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“It’s not our fault, those nasty GPs made us do it”

“Morning, how are you? So you’re struggling with your knee? Ok, let’s take a look, pop up on the couch.

Right, what I suggest for the time being is some anti-inflammatories and gentle exercise. It’s better to avoid those drill wielding hospital doctors for as long as possible. It’s a bit of a slippery slope once you embark on the surgical route. Let’s see if time and patience will do the trick.

Hello again, no better? Physiotherapy for you then I think. They can work wonders.

Still no better? Righto, let’s get an X-ray sorted and we’ll get you off to the orthopaedic guys, to see if they can help. There are a number of possibilities and treatment options depending on X-ray and scan results, let’s see what they say.”

So, this is option one. This is what goes on in every GP surgery, every week of the year, but let’s take a look at the parallel universe of the British Orthopaedic Association.

“Morning, how are you? So you’re struggling with your knee? Ok, let’s get an MRI and ask the orthopaedic surgeons to see you.

REALLY??? Are you serious?

General Practice and Practitioners are becoming inured to the constant barrage of abuse and approbation from politicians and the media, but there is a particularly offensive sting to ill-considered criticism from colleagues, who frankly should know better than to throw stones in their secondary care glasshouses.

The phrase, “…….if GPs are doing their job properly….” has a wonderfully arrogant and patronising ring to it don’t you think? And as for, “………performance of this investigation (MRI) replaces the traditional medical skills of history taking and physical examination of the patient…”, well frankly, words fail me.

General Practice effectively manages the vast proportion of clinical presentations without the need to refer to secondary care. Those that are referred are done because further management is beyond the clinical expertise of the referrer, hence transition to the supposed ‘specialist’.

But it appears not. Orthopaedic surgeons are apparently incapable of utilising “the traditional medical skills of history taking and physical examination of the patient”. Nor are they able to deal effectively with patient expectation. No, instead it appears it’s the GPs fault for not managing the patients properly in the first place.

If we listen carefully outside the orthopaedic clinics, we will hear the bleating cries of the poor little lambs, “we didn’t want to do an arthroscopy, those nasty GPs made us do it.”


NHS Titanic

I’m not known for being a drama queen, (stop muttering at the back!) but I’m getting increasingly edgy with Primary Care strategy planning, so perhaps a little drama is actually required.

This morning opened with Jeremy Hunt’s vision for the future of General Practice.

10,000 new clinicians

Improved marketing

New data to highlight under-doctored areas

And that piece de resistance, 7 day access

All day, the Twitter feed and Facebook page of ResilientGP has been buzzing with angry, disaffected GPs venting their spleen at this charade; calls to arms, suggestions of mass resignation, genuine despair.

Examples abound of 7 day access pilots shutting their doors because of limited interest in weekend appointments, surgeries closing because of inadequate funding, story after story of the dumbing down of Primary Care Services. I’ll share one with you…..

“It would appear that my locum services and that of my three GP colleagues are no longer required at one surgery that we work at. We have been replaced by 2 (yes 2) Nurse Practitioners who will apparently do the same work, charge less and have agreed to sign the lease to the building.

News of this came ironically after I had just been reviewing a patient who our Nurse Practitioners had been dealing with for the past 12 months – normal spirometry but on Spiriva, Symbicort and theophylline for ‘chronic cough’. After loads of scripts for steroids, expensive inhalers and antibiotics, the patient came to see me as she had been told by said Nurse Practitioner that she needed a referral to the allergy clinic as nothing is working. (Even had the name of the allergy consultant written down that I ‘had’ to refer to).

After 1 year of inappropriate management, she has now been sorted with some omeprazole.

Nurse Practitioners and Physician Assistants – really the future of General Practice???”

Now, don’t get me wrong, nurse practitioners are highly skilled professionals in their own right and I’m all for skill mix, but how can this be right? We have seen the chaos that has been created with 111 by taking clinicians out of the triage process; inappropriate use of the ambulance service, increased waiting times in A&E, ramped up demand in Primary Care and reduced self-care, (after all, you can’t be too careful!)

Do the public realise that the official strategy to the future of the NHS is this dumbing down?

It takes years of training and experience to practice medicine effectively, safely and cost-effectively. Patient safety will be compromised, costs will rocket, the Secondary Care system will collapse with the lack of risk management.

And what’s with this extra marketing business? That’s like standing on the deck of the Titanic after it had hit the iceberg saying “Roll up for the most amazing cruise of your life, sign up, sign up……” The only people coming aboard this Titanic will be the treasure hunters after it has sunk!

I feel like standing on a soap box on Hyde Park corner, I’m no soothsayer, but the end of the NHS is nigh.

Wow, you look well………

Wow, you look well…….

An opening gambit, a friendly utterance which if you’re lucky, promotes an instant feeling of wellbeing in your patient. 

This time, it was said with complete, genuine enthusiasm, for next through the door was Amy, a ten year old I’d known from birth, an absolute fighter who had overcome the odds and survived numerous surgeries for hypoplastic left heart syndrome. She looked beautiful, bright, bubbly and full of vigour and Mum looked on with a beatific smile on her face, whilst the child she hadn’t thought would survive, described her symptoms of a ‘routine’ illness. Reassuring normality.

How different to the last child I’d tried to help with hypoplastic left heart syndrome…….

I was a few weeks into my Obs and Gynae SHO rotation.

Mrs Knight had gone into spontaneous labour. Although she had polyhydramnios (excessive amniotic fluid), all of her pregnancy scans had been normal, so we weren’t anticipating problems. The labour went perfectly, husband in attendance, another awe-inspiring but routine delivery anticipated. Final stage, final push and out popped Charlie, a petite, perfectly formed baby boy.

Perfect, except that he wouldn’t cry or respond. Nothing too unusual or untoward. We transferred him up onto the resuscitation unit, trying to elicit a cry, rubbing his skin, then oxygen until finally he pinked up a little. Had we heard a little mewling cry? Then nothing again……..emergency bleeps, an every growing number of healthcare professionals gathered around the little bed, paediatricians called, senior obstetricians descended, attempted ventilations by first junior, then more senior colleagues. Cardiac compression, mask ventilation, another attempt at tracheal ventilation. Endless cycles. Increasing desperation on the faces and in the actions of the doctors and nurses, whilst all the time, Charlie’s parents looked on, helpless and distraught.

We couldn’t resuscitate him. For a few seconds at a time he looked as if his colour was improving when he was given oxygen, but it was never sustained and after an hour, we had to admit defeat.

We moved The Knights to another room. They couldn’t bear to be in the same room as the body of their baby son. He was so beautiful, so perfect in every way, to all intents and purposes, just sleeping peacefully. We wrapped him in the shawl that they had brought with them and laid him in a moses basket.

I went and sat with The Knights and held her hand, husband angry, pacing the room, wife shattered, speechless, motionless, numbed with grief. “Would you like to see Charlie?”. They reacted in horror. To see him would be to accept that he had died, he couldn’t be dead, they wouldn’t let him. We sat. I tried again. “He’s so beautiful, would you like me to at least bring him in so you can see him, you don’t have to hold him.”

I carried the moses basket in and put it at the foot of the bed. Gently I lifted their lovely little boy out, swaddled tightly in his shawl. He looked so peaceful, they wanted him so badly to just be asleep. I sat next to them and cradled Charlie in my arms. Stolen glances towards the bundle in my arms, then Mrs Knight could bear it no longer. “Can I hold him now?”

I left them, Charlie in his Mother’s arms and with Dad’s arms wrapped tightly round the two of them…..

Charlie, postmortem was diagnosed with Hypoplastic Left Heart Syndrome & Tracheo-oesophageal Fistula, hence the difficulties in ventilation and his momentary resuscitation improvement.

Learning and practising medicine is full of highs and lows. Some memories stay with you forever…..