In our 105th edition, Sara concludes her article on a fresh pair of eyes; Judith would rather we didn't eat each other; Rachel has some news on medical indemnity; Liz answers your Type-2 queries; Eva and Nicky have both explored specialties outside of primary care that have enhanced their enjoyment of general practice; Kate wants us to get physical, and Louise has summarised Nice's latest on ureteric and renal stones.
The Sessional GP
Supporting sessional GPs to improve patient care
image © Claire de Mortimer
February 2019
The power of a fresh pair of eyes
Following on from her previous article Dis-continuity; putting care into context, Dr Sara Chambers explores the idea that sometimes continuity of care is deployed to paper over the cracks where 'continuity of management' and 'information' is lacking or even absent, and why the locum's perspective needs to be part of a future solution. None of the value that I believe locums can bring detracts from the evidence that continuity of relationship is a vital tool in the armoury of general practice. Indeed, for some patients it will be the most important factor in their care. But it is not the only tool, and it favours no-one to over-emphasise relationship continuity as the key aspiration in general practice to the neglect of other factors, most importantly the systems that ensure continuity of management and information, which are the true backbone of good care for all patients, including the many who see different GPs. And again, the experience of locums “being a fresh pair of eyes” has something to teach us about how we can improve our systems to ensure that all patients get the continuity they need. Too often, as a locum, I see evidence of a dysfunctional over-reliance on relationship continuity, which is then used to paper over serious cracks in a system that lacks continuity of management and information, so that a patient’s management and safety becomes dependent on the cognitive energy and memory of a GP. Since most GPs are diligent and competent, this can work adequately most of the time. But as Lucian Leape, the pioneer in patient safety identified in his 1999 landmark report, most errors in healthcare arise from faulty systems, and this places immense individual responsibility and demand on GPs who are often blind to the fact that they are overloaded and propping up a weak system. Locum GPs, being outsiders, a “fresh pair of eyes”, and often working when the ‘lynchpin’ GPs are away, are ideally placed and experienced at identifying these weak systems of management and informational continuity. From my own experience, these weaknesses include unclear channels of communication and responsibility for care within a practice, inadequate medical records which do not capture the nuances or soft information about patients, and bewildering variations and lack of clarity in referral procedures, result handling procedures and repeat prescribing systems. Sadly, at the moment, instead of tapping into this unique perspective of locums, a common response to a lapse in care involving a locum is to personalise blame, rather than questioning the system that contributed to the error, feeding into the narrative that continuity and quality of care is disproportionately based around individual practitioners. A rewarding area of work would be to foster a positive and open-learning, Black Box thinking culture, and build mechanisms for allowing feedback from locums on these weaknesses. Let’s move the narrative away from only focusing on the performance of individual GPs, and instead use this expertise to build systems that support all doctors to work at their best and enable every GP consultation to be as effective as possible: a system that is so reliable and transparent that if disaster struck, a team of locum staff could step in and safely hold the fort. Not ideal, and in no way a desirable replacement in the long term for those patients that need relationship continuity, but a backstop of safety for the majority and a good way of conceptualising what a safe system should look like. Such a robust, reliable system would also bring day-to-day benefits of supporting practices in providing core general practice, making them safer and more efficient for their own staff and GPs, but also helping them attract GP locums to aid them in this, or even recruit for permanent posts. Practices now face competition from the various flavours of local overflow demand management clinics, as GP locums are starting to report that they are being attracted away from core general practice to work instead in from the various locality centres offering extended access e.g. MIAMI, overflow hub clinics or urgent care centres. Even when earning less and often working at unsociable times, many locums nonetheless prefer this work because they feel better supported by working within a more standardised system where they are part of a team, getting support from their colleagues as needed. In comparison, it just feels too unsafe and difficult to face the numerous obstacles that arise in working in practices who can vary enormously in their processes and level of induction and engagement and support. Systems to improve engagement between GP locums and practices could attract more GP cover back into providing core general practice. There are many marginal gains that could be made by implementing standardised induction procedures for all new and visiting staff in practices, and improved consulting room level information management. I can state from my personal experience as a locum that a welcome induction tour, a concise locum induction pack and a point of contact during a locum session can bring unstinting loyalty and goodwill from a locum towards a practice. And this key area is why NASGP has worked so hard to develop LocumDeck and Spip as tools to promote this co-operative working between locums and practices in all their great variety. So what’s the real, perhaps more difficult, answer to my original questioner on how often as a locum I found a fresh pair of eyes to be valuable? Well, I am now middle-aged; I have twins who are now young adults, and ageing parents. I want them to have safe, timely access to GPs who are equipped and supported by a reliable system that allows them to work seamlessly in a practice, understanding how it works and how it interacts with other vital services, so the GP is freed to concentrate on the most important job in the NHS; being a GP, focusing on the patient’s problems and building a therapeutic relationship, however brief that might be. And for my parent’s generation, or any patient with complexity or long term illnesses, I hope for a system that supports and nurtures continuity of relationship with a named GP when it is needed. How do we achieve this? Alongside the goal and the studies and the statements about how important continuity of relationship is in general practice, I want my profession to declare that the goal of a “disaster-proof, locum-ready” safe system, that facilitates true continuity of management for all patients, should have equal parity. And then I hope that new questions will start to be asked of GP locums about how, with our unique perspective as a “fresh pair of eyes”, we can be involved in building and improving those systems. Sara Chambers is a GP locum and is quality lead of the National Association of Sessional GPs sara@nasgp.org.uk
By Sara Chambers @sara71chambers
systems to improve continuity
"a common response to a lapse in care involving a locum is to personalise blame rather than questioning the system that contributed to the error, feeding into the narrative that continuity and quality of care is disproportionately based around individual practitioners."
NASGP member Eva Kalmus describes how she became co-chair of the new GeriGP group of the British Geriatrics Society, and why being a portfolio GP has never been boring. When I did my GP training, about half of the GP trainees undertook a self-made rotation of approved jobs, followed by a year in general practice to qualify. Some studied for MRCGP towards the end, and many transferred from other medical specialities. If I had stayed in hospital practice it would have been geriatrics for me. I was a geriatric SHO for an extra nine months with some wonderful, knowledgeable geriatricians and later held a clinical assistantship on long-stay wards, the NHS’s equivalent to today’s nursing homes. During my first FY1 job I had been inspired by a compassionate and wise consultant geriatrician, appreciated and admired by patients and staff alike. Years later, as a salaried GP, my practice manager forwarded me an advertisement seeking medical cover for community hospital beds; he said that the practice was not interested, but what about me? I continued with some GP sessions but had a wonderful 10 years as part of a multi-disciplinary team looking after mostly older people and learnt so much about rehabilitation, pragmatic discharge planning and cross-organisational working. I also worked in virtual and community wards, providing enhanced care in their own homes to patients at risk of admission to hospital and even dipped my toe in commissioning waters - discovering that I definitely got more satisfaction from patients than meetings! The community hospital moved onto the acute hospital site for a few months’ rebuilding work and I rediscovered my curiosity about the best that specialist medicine could offer to older people. The clinical director offered me an unfilled post for a community geriatrician. So my job title of Interface Medicine GP was invented, and I have had a rollercoaster four years managing moderate and severe frailty around an acute setting. These patients decompensate significantly in response to a minor stressor and so are admitted and treated aggressively, but then take a long time to recover - if they do at all - and are often confused, deconditioned and institutionalised by their prolonged hospital stay. For some, a team - of which I was part - could prevent the admission, but much of the work is smoothing the path to a rapid and effective discharge when hospital no longer offers a net benefit. It was from these experiences that I felt the need for mutual professional support. Some geriatricians expressed unease that a “mere GP” can undertake some of their role successfully, albeit differently. And some GPs are not aware of the complex issues involved for people with greater degrees of frailty who particularly need continuity of care, advanced care planning and the necessity of good communication with them, their carers and other professionals coming into contact with them. Over time I’ve probably learnt more than the average GP about the geriatric giants summed up recently as the 5Ms—mind, medication, mobility, multi-complexity and matters most. My knowledge of acute medicine has been updated, but I am not keeping entirely up to date with the latest guidance on contraception, child health etc because I do not think there is enough space in my brain or time to cover it all thoroughly. However, I reject the concept of being a second-class geriatrician: through conferences, following up leads from appraisers and some good luck, I have now met a growing number of GPs working in a variety of new models of care. We can spend more time, and focus on these complex patients as well as developing services offering more proactive and holistic care, than is possible in traditional general practice. We have borrowed and modified some geriatric tools of the trade such as multi-disciplinary team working, and merged this with the primary care team model with which we are already familiar. One of the most striking observations for me returning to an acute care environment after many years’ break was noticing how differently hospital doctors communicate with patients. I started taking a folding chair with me on ward rounds so as not to stand over patients, and resented the lack of privacy in multi-bedded bays separated only by a fabric curtain from the next patient and their visitors. I have come to love the simple, cheap communicator boxes provided by audiology departments, operable by arthritic hands whose eyesight may also be failing, unlike the miniature hearing aids of today. The patient has a chance of stating preference and even refusing unwanted interventions! I’ve also developed a reputation for taking on “difficult patients and families”. I had the advantage of greater control over my time than some other doctors, but mainly observed that apart from a small, consistently dissatisfied minority, these “difficult” individuals wanted time, honesty, clear communication and respect. Caring (well) for someone with multi-morbidity, frailty and/or cognitive impairment is tough. Guidelines do not currently adequately cover most of these medical situations, but providing good personalised and palliative care for patients with significant frailty is possible. The subtitle to my job has been inaccurately described as “shall we just not” when another blood test, MRI scan, clever diagnosis and prolonged hospital stay will not benefit the patient. So just over a year ago a handful of GPs, including me, decided to form the GeriGP group within the British Geriatric Society (BGS), which has been wonderfully supportive. We are going from strength to strength: we have been consulted by national bodies on policy, and are conducting a survey of our members on how they are working to support older people with frailty. We have also given presentations at BGS conference and are working on appraisal, qualifications and professional development opportunities in this area. And if you are a GP who has other medical interests, there may be surprising opportunities and interesting possibilities to counter the prevailing despondent mood in primary care. If you are particularly jaded, a few of the GeriGPs have been able to turn an interest into their main employment, preventing some from leaving medicine altogether. It has been an interesting journey, and an amazing opportunity to follow a medical discipline for which I have a special fondness, especially being able to apply many of the nuances of my practice as a sessional GP. Eva Kalmus evakalmus@doctors.org.uk
By Eva Kalmus @EvaJK NASGP member Eva Kalmus describes how she became co-chair of the new GeriGP group and why being a portfolio GP has never been boring. When I did my GP training, about half of the GP trainees undertook a self-made rotation of approved jobs, followed by a year in general practice to qualify. Some studied for MRCGP towards the end, and many transferred from other medical specialities. If I had stayed in hospital practice it would have been geriatrics for me. I was a geriatric SHO for an extra 9 months with some wonderful, knowledgeable geriatricians and later held a clinical assistantship on long-stay wards, the NHS’s equivalent to today’s nursing homes. During my first FY1 job I had been inspired by a compassionate and wise consultant geriatrician, appreciated and admired by patients and staff alike. Years later, as a salaried GP, my practice manager forwarded an advertisement to me for medical cover to community hospital beds; he said that the practice was not interested, but what about me? I continued with some GP sessions but had a wonderful 10 years as part of a multi-disciplinary team looking after mostly older people and learnt so much about rehabilitation, pragmatic discharge planning and cross organisational working. I also worked in virtual and community wards, providing enhanced care in their own homes to patients at risk of admission to hospital and even dipped my toe in commissioning waters - discovering that I definitely got more satisfaction from patients than meetings! The community hospital moved onto the acute hospital site for a few months’ rebuilding work and I rediscovered my curiosity about the best that specialist medicine could offer to older people. The clinical director offered me an unfilled post for a community geriatrician. So my job title of Interface Medicine GP was invented, and I have had a rollercoaster four years managing moderate and severe frailty around an acute setting. These patients decompensate significantly in response to a minor stressor and so are admitted and treated aggressively, but then take a long time to recover - if they do at all - and often are confused, deconditioned and institutionalised by their prolonged hospital stay. For some a team - of which I was part - could prevent the admission, but much of the work is smoothing the path to a rapid and effective discharge when hospital no longer offers a net benefit. It was from these experiences that I felt the need for mutual professional support. Some geriatricians expressed unease that a “mere GP” can undertake some of their role successfully, albeit differently. And some GPs are not aware of the complex issues involved for people with greater degrees of frailty who particularly need continuity of care, advanced care planning and the necessity of good communication with them, their carers and other professionals coming into contact with them. Over time I’ve probably learnt more than the average GP about the geriatric giants summed up more recently as the 5Ms—mind, medication, mobility, multi-complexity and matters most. My knowledge of acute medicine has been updated, but I am not keeping entirely up to date with the latest guidance on contraception, child health etc because I do not think there is enough space in my brain or time to cover it all thoroughly. However, I reject the concept of being a second-class geriatrician: through conferences, following up leads from appraisers and some good luck, I have now met a growing number of GPs working in a variety of new models of care. We can spend more time, and focus on these complex patients as well as developing services offering more proactive and holistic care, than is possible in traditional general practice We have borrowed and modified some geriatric tools of the trade such as multi-disciplinary team working, and merged this with the primary care team model with which we are already familiar. One of the most striking observations for me returning to an acute care environment after many years’ break was noticing how differently hospital doctors communicate with patients. I started taking a folding chair with me on ward rounds so as not to stand over patients, and resented the lack of privacy in multi-bedded bays separated only by a fabric curtain from the next patient and their visitors. I have come to love the simple, cheap communicator boxes provided by audiology departments, operable by arthritic hands whose eyesight may also be failing, unlike the miniature hearing aids of today. The patient has a chance of stating preference and even refusing unwanted interventions! I’ve also developed a reputation for taking on “difficult patients and families”. I had the advantage of greater control over my time than some other doctors, but mainly observed that apart from a small, consistently dissatisfied minority, these “difficult” individuals wanted time, honesty, clear communication and respect. Caring (well) for someone with multi-morbidity, frailty and/or cognitive impairment is tough. Guidelines do not currently adequately cover most of these medical situations, but providing good personalised and palliative care for patients with significant frailty is possible. The subtitle to my job has been inaccurately described as “shall we just not” when another blood test, MRI scan, clever diagnosis and prolonged hospital stay will not benefit the patient. So just over a year ago a handful of GPs, including me, decided to form the GeriGP group within the British Geriatric Society (BGS) https://www.bgs.org.uk/gerigps, which has been wonderfully supportive. We are going from strength to strength: we have been consulted by national bodies on policy, and are conducting a survey of our members on how they are working to support older people with frailty. We have also given presentations at BGS conference and are working on appraisal, qualifications and professional development opportunities in this area. And if you are a GP who has other medical interests, there may be surprising opportunities and interesting possibilities to counter the prevailing despondent mood in primary care. If you are particularly jaded, a few of the GeriGPs have been able to turn an interest into their main employment preventing some from leaving medicine altogether. It has been an interesting journey, and an amazing opportunity to follow a medical discipline of which I have a special fondness for, especially being able to apply many of the nuances of my practise as a sessional GP. evakalmus@doctors.org.uk @EvaJK
"We can spend more time, and focus on these complex patients as well as developing services offering more proactive and holistic care, than is possible in traditional general practice."
Adapting primary care to the management of the frail elderly
i'm a geri gp
A journey into counselling
are you listening, doctor?
By Nicky Kiernan @drnickykiernan NASGP member Eva Kalmus describes how she became co-chair of the new GeriGP group and why being a portfolio GP has never been boring. When I did my GP training, about half of the GP trainees undertook a self-made rotation of approved jobs, followed by a year in general practice to qualify. Some studied for MRCGP towards the end, and many transferred from other medical specialities. If I had stayed in hospital practice it would have been geriatrics for me. I was a geriatric SHO for an extra 9 months with some wonderful, knowledgeable geriatricians and later held a clinical assistantship on long-stay wards, the NHS’s equivalent to today’s nursing homes. During my first FY1 job I had been inspired by a compassionate and wise consultant geriatrician, appreciated and admired by patients and staff alike. Years later, as a salaried GP, my practice manager forwarded an advertisement to me for medical cover to community hospital beds; he said that the practice was not interested, but what about me? I continued with some GP sessions but had a wonderful 10 years as part of a multi-disciplinary team looking after mostly older people and learnt so much about rehabilitation, pragmatic discharge planning and cross organisational working. I also worked in virtual and community wards, providing enhanced care in their own homes to patients at risk of admission to hospital and even dipped my toe in commissioning waters - discovering that I definitely got more satisfaction from patients than meetings! The community hospital moved onto the acute hospital site for a few months’ rebuilding work and I rediscovered my curiosity about the best that specialist medicine could offer to older people. The clinical director offered me an unfilled post for a community geriatrician. So my job title of Interface Medicine GP was invented, and I have had a rollercoaster four years managing moderate and severe frailty around an acute setting. These patients decompensate significantly in response to a minor stressor and so are admitted and treated aggressively, but then take a long time to recover - if they do at all - and often are confused, deconditioned and institutionalised by their prolonged hospital stay. For some a team - of which I was part - could prevent the admission, but much of the work is smoothing the path to a rapid and effective discharge when hospital no longer offers a net benefit. It was from these experiences that I felt the need for mutual professional support. Some geriatricians expressed unease that a “mere GP” can undertake some of their role successfully, albeit differently. And some GPs are not aware of the complex issues involved for people with greater degrees of frailty who particularly need continuity of care, advanced care planning and the necessity of good communication with them, their carers and other professionals coming into contact with them. Over time I’ve probably learnt more than the average GP about the geriatric giants summed up more recently as the 5Ms—mind, medication, mobility, multi-complexity and matters most. My knowledge of acute medicine has been updated, but I am not keeping entirely up to date with the latest guidance on contraception, child health etc because I do not think there is enough space in my brain or time to cover it all thoroughly. However, I reject the concept of being a second-class geriatrician: through conferences, following up leads from appraisers and some good luck, I have now met a growing number of GPs working in a variety of new models of care. We can spend more time, and focus on these complex patients as well as developing services offering more proactive and holistic care, than is possible in traditional general practice We have borrowed and modified some geriatric tools of the trade such as multi-disciplinary team working, and merged this with the primary care team model with which we are already familiar. One of the most striking observations for me returning to an acute care environment after many years’ break was noticing how differently hospital doctors communicate with patients. I started taking a folding chair with me on ward rounds so as not to stand over patients, and resented the lack of privacy in multi-bedded bays separated only by a fabric curtain from the next patient and their visitors. I have come to love the simple, cheap communicator boxes provided by audiology departments, operable by arthritic hands whose eyesight may also be failing, unlike the miniature hearing aids of today. The patient has a chance of stating preference and even refusing unwanted interventions! I’ve also developed a reputation for taking on “difficult patients and families”. I had the advantage of greater control over my time than some other doctors, but mainly observed that apart from a small, consistently dissatisfied minority, these “difficult” individuals wanted time, honesty, clear communication and respect. Caring (well) for someone with multi-morbidity, frailty and/or cognitive impairment is tough. Guidelines do not currently adequately cover most of these medical situations, but providing good personalised and palliative care for patients with significant frailty is possible. The subtitle to my job has been inaccurately described as “shall we just not” when another blood test, MRI scan, clever diagnosis and prolonged hospital stay will not benefit the patient. So just over a year ago a handful of GPs, including me, decided to form the GeriGP group within the British Geriatric Society (BGS) https://www.bgs.org.uk/gerigps, which has been wonderfully supportive. We are going from strength to strength: we have been consulted by national bodies on policy, and are conducting a survey of our members on how they are working to support older people with frailty. We have also given presentations at BGS conference and are working on appraisal, qualifications and professional development opportunities in this area. And if you are a GP who has other medical interests, there may be surprising opportunities and interesting possibilities to counter the prevailing despondent mood in primary care. If you are particularly jaded, a few of the GeriGPs have been able to turn an interest into their main employment preventing some from leaving medicine altogether. It has been an interesting journey, and an amazing opportunity to follow a medical discipline of which I have a special fondness for, especially being able to apply many of the nuances of my practise as a sessional GP. evakalmus@doctors.org.uk @EvaJK
Taking some time out of general practice to learn some new skills has helped Nicky Kiernan to re-connect with being a GP, and form deeper connections with her patients. 'Listen actively to the patient for the first few minutes of every consultation and they’ll tell you everything you need to know.’ Isn’t that what we’re taught to do first and foremost in our preparation for the clinical skills assessment of the MRCGP examination? But how many GPs, realistically have the time to truly listen to their patients nowadays? And by listen, I mean really listen; not just extract the bare bones of necessary information to reach a diagnostic conclusion but really hear the patient when they are telling us their life stories? From the early days of medical school, I was pretty certain that I wanted to be a GP. I grew up with a rose-tinted image of being the archetypal local village GP who knows every nuance of their patient’s complicated lives. I imagined being party to the ups and downs of family life; of being a silent witness to the joys and traumas of the local community. But qualifying as a GP provided me with a reality far from this. The patients, I found, were only too willing to tell me their stories. And even fourteen years post-qualification, I still feel honoured by the implicit trust that patients place in me when doing so. But the time to listen, and to really hear them, was limited, and only seemed to shrink further the more experienced I became. I would find myself interrupting their narrative to reach a diagnostic conclusion and make a management plan, and then wondering afterwards what more they would have shared with me, if only I had more time to be present and actively listen. Determined not to turn my back on years of hard work and training, with the help of a careers counsellor, I sought other areas of interest where I might be able to listen and bear witness without this time pressure. This period of self-reflection and assessment led me to embark on training to be a counsellor. Two and a half years later, as I approach the last six months of my level 4 CPCAB Diploma in Therapeutic Counselling, I find myself reflecting on my journey so far and, all that it has taught me. Far from providing an alternative career path, as I had initially considered, it has re-ignited my passion for general practice and I am happier today as a locum GP than I have ever been in my career so far. I embarked on the counselling training thinking that I would be helping other people, and there is no doubt that to be a counsellor requires a great deal of altruism. But what I hadn’t bargained for was the vast extent to which I would end up helping myself, healing my relationship with medicine as a career, and improving my interactions with patients. Having given myself the time to engage in self-development exercises, journalling, completing written assignments and reflecting with trainee counsellor colleagues on who I am and why I behave as I do, I have, as a by-product learnt who I am as a doctor. I now have a keen awareness of how I wish to practice, what my personal boundaries are and what I bring to the consulting room with me. After working as a part-time salaried GP for seven years, this new-found confidence in myself and my abilities, empowered me to take the step of becoming a locum GP. I now work in a variety of practices in Berkshire and can choose my own hours, workload and surgery set-up. This allows me, in part, to be the type of doctor that I want and need to be. If I choose to sit and listen to a distressed patient for an extra five or ten minutes, then that’s my choice. And the pressure of clock-watching has to some degree lessened. The skills I have learnt as a trainee counsellor have also impacted on how I work as a doctor. It’s my opinion that most doctors are empathic; it comes with the territory. But what I personally found difficult to do so well was to deeply empathise with the patient in front of me, and then step back and be able to completely respect the patient’s autonomy. I certainly used to feel a great deal of responsibility for my patients and I still do; it’s the caring part of me that wants the best for my patients. But I now have a greater understanding of what it means to really allow the patient autonomy; to understand that they will make their own choices in life. My role as a GP is to provide them with the necessary information for them to be able to do this safely and in an informed way. Having spent many hours exploring the concept of ‘congruence’, I am now much more able to name the hidden agenda in a consultation. Congruence, named as one of the core conditions needed for therapeutic growth in counselling by the founder of person-centred counselling, psychotherapist Carl Rogers, describes the ability of the counsellor to be authentic or real and to act in accordance with his or her own true feelings. In the counselling room, this often equates to speaking the unspoken in the room. In my experience, this is paralleled in general practice by that moment in a consultation where you suspect there is an underlying hidden agenda, often related to a psychosocial factor. My training as a counsellor has equipped me with the language and confidence to tackle potentially difficult hidden agendas more openly and bravely and thereby improved my consultation skills. The rose-tinted view I once had of general practice has certainly faded now and I recognise that during the period in which I trained the face of general practice shifted. But what my journey into counselling has taught me most of all is to be able to accept this. To know that the reality of general practice today is not what I thought it was going to be and that that’s okay. By exploring other areas of interest and slowly building a portfolio career, I can find a space within healthcare in which I can be the doctor that I was always meant to be. I can fulfil my need to connect with people and hear their stories, through counselling and still be a great GP. My background as a GP has been both a help and a hindrance throughout my time as a counselling trainee, but overall I feel that doctors are well placed to be great counsellors. It’s a skill that many of us employ on a daily basis already and our inbuilt communication skills are a great foundation upon which to build. If you are someone who loves to listen to your patient’s stories, are inquisitive and curious about humanity in all it’s great difference and individuality and can sit comfortably with expressed emotion, you may wish to consider undertaking a similar journey. For me personally, in an era of general practice where workloads are ever increasing and time spent with patients is diminishing, sitting in the counsellor’s chair with all the life experience I bring with me, both personal and professional, feels like a very comfortable place. And I have medicine to thank for that; without it I would never have found my way here. Nicky Kiernan nickyk20@hotmail.com
"Far from providing an alternative career path, as I had initially considered, it has re-ignited my passion for general practice and I am happier today as a locum GP than I have ever been in my career so far."
confused by type-2?
"If you’ve done them on time in the past but they are not showing, then it’s best to do them again and resubmit them..."
LiZ Densley clarifies some of the most frequently asked questions
By Liz Densley @honey_barrett
With the deadline for completion of Type 2 certificates by the end of February, we thought we’d cover some of the questions we’ve been asked recently. Why do we have to fill in a form? The intention of the certificate is to check that the right tier rate has been applied and to provide a mechanism for calculating balances due to be paid or repaid. The certificate is then used to update your pension record What happens if we just ignore it? If you don’t complete and submit a form, your pension record won’t get updated properly – so you’ll be paying for benefits you’ll never receive. How do I know if I’ve done forms in the past? Often the practice manager will complete forms on behalf of the salaried doctors (this can be quite dangerous if they don’t know the full picture), and you may not even remember being asked to sign a form. If you ask for a Total Rewards Statement you will be able to see your pensionable income and if there are gaps, then your certificate hasn’t gone through the system (but remember that 2017-18 won’t show up until late summer this year). I’m sure I’ve done certificates before but it’s not showing on my pension record. If you’ve done them on time in the past but they are not showing, then it’s best to do them again and resubmit them (and follow up to make sure they do go through). What is this amnesty I’m reading about? It’s basically their way of saying if you’ve not done it before – or they’ve lost the forms – do them now and get your records updated. Unfortunately, they give a deadline of 28th February which doesn’t give much time to hunt out historic documents. What is pensionable income? For a salaried doctor it will be the figure shown on your payslip as pensionable income (as opposed to taxable or NIC’able income). If it doesn’t show on your payslip (and it does not show on a P60 usually), then you will need to contact your payroll provider. NB GP registrar salary is an officer post, and is not pensioned through this certificate. For a locum GP it will be 90% of the amount invoiced and shown on Form B’s, excluding the extra received as the employer contributions. For GP SOLO work it will be the gross amount shown on the certificate with no deduction for expenses. Do locums have to complete Type-2 assessment forms? ‘Pure’ locums don’t have to do a Type 2 certificate, but if you have any salaried work at all, then you do need to do a Type 2 certificate and include your locum work and any other pensionable practitioner work in order to arrive at the correct tier rate. What if locum Form Bs don’t match what I’ve invoiced? If it’s just timing, use the Form Bs for the months in the fiscal year – so April 17 to March 18. If you’ve missed putting some work on your Form Bs, then do not include that work as pensionable income and either return the employer contributions to the practice who paid them – or renegotiate your fee from them to include what you actually received. You are only acting as a collection point for the employer contributions – it is not your money to keep personally. What if I have had gaps in service? At the time of writing, the annualisation calculator has still not yet been issued. This should clarify what a ‘gap’ actually is, so you can calculate what your deemed income would be for the purposes of calculating your tier rate. If you do have gaps, then it might be worth holding off a bit until the new guidance is issued (but they haven’t moved the 28th February deadline). You do need to take these forms seriously – get help if you are struggling with them. Liz Densley is medical specialist Director with Sussex Chartered Accountants, Honey Barrett and secretary of aisma (the association of independent specialist medical accountants). Contact her on 01424 730345 or at liz.densley@honeybarrett.co.uk
state-backed indemnity: what it means for sessional GPs
There's still some uncertainty about the new state-backed indemnity scheme for England and Wales, and Rachel Birch from the MPS has the answers. What is state-backed indemnity? The state-backed scheme will provide GPs with indemnity for clinical negligence claims, arising from work undertaken under NHS-contracted primary medical services. This will be a similar arrangement to the claims indemnity that is provided to NHS hospital doctors. The scheme will come into force in England and Wales on 1 April 2019. The health departments in Scotland and Northern Ireland have not yet announced whether they will introduce similar arrangements as those proposed for England and Wales. What will the scheme cover? The BMA has advised that partners, salaried, locum and out-of-hours GPs will be covered by the scheme for NHS-commissioned work. All members of the practice team, including those supervised by GPs (eg: nurse practitioners, paramedics) will be covered by the scheme. Last week the General Practitioners Committee (GPC) published the GP contract agreement for 2019/2020, providing further information on the scheme. The scheme will be run by NHS Resolution, and will cover clinical negligence for all GPs and staff working in NHS GP providers, both in and out of hours, for NHS work. What won’t the scheme cover? Salaried and locum GPs will still need to ensure they have adequate indemnity arrangements for claims arising from any non-NHS services they help provide. Examples may include providing travel vaccinations, writing medical reports, doing insurance work, undertaking private medical examinations or doing medicolegal work. A state-backed indemnity scheme won’t provide support for matters such as complaints, General Medical Council investigations, Coroner’s inquests, disciplinary matters, criminal or any other legal proceedings that GPs may be subject to. Why sessional GPs still need their medical defence organisation. It is an unfortunate fact of the modern medical working life that professional risks are real. It is said that a full-time GP may nowadays expect to receive two clinical negligence claims over a typical career. Medical Protection figures show that they can also expect to receive nine complaints or professional challenges during that same time period. In fact, from October 2017 to September 2018, Medical Protection helped a third of all their UK-based GP members with over 6,000 such cases. Facing an investigation or complaint can be a distressing experience professionally, emotionally and financially. Criminal investigations are incredibly daunting and could even put your liberty at risk. A Coroner’s inquest into your practice after the death of a patient could mean you need to produce evidence in court to justify your actions; opening you up to a searching cross-examination or criticism. Facing a GMC investigation could end your career, while a patient complaint to the ombudsman could quickly escalate into something more serious. The state-backed indemnity scheme won’t protect sessional GPs in these situations. It is for this reason that salaried and locum GPs will need protection above and beyond the state-backed indemnity scheme. Sessional GPs should maintain their membership with their medical defence organisation (MDO), so that they can continue to request support for such situations. Many sessional GPs may also need a small amount of claims protection (for their non NHS-work). What can sessional GPs expect from their medical defence organisation? The support of their MDO is vital in many situations such as those above, where a GP’s ability to continue working and making a living may be affected. It’s a common misconception that bad things happen to bad people and if you’re a good GP everyone else will see it that way. Unfortunately that’s not always the case, and even when no medical mistake has been made, a complaint or allegation could still be made - driven by a misconstrued interaction, poor communication or an emotional volatile situation. Complaints and claims are rarely expected, and often come out of the blue. Many can be easily rectified with the right advice and support, and although few escalate in ways that can threaten a doctor’s professional livelihood or even their liberty. GPs deal with such a diverse range of patients and ailments that they cannot expect to make the right diagnosis every time. Even if you are sure you’ve done nothing wrong, once a complaint is made or a GMC investigation starts, there is always a sense that the doctor needs to prove their innocence, and that’s hard to do alone. Receiving a complaint to the GMC is always stressful, and if the case proceeds to a Fitness to Practice Hearing it will also be very costly and require specialist representation. The MDO is there to protect its GP members financially and emotionally, while providing them with the best expert and legal representation. GPs without legal representation fair particularly badly. The vast majority of GPs (84%) erased from the register as a result of a Medical Tribunal hearing had no legal representation, whereas nearly all GPs (91%) who do not receive a sanction had legal representation. Having an expert at the end of the phone to help with practical and ethical dilemmas can make all the difference when GPs find themselves in a vulnerable or distressing situation; having someone there to support them can provide huge reassurance. In certain situations, the MDO’s press office can provide invaluable media advice. In addition, there is always the range of education, workshops, journals and risk management tools available. What should sessional GPs do now? It is important that sessional GPs ensure that they will still have appropriate cover after 1 April 2019. The cost of this will be significantly less than current subscriptions. Rachel Birch rachel.birch@medicalprotection.org
By Rachel Birch @MPSdoctors
You'll still need cover, but it'll cost a lot less
"The state-backed indemnity scheme won’t protect sessional GPs in these situations. It is for this reason that salaried and locum GPs will need protection above and beyond the state-backed indemnity scheme."
"Research has shown that there are specific times in the life cycle where strength and balance activities would be most beneficial to health."
Most people appreciate that being active is important for our health and wellbeing. Many are also aware that to really get the health benefits from cardiovascular exercise we need to be getting our heart rate and respiratory rate up to a moderate or vigorous intensity for at least 150 or 75 minutes a week respectively. What many people are unfamiliar with, however, is the importance of balance and strength training from cradle to grave. Evidence suggests that there are strong associations in middle and older age between poor balance, poor strength or poor physical function and mortality, and that lower strength in late adolescence and early adulthood link with increased vascular risk in later life. Given that surveys in the UK report that 69% of men and 76% of women are not meeting the strength and balance guidelines (two or more sessions a week), this has implications for us all. How does strength and balance change across the lifecourse? Muscle strength, bone strength and balance ability increase in childhood and peak in early adulthood. A decline in muscle mass is seen from around the age of 30 years but this is more notable from the age of 50 years (0.5-1% loss a year) and after 75 years (2-4%). Low muscle strength, also known as sarcopenia, is linked with frailty. It is more common in older adults but can occur at any point due to lifestyle factors such as sedentary behaviour. Studies have shown that there is approximately a 50% decline in muscle strength between 25 to 85 years. This loss of muscle strength is seen as the primary limiting factor for functional independence. We need that muscle strength to be able to get out of a chair, climb stairs and to have the capacity to maintain balance when we trip. Women statistically have less muscle mass than men and so reach the fall threshold earlier with age related loss. Evidence shows, for example, that 25% of women are at risk of not being able to get up from a low chair independently between 70-74 years compared to 7% of men. Similarly, obese individuals will have a lower muscle strength in lower limbs compared to body weight which impacts negatively on performance too. Bone density peaks around 20-40 years. After that there is progressive loss, which is accelerated in women after the menopause. So building that bone strength when we are young is important, as is engaging in activities that maintain bone strength as we age. Not surprisingly, balance also declines as we age and is often affected by many other factors such as obesity, reduced sensitivity of skin receptors, reduced cognitive processing, visual impairment, joint problems, pain, poor coordination and vestibular dysfunction. When should we focus on strength and balance activity? Research has shown that there are specific times in the life cycle where strength and balance activities would be most beneficial to health. 18-24 years to maximise bone and muscle strength gains 40-50 years to maintain strength and reduce that downward spiral Over 65 years to preserve balance and maintain strength and independence Of note, there are certain transition periods in life which have been identified as being important too. These transitions represent times in our lives when we might become less active and / or more sedentary. They include pregnancy, the menopause, following a diagnosis or medical condition ie stroke, on retirement, becoming a carer or following a period of hospitalisation or prolonged illness. These periods can result in accelerated loss of strength, balance and cardiovascular fitness, and thus represent optimum times to instigate strength and balance training. Women might experience more of these life changes than men (pregnancy, menopause and becoming a carer) on top of the already statistically lower muscle mass. What should we be doing and which activities help the best? According to a review by Public Health England and the Centre for Ageing Better, we should be doing strength activities twice a week which include “high intensity resistance training, some impact exercise (running, jumping, skipping etc) and balance training”. A useful table in a report by Foster & Armstrong on what types of physical activities are effective in developing muscle and bone strength and balance shows the positive impact of different types of activity on muscle, bone and strength outcomes. Those with established osteoporosis, history of vertebral fractures or frailer older people with or without significant cognitive impairment need to seek advice from a physiotherapist as there are some activities that they should avoid and some that they should only do supervised. There are clearly many other activities not listed on the table such as swimming, skiing/snowboarding, hillwalking, climbing and martial arts other than tai chi that will improve muscle and bone strength and balance. The important aspect, according to Health Survey England is that the effort of the activity is enough that “the muscles feel some tension, shake or feel warm” and ideally for this to be sustained for bouts of at least 10 minutes. With this is mind, many everyday activities could fall into strength and balance work such as climbing stairs, gardening and DIY. They don’t necessarily have to be planned extras. So this makes it easier when thinking of how we can integrate it into our ever busy schedules. #OneChange As you can see, getting strong and staying strong is important across the lifecourse and especially at particular periods of change, yet many of us are not doing enough. So how could we tackle this and start doing more? First, we need to consider where we are currently and where we would like to be. We then need to break down our goals into realistic and achievable steps. #OneChange is a fun way to do this. It is about nudging or coaxing us to change our behaviour or to start a new healthy habit. An effective and simple way to do this can be to anchor the new habit with a current activity such as boiling the kettle or brushing your teeth. So to kickstart this, my #OneChange is to stand on one leg whilst brushing my teeth. What is yours?! Dr Kate Little, a GP Clinical Champion for Physical Activity and the founder of physicianburnout.co.uk, a resource for doctors that are feeling fed-up, stressed, anxious, depressed or burnt-out. Kate has worked as a GP in the NHS for the last 16 years in a variety of roles – partner, salaried & locum. She has also worked in medical education as a GP trainer and facilitator, and as a GP appraiser.
By Kate Little @katelittle71
get strong, stay strong
Balance and strength
© Claire de Mortimer, GP locum, detail, acrylic
But it's still not illegal in England.
Recently, in Tromsø, the Arctic capital of Norway, I came across the name Carleton Gajdusek. That name took me back many years and halfway round the globe to a village in the Fore district of Papua New Guinea. A man is standing in the doorway of his hut, clinging to the doorpost, his head nodding, before making his way unsteadily, emaciated and ataxic, to another hut. He has kuru. Dr Gajdusek was an American virologist and he spent the last years of his life in Tromsø. He won the Nobel Prize for his work on the aetiology of kuru. Traditionally, the Fore people honoured their dead by eating their flesh, the men receiving the muscles for strength, the women being left with the brain and scrag ends. The custom of eating human flesh had already died out with the missionaries, and Gajdusek hypothesized that kuru was caused by an infective agent – he called it a ‘slow virus’– with a long incubation period. He postulated that it was concentrated in the nervous system, explaining why women were more likely to develop kuru than men. He showed that chimpanzees injected with brain tissue from dead kuru sufferers developed the disease. We now know that kuru, like vCJD and some other fatal neurodegenerative conditions, is a prion disease. Cannibalism has a deep, transgressive and occasionally pathological fascination. Remember Hansel and Gretel? Cannibalism runs through Evelyn Waugh’s Black Mischief: Basil Seal sees a red beret in a cooking pot and realizes that he has just eaten his girlfriend. In 1991 The Silence of the Lambs attracted huge audiences and five Oscars. Early maps showed distant continents inhabited by monstrous beings and by cannibals. Geographical features became more accurate but the myths survived. Many of the monsters were clearly imagined. But we cannot be sure about the cannibalism. How far can early explorers’ and missionaries’ accounts be trusted? Depicting the inhabitants as savages permitted Europeans to subjugate them in the name of civilization, and to exploit their resources. Even if sometimes, as in Jamestown, Virginia, in 1609, it was the European colonists who resorted to cannibalism. Modern techniques show that post-ice-age Britons in Gough’s Cave in Cheddar Gorge butchered other humans. In the 15,000 years since then, there is uncomfortable evidence of cannibalism almost everywhere researchers look. Though it is rarely clear whether the victims were killed for their meat, or what the purpose was. To honour the dead, to intimidate or punish enemies, to celebrate victory, to stave off starvation, as a remedy or a ghoulish gourmand treat? I try to imagine what it might be like to butcher another human. Of course I have cut the flesh off a human. A living human. Making that first incision into a draped abdomen was always breaking a taboo. Once inside I just got on with the job, perhaps the same emotional shift happens to people desperate enough to cannibalise. But ‘Eating people is wrong’ as Junior declares in the Flanders and Swann song, so even those who have eaten human flesh as a last resort to survive are reluctant to admit it. In 1846 a wagon train set out from Missouri for California. Heavy snow trapped the pioneers in the Donner Pass for nearly four months till a relief party arrived. Some of the 48 survivors were unwilling to admit that they had survived by eating the flesh of their dead colleagues. We don’t know what discussions went on in the Donner Pass, but when the plane carrying a Uruguayan rugby team and their supporters crashed on a remote glacier in the Andes, the survivors agreed that should they die, their bodies should be eaten to give their companions a chance of life. Two months later, 16 people were rescued. Knowledge of the survival pact mitigated the initial horror with which the events were greeted. Still, acknowledging cannibalism would tarnish the image of true British heroes. No-one survived John Franklin’s expedition to navigate the Northwest Passage in 1845. Almost certainly the crew resorted to cannibalism, but that is something Victorian Britain didn’t want to know about. And perhaps it still makes us uneasy Armies besiege cities to starve the population into submission. Not surprising that once the cats and the rats have been eaten, starving people consider their dead fellow-citizens as a source of food. Over half a million people in Leningrad died during the three dreadful Russian winters of the Nazi siege. Some days several thousand people succumbed to starvation and cold. Each spring the melting snow revealed cannibalized bodies. There is no law in England against eating human flesh, and finding a legal response reflecting the revulsion felt when psychiatrically disturbed people eat human flesh, sometimes in public, is difficult. Killing people for food is of course murder, however tragic the circumstances. In 1884 the yacht Mignonette was caught in a storm. After several days in a lifeboat two of the survivors decided to kill the cabin boy. They were convicted of murder, although, perhaps due to public sympathy, their capital sentence was commuted to a short period of imprisonment. These days smartphones may save stranded travellers from having to take such extreme decisions to survive. But our planet is heating up and drying up. Food security is already a problem. Thousands of people from lands which can no longer support them are fleeing to more fortunate countries. In time, billions could be crowded into such space as is left, without land or resources to feed them. What might happen then? Soylent Green, a film made in 1973, offers a scenario of a world in 2022 – only three years from now. Climate change, pollution and overpopulation have driven people into cities, and for food they rely on diminishing quantities of ‘Soylent Green’, a nutritious biscuit made, its manufacturers claim, from plankton. But demand is exhausting the supply of plankton, so where does the protein come from? Charlton Heston finds out, and as the authorities take him away to silence him he yells out “Soylent Green is people”. Judith Harvey judithharvey12@gmail.com
By Judith Harvey @judithharvey12
eating people is wrong
"There is no law in England against eating human flesh, and finding a legal response reflecting the revulsion felt when psychiatrically disturbed people eat human flesh, sometimes in public, is difficult. "
Updated advice from Nice
"Uretoscopy is an option for treatment for most stones up to about 20% and may be used first-line. It is often used in young people and children."
renal and ureteric stones
By Louise Hudman
This is a new guideline from NICE on managing renal and ureteric stones, published in January 2019. I'll give a summary of what is new, then do a more detailed summary below. What is new in this guideline? Investigations should be done within 24 hrs of presentation... (I'll just stop for a little laugh here...). Apparently the cost savings of this come from a reduction in complications down the line. NSAIDs should be first-line analgesia, with iv paracetamol coming in at second. Opiates are third line. Avoid antispasmodics - they have no benefit over NSAIDs and only iv antispasmodics have been used in the trials. They also have more side-effects. Medical expulsive therapy (eg alpha-blockers - tamsulosin). These can be considered for people with distal ureteric stones of less than 10mm. So basically they'll be used after imaging. Surgical treatment (including lithotripsy) should be offered within 48 hrs of diagnosis or readmission if pain is ongoing and not tolerated or if the stone is unlikely to pass by itself. Lifestyle advice. There is fairly limited evidence on what lifestyle measures are beneficial, but NICE does advice a few measures. What imaging should be done? CT imaging is first-line. This should be done in adults (other than pregnant ladies). USS - for children and pregnant ladies. Consider a CT for young people and children if there is still uncertainty after the USS. Both of these should be done within 24 hrs of presentation. What other investigations should be done? Consider stone testing in adults. Measure calcium levels in adults. Consider referring children and young people to a specialist for further assessment and metabolic investigations. What analgesia should be given? NSAIDs are first-line. Any route can be used. Most of the evidence is for iv and im, but it is felt that oral or PR is likely to be as effective. They are as effective as other analgesia and they reduce the need for other analgesia. Paracetamol iv is second line. There haven't been any studies done on oral paracetamol and it is thought to be less effective than iv. Opioids should only be used third line because they are no more effective than NSAIDs or paracetamol. Don't use antispasmodics - they have lots of side-effects and are no more effective than NSAIDs. They have also been used in the iv form in trials. Combinations of NSAIDs and oral paracetamol. There wasn't felt to be enough evidence to recommend this. There is some evidence of benefit, though of limited quality. Should medical - expulsive therapy be used? Alpha-blockers like tamsulosin used to be used in the treatment of stones. In 2015 a large trial suggested that there was no benefit from them and so their use reduced. Since then other studies have suggested that they are effective. Therefore NICE advises us to consider using them for distal ureteric stones that are less than 10mm. In reality this therefore means that they will be used after imaging has been done. Calcium channel blockers are not advised in the guideline. However they are effective, just not as effective as alpha-blockers. What will be done with them in secondary care after imaging? Watchful waiting Consider watchful waiting for asymptomatic stones if: the stone is < 5mm OR the stone is > 5mm, but after careful discussion the patient agrees to watchful waiting. Just some stats (not from the NICE guideline)... Up to 90% of stones 4mm and less will pass spontaneously. 50% of those 4-6mm will pass spontaneously. 20% of stones over 6mm will pass spontaneously. Surgical options I'm not going to go into much detail here as we won't be doing this bit. Shock wave lithotripsy is first line for most small stones. Uretoscopy is an option for treatment for most stones up to about 20% and may be used first-line. It is often used in young people and children. Percutaneous nephrolithotomy is preferred for larger stones (eg > 20mm) or for staghorn calculi. How should stones be prevented from recurring? As I advised above, the evidence for lifestyle interventions is limited. However NICE suggests the following: Adults should drink 2 - 3L of water a day. Young people 1-2L depending on their age. Add fresh lemon juice to water to drink. There is limited evidence from 1 trial for this. Avoid carbonated drinks. Adults should have a daily salt intake of no more than 6g and children of 2-6g depending on their age. Maintain a normal calcium intake (700 - 1200mg for adults and 350 - 1000mg for children). There is a useful dietary calcium calculator here. Follow a healthy lifestyle. Potassium citrate or thiazides may be advised for certain people with recurrence of stones. Louise Hudman louisehudman@gmail.com
www.nasgp.org.uk
Promises, promises
This magazine is supported by an educational grant from the Medical Protection Society.
