Each year, all directors at West Suffolk NHS Foundation Trust spend time going “back to the floor”. Last year I spent a night shift with one of the most important doctors in the hospital: the medical registrar.
This year I chose to learn more about the practice and life of another crucial group of doctors: general practitioners. Indeed I have frequently heard Clare Gerada, Chair of the RCGP, telling the likes of Roy Lilley that he needed to come and see for himself what modern general practice is really like.
The last time I was in general practice (other than as a patient or for meetings) was as a medical student in a single-handed lock-up shop on the Hackney Road. Depressingly this was more than 20 years ago. I imagined that perhaps things had changed a bit. I certainly hoped they had, as the experience hadn’t been one that inspired me to take up general practice.
I identified a Friday afternoon and evening when I could be free. I approached several practices to see if they could accommodate me. Once GP colleagues got used to the idea of my wanting to broaden my horizons they were most welcoming to the idea. As an aside it was noticeable & slightly surprising that there seemed to be a bit of a tendency for some practices to scale back operations on a Friday evening whereas I had expected it to be a case of all hands on deck before the weekend.

“There is no doubt that general practice is both busy and pressured. I would however argue that it is no busier nor pressured than many branches of hospital medicine”

Getting to know the practice

Whilst the GPs held a lunch-time practice-meeting I was shown round the practice. It looks after 11,500 patients in the market town of Bury St Edmunds. It’s fair to say that compared to the Hackney Road, Bury does not have excess deprivation nor ethnic diversity. There are 5 partners (4 WTE) 3 salaried GPs and a registrar. They also have a branch surgery. None of the doctors participated in the local out of hours service.The practice is in the middle of building a significant extension to modernise its facilities and future-proof the building.
The practice manager and her staff kindly spared me their time to see how they worked but also it gave me an invaluable insight into how the hospital is perceived within general practice.
Training registrars was valued but the paperwork was escalating and off-putting. There was considerable variation between the registrars as to how long it took for them to make a net contribution to the work of the practice. Inevitable I suppose.

GP IT systems

Choose and book is effectively our hospital’s shop window and yet we do not really have any control over how we are seen. Reassuringly there seemed to be plenty of slots available, our booking clerks were perceived as helpful and the norm was to refer patients to us. A few NHS patients did go via C&B to the local private hospital (the patients like being guaranteed to see the consultant, i.e. our own staff competing with us, but that’s the subject of a different rant) but their restrictions with regard to patient selection in terms of low BMI, lack of significant co-morbidities etc meant that relatively few patients went there. Who says cherry-picking doesn’t happen?
The practice use an old version of EMIS although they are considering their options as they need to update the system. Changing to a different supplier would however require three days down-time and re-training al their staff, although the numbers who would need this training are tiny compared to implementing a new integrated IT system in a hospital!
The system looked comprehensive but a bit clunky. There did seem to be lot of free-hand typing involved. At one point the document management system seized up but the doctor was conveniently able to pop next door for some IT support from the practice manager. As ever, the solution seemed to involved the perennial “turn it off, and on again” solution! It would not be easy to provide this level of support to clinicians in a hospital struggling with IT.
It was interesting to see how our communications are seen and received in general practice. As a result of (quite reasonable) commissioner pressure we have put in huge efforts to send promptly to our GP colleagues electronic information for all discharges (A&E and in-patient) as well as all clinic letters. We have recently implemented a new dedicated IT system in the emergency department and it’s quite clear that the way this sends information to the GP is a step backwards and will need looking at. In addition they get a “discharge summary” from A&E even if the patient is admitted to a ward and this is a document that isn’t particularly helpful to them.
The information in some of our documents is minimal and it can be hard to find the bits that really matter. I came to appreciate that when you get 20-30 electronic letters to read each day, making the salient points obvious is imperative.
NHS 111 has only just gone live in the area so it was too early to tell if it was going to produce significant extra work or not.

Getting down to business

Having got to know the practice I was then invited to join one of the partners, who job-shares with a colleague.
Her first task was to insert a Mirena coil which was done very efficiently.
Following this it was down to a surgery of predominantly urgently booked patients. The practice runs a quite strict “personal list” system, though a Friday evening clinic does inevitably have a mix of personal patients and those of other doctors.
It soon became obvious that the variety of cases that a GP is expected to see is something totally alien to my specialist surgical practice. In one clinic the breadth and scope of practice was amazing. The mix included opthalmology, anxiety over palpitations, gynae, paeds, atypical joint pains, respiratory, sore gums (it was easier to get a GP than a dental appointment) and pre-syncope.
Towards the end there were several patients who needed to be telephoned. One described a drug reaction that wasn’t settling with anti-histamines and so was invited to come down to be checked out and reassured.
Two (or even three) of the patients had a component of their presentation that might possibly include a non-organic origin. In addition there was a patient, new to the practice, with a complex mixture of substance abuse and mental health issues. This was inevitably a protracted consultation and even so it wasn’t possible to pin down all the issues let alone address them all in one appointment. This consultation inevitably led to the rest of the evening running late.
At the end of the clinic there were more incoming scanned letters & results to review and two referral letters to dictate.
The work was done at about 7, to leave a darkened practice, with one remaining partner and the cleaners.

Reflections

• Overall I was most impressed with the competent, professional and calm way the practice was run and the high standards of care that I witnessed. Primary care is VERY different to the clinical practice that I am used to. The breadth of practice was huge and something that I personally would find tough. Clearly with experience comes a range of knowledge but at times it must be hard to keep a few steps ahead of the patient and there is always the risk of missing something.
• There are definitely things that I will take back as to how we communicate better with GPs but it is also difficult for hospital IT systems to communicate with the variety of GP systems out there.
• It was also reassuring that the general impression out there of West Suffolk seemed to be positive.
• Not all of the patients seemed to justify (in my uneducated surgical opinion) an urgent GP appointment. In fact a couple of them possibly didn’t need to see a doctor at all.
• I was surprised that there is no obvious triage system for those patients requesting urgent slots. Clearly the old days of the dragon like receptionist interrogating patients for the reason they wanted to disturb the doctor should not be recreated. However I wonder if it might be worth some triage by experienced nurses to ensure that the patients saw the most appropriate health professional.
• I am used to (and like) having some idea why the patient is coming to see me before I invite them into the room, though this may just be me demonstrating why I am not a GP.
• Finally there is no doubt that general practice is both busy and pressured. I would however argue that it is no busier nor pressured than many branches of hospital medicine.

I am most grateful to all those who were most welcoming to me and for the experience I gained.