All posts by Robert Campbell
Robert Campbell

Robert Campbell

About Robert Campbell
Robert Campbell

Started work writing medical cards in 1966 at Staffordshire Executive Council. Have worked at Inner London Executive Council, Hertfordshire Executive Council, Lambeth Southwark and Lewisham FPC, Birmingham FPC, Dudley FPC and Wakefield FPC and Family Health Services Authority. I was seconded to the NHS Appeals Unit and have worked as a full time GP practice manager since 1992 until 2010. I was also an AMSPAR trainer at Park Lane College, Leeds. Now I work as a freelance author.

Are Electronic Prescriptions efficient and effective?

 Electronic Prescriptions

When the EPS system was first proposed my understanding was that it would speed up the dispensing of prescriptions. However my continuing experience is that this is not so for the following reasons:

1. Patients need to check that the nominated pharmacy is correct particularly if they have been away from home and changed the pharmacy temporarily.

2. GP Practices are taking longer to issue repeat prescriptions – sometimes more than two days.

3. Small pharmacies often have stock problems meaning patients might have to wait far more than two days for their drugs.

4. If a pharmacy is out of stock the patient has the right to take the prescription to another pharmacy. However this means giving the patient a complex code and returning the prescription to the NHS spine so that another pharmacy can issue. A simple print out of the out of stock item would suffice.

5. GP practices too on a separate issue are changing patients medication without checking that supplies are in stock at the nominated pharmacy. I have had problems with Peptac, Ranitidine and Nystatin.

I would be interested to hear your solutions to these problems.

Email – Snaptwig64@gmail.com

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Telephone versus Face to Face Consultations

Are telephone consultations replacing face to face consultations?

As GP Practices battle to provide adequate numbers of face to face appointments I was wondering if other forms of providing consultations are on the increase. I spotted recently a notice in my local surgery which declared that almost one third of consultations in July had been on the telephone. This amounted to a remarkable 40+ per day, and it struck me that that would have taken some dealing with. What it didn’t say was how many telephone conversations resulted in a need for the patient to be seen face to face. What if the patient actually needed to be examined, not just subjected to a telephone inquisition.

Telephone Consultations not effective?

A major survey carried out in 2014 the results of which are on the NHS Choices web site,( https://www.nhs.uk/news/medical-practice/phone-consultations-do-not-reduce-gp-workload/) suggested that whilst telephone consultations provided an alternative method of consultation they were not necessarily as effective. The survey also claimed that telephone consultations did not reduce a GPs workload. It found that almost 12% of consultations had been carried out on the telephone, representing a four fold increase over the previous 20 years. I do recall that the process of telephoning patients who had requested an urgent appointment or a home visit starting in my Practice around 15 years ago very reluctantly and only a handful of calls were made in the early days. One GP in particular much preferred a face to face contact and had five minute appointments.

Triaging Calls becomes run of the mill!

Nowadays, a system of triaging appointment requests is not unusual, although the personnel that filter the calls may range from a receptionist to a nurse practitioner or a doctor first. In my mind there are always inherent risks involved where a non-clinician becomes involved. To be on the safe side it requires a well trained and experienced clinician to sift and sort the problems presenting on the telephone. I recently came across an example of a telephone consultation being offered by a receptionist in three days time but when the patient needed a referral. So Practices do need to adopt a safe system of filtering calls and allocating appointments. Practices tend to get a GP to phone the patient back, if no offer of an appointment is accepted or simply to be on the safe side!

Seeing today’s patients today

Around the time the Quality Outcomes Framework was introduced the idea of seeing today’s patients today was also marketed, which at the time was a fine aim, but the pressures of demand from patients and the inadequacies of supply from doctors have since created a situation where Practices desperately look for alternatives ways of providing a service to patients. The concept of 10 Minute appointment may no longer be valid or achievable. When we first used a senior Practice Nurse to see patients with minor illnesses I have to say that it broadly failed. The nurse saw less patients than the doctors and there was of course the problem of raising prescriptions. The nurse was not a prescriber. Now the likelihood is that a Practice will have a nurse prescriber, even a pharmacist and better training and qualifications mean that the prescriber will probably see just as many patients as their GP colleagues. I can certainly comment that a good nurse practitioner can become a valuable and effective member of the Practice.

Demand outstrips Supply

However, what happens if the level of demand still outstrips the availability of prescribing clinicians. Here are some thoughts:

• Over the Counter Medicines

Encouraged by CCGs and NHS England practices are introducing widely schemes to not prescribe OTC (Over The Counter) preparations that can be purchased from a pharmacy. So once patients realise that their medical practice will no longer prescribe simple remedies will the demand for appointments reduce. Practices or CCGs might employ a pharmacist to help manage more effective prescribing. According to NHS England 40% of Practices have access to a Clinical Pharmacist. (https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/cp-gp/)

• Signposting to Pharmacy

Signposting patients to pharmacies is another alternative. But it depends how well staffed and how well stocked a pharmacy is for such a service to be successful. A recent suggestion that Gasviscon Advance be replaced by Peptac resulted in a 24 mile round trip to a local town to find a pharmacy that stocked. It cost over £3 whilst Gaviscon Advance was around £8. The bus journey would have cost me £11. Practices, both GPs and Practice Pharmacists need to work with local pharmacies when changing either their prescribing habits or offering OTC advice to patients.

• Using 111

Suggesting patients, make a first port of call to the NHS (111) telephone line is another option. In June 2015, 111 received an average of 23 calls per minute. That month approaching 1 million calls were received. Now that takes some managing.

Possible Pitfalls

But nothing in my view replaces seeing a patient. Those answering the telephone to filter requests for appointments need to be aware that patients might not describe their problem adequately. Likewise they may want to tell an unknown voice what they would tell a doctor or nurse. The idea of an experienced and trained clinician phoning a patient back is probably much safer. But there will be occasions when actually seeing the patient and examining them cannot be achieved in a telephone conversation. The question is what is the appropriate balance between seeing patients face to face or talking to them on the telephone.

More recent findings

The BMJ published an article last September (2017) (https://www.bmj.com/content/358/bmj.j4345) which looked at the growing Practice of patients speaking to a doctor first. Even the new Health Secretary is promoting the development of online GP services. But the question remains as to whether it is a better way to provide services or just an alternative. The BMA article states that much of the work of general Practice can be managed on the telephone. The reduction in consultations is compensated by the time spent on the telephone, but around half of the patients still need to be seen face to face. The article goes onto explain that the success of a telephone system depends on how well it is organised. There is an issue of prompt call back and Practices need to make allowances for patients who have problems dealing with telephone calls. Perhaps too Practices need to make clear that the telephone consultation is a new feature of the service being provided and not an alternative caused by lack of doctors and high demand!

Robert Campbell

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“It’s not a bottomless pit”!

Steps are being taken throughout general Practice to reduce the prescribing of medications for minor ailments that can be bought at a pharmacy ‘over the counter’.

NHS England have published a leaflet for patients which explains what GPs are trying to do, encouraged by CCGs and Practice Pharmacists.

https://www.england.nhs.uk/wp-content/uploads/2018/08/1a-over-the-counter-leaflet.pdf

But are those promoting the non-prescribing of OTC products overstepping the mark. Should they be telling patients that they can no longer prescribe OTC products. Are they simply trying to substitute cheaper products. Are they following national NICE guidelines are using a different product which they regard as just as effective whilst still saving money. What is going to happen to small pharmacies who loose dispensing fees

In my view Practices need to be very careful about the way they introduce these changes and the words and style of language they use when doing so. Each patients case needs to be treated on its merits and reference should be made to clinical letters and recommendations made by consultants.

My understanding is that the shift to OTC products not being on prescription is not a blanket decision and GPs need to be aware of that.

 

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Sunday Newspapers and Ghost Patients

Yet again the national Sunday press are harping on about ghost patients and the apparent cost to the NHS of over £500 million pounds per annum.

Ghost patients is a problem that NHS Managers in Primary Care have been aware of since the inception in the NHS on 5/7/1948. When I first started work in 1996 we used to send letters, known as Notices to patients when a doctor ceased to practice. If we sent out 2000 letters then at least 600 would be returned undelivered. This was a natural way of removing ‘ghost’ patients.

However in 2004, the new GP contract abandoned personal GP lists to be replaced by Practice Lists. Notices to patients ceased to be sent and medical cards ceased to be issued routinely too. Adam Smith the economist talked about war reducing the population – similarly notices to patients about Practice changes removed the, sorry, dead wood.

Nowadays there letters are only sent to patients about national screening programmes and  the dead wood effect by comparison is minimal. GP Practices are also expected to clean up their patient registration data but there are no real incentives for them to do this as they will simply loose income. Arguably it not the Practices fault that patients have moved on and not told them.

I would argue that ghost patients are a natural phenomenon of the system and it is unlikely that it will change. GP negotiations on Practice income do take into account the ghost element but the very idea of ghost patients always  captures journalists imagination.

Here are some reasons why ghosts occur :

  • Practices do not normally become aware of Patients who die abroad.
  • Patients move to a new address and for a short time may be registered twice or not at all at their new address.
  • Children may be one adopted and former registrations not traced or removed
  • Patients may change their name and still remain registered somewhere else
  • Patients may register who are refugees or asylum seekers and  remain registered although they have move on or return abroad
  • Emmigrants may remain registered but live abroad. In some cases thus may be deliver so they can return home for NHS treatment.

Looking at the figures quoted in the Sunday papers, about 6 patients out of 100 might be ghosts. This means around 55 patients per whole GP are ghosts. This amounts to around £8,350 per GP.

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New Guides to Policies

I have added to the Practice Index Forum two new documents to help GP Practice Managers prepare Policies, Protocols, Procedures, Plans and Presentations that might be required by the Care Quality Commission.

It all started with the voluntary Quality Framework so the first shorter document give a summary of the topics that as a bare essential ought to be covered by a ‘document’. The second document is more detailed and attempts to provide the basis for a multitude of documents.

The link to the site is

http://www.practiceindex.co.uk/forum

 

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