. Hey ho!

[Janey Dal]

So a few days off still doesn't bring a proper break! I am a member of a local Practice Managers' WhatsApp group and messages keep coming in whilst I'm off .

The decision to create a WhatsApp group came about as a direct result of the cyber attack a couple of years ago. The attack had started on the Friday and we all assumed it would be dealt with over the weekend. However IT had realised that it was extremely severe and had tried to get the practices to go in on the Sunday and switch on all the pcs so they could do some remedial work remotely. They emailed all the practice managers and of course most of them didn't read their emails over the weekend so didn't realise.

I was lucky that my senior partner had found out via a fairly circuitous route and texted me to ask me if I would go in and switch all the pcs on, which I did on the Sunday. So that's the reason for the WhatsApp group which has proven very useful.

We are now using it to remind each other when to submit various mandated statistical returns for NHS England. These are in huge numbers and on random dates but are also part of the contract with NHS England so we could be penalised if we don't submit them.

There are seriously about 40 of these returns that have be done either monthly, quarterly, 6 monthly or annually. You really get confused with them all because from our perspective they are meaningless eg how many of our staff have had a flu jab and what is their job? I mean really? Who cares? We are obliged contractually to offer staff the flu jab at work and they are entitled to refuse. So what are the NHS proving from this information?

[maz]

Well there was a senior manager who came up with the idea, a few under managers who had to work out how to implement it, further larger numbers of assistant under managers tasked with area responsibilities, many general admin workers putting it into place, then the various practice managers having to fill in the forms! Finally, all the IT guys and gals who then have to sort the computer problems out from over use!

[Janey Dal]

Indeed Marilyn.

So this week a lovely patient rang and asked for more Diazepam. Nope! Not happening! He was already on copious amounts of strong meds, had opening admitted to buying prescription drugs on the street and had agreed with his GP to embark on a reducing regime.

We then got a phone call from the hospital saying he'd been on to them asking how he could get his GP practice to give him the meds. They advised it was nothing to do with them so the patient said that he was going to go down to the practice and beat "every f***** up". The hospital rang to warn us.

Sadly although this was a threat it was via a 3rd party so I couldn't justify removing him from the list with immediate effect. I was a bit frustrated.

And then - oh the joy! He rang me to complain.

He was barely coherent when I spoke to him - either drugs or alcohol. I told him I couldn't understand what he was saying properly so he slurred that he would put his step dad on the phone. Oh good! I thought, someone who is sensible.

Step dad "He just wants his f****** Diazepam" were his first words .

I was so tempted to say "Well he can't f****** have it!" but I must be professional .

The patient came back on the phone and started shouting and swearing and then he threatened to come down to the surgery and bludgeon us all to death .

"And you know what I'm going to do Mr Doodah?"

"What are you gonna do, you cow?"

Me in my sweetest voice: "I'm going to put the phone down, ring the police to get an incident number and have you removed from the practice with immediate effect. Goodbye!"

What a prat! He didn't come down to the surgery he was all mouth, but that mouth got him assigned to the Special Allocation Scheme for violent patients.

[Janey Dal]

So this week the subject of wasted appointments!

One patient made an appointment with the nurse practitioner because she had over-bleached her hair and it was snapping off .

"You need to go to the hairdressers!" advised the nurse with some disbelief.

"I did but they can't help me!" protested the weeping girl .

We've had a patient turn up to see the nurse with a blister on her toe and one with a rash that had gone by the time she got to surgery but still expected the nurse to diagnose her. Another patient this week booked a telephone appointment because he thought he had a chest infection and somehow thought the doctor could diagnose this over the phone. And another who had just registered with the practice and explained he 'just wanted to pop in and meet his doctor'. He didn't have anything wrong with him .

A patient rang for an urgent same day appointment because she had got up that morning and could smell sausages even though nobody was cooking them in the house. The Receptionist persuaded her that a doctor's appointment was not going to help her.

Another patient's daughter phoned to request a home visit for her mum. However the daughter said mum would only let Dr Brown in the house and nobody else. The receptionist advised that this would be impossible because Dr Brown wasn't in surgery that day. "Well can I just tell her it's Dr Brown and then we'll see what happens if somebody else turns up, she might not let them in mind!"

Obviously we are happy to send a doctor out to see a patient on the off chance they may be allowed inside the house . As the complaint was just for an abscess on her arm we suggested a District Nurse. "Well that would be okay but it will have to be Debbie. She won't let anybody else in!"

There are days when you really are lost for words .

And on the other side a lady turned up for her flu jab and was so acutely unwell we had to phone an ambulance to get her admitted to hospital and on the way out the surgery, being wheeled by the paramedics, wanted to know if she could still have her flu jab.

There's never a dull moment and never a day when I don't wonder at what goes on in people's heads. And these people have the vote .

[MikeyB]

Interesting to hear the receptionist response to the patient with phantosmia (smelling things that aren’t there). Possible causes: sinus infection, nasal polyps, a precursor to migraine attacks and epileptic fits, and many other causes, including (very rarely) brain tumours. All are treated by doctors, not receptionists. Of course, there is always the “no cause identified” group, but that is a medical decision.

Just saying.

[Janey Dal]

I know Mike and indeed it was run past the doctors prior to the Receptionist dissuading her from the appointment. We do run a safe practice I promise you .

So this week we have had a family of patients who have come to my attention. A few months ago they were attended en masse because their dog had died and they were frightened that they would die of whatever the dog had died of. Despite the fact that they had no symptoms at all and whatever the dog had died of was not something that transmits to humans.

This week they are convinced that their tap water is contaminated (they live in the middle of an estate) and had already asked the water authorities to come out to test it which they did. Nothing sinister was found and again they have no symptoms of anything, they are perfectly healthy.

Regardless of this they have sent the analysis of the water and asked the GP to look at it . So GPs need to be experts on tap water samples now?

When I looked back at the father's record he recently attended A&E with a splinter in his finger . Sounds like a family of hypochondriacs to me!

And yes we laugh but these people are costing the health service a lot of money because of their attitude to their health.

We cannot easily say no to them having appointments because there may be 'something' they aren't telling us over the phone when booking the appointment but really?

[maz]

Just been away for a couple of weeks, so it is great to come back to some GP surgery funnies, thank you Jane. But, goodness me you do have some trying patients. I really don't know the answer to some of these people.