The latest British Journal of General Practice (BJGP) contains an interesting article about medicines safety. The authors identify a list of potentially dangerous medication situations (e186 and e187). We felt that this sort of list may offer itself towards an audit or two! The pdf can be found here (and is currently free online).
It has been a busy week with the publication, by NHS England, of the Urgent and Emergency Care Review and also the GP Contract for 2014/15. The role of GPs in providing prompt same day access was highlighted in both reports, forming part of a plan to ease some of the pressure currently faced by emergency departments and also addressing the desire to reduced unplanned admissions.
The GP contract included some significant changes including the removal of a number of QOF points and areas. The “headline” change would seem to be the enhanced service to reduce unplanned admissions and to provide proactive case management for patients identified by risk profiling. Specific ways to support this would be direct telephone access to a patient’s GP for Emergency Departments and Paramedics and improving same day access. In addition, all patients aged 75 years of age or older will have a named accountable GP who will co-ordinate their care and Practice boundaries will be removed. NHS England will co-ordinate urgent same day care for those patients registered away from their home. The push to harness the power of the internet continues and patients should have online access to their summary care record and be able to book online appointments and request medication (see the RGCP document Patient Online: The Road Map).
It is important to note that money is being recycled to enable these changes rather than new funding being directed to General Practice. Perhaps with this in mind, the RCGP have started a campaign “Put Patients First: Back General Practice” to campaign for additional resources. There is a lot interesting information in the campaign brief and you can sign receive updates either through Twitter or Facebook.
There will be a lot of changes in General Practice over the coming months, some of which will be very challenging. I think that as GP trainees it is important you consider how you would approach these challenges and what the pros and cons may be.
The Liverpool Care Pathway (LCP) has come under increasing scrutiny in recent months. Originally created as “a model of care which enables healthcare professionals to focus on care in the last hours or days of life when a death is expected.” (The National End of Life Care Programme) the LCP has been criticized in some sections of the press, who have led with emotive headlines.
Even within the medical profession there are conflicting opinions. In one survey 90 % of doctors said that they would want to be placed on the LCP if they had a terminal illness. However other voices within the profession have raised concerns about patients being placed on the LCP who may have a chance of recovering.
Amidst these conflicting points of view a different approach has been taken by Guy’s and St Thomas’ NHS Foundation Trust. They have produced a tool known as the AMBER care bundle©, which aims to provide “greater clarity around preferences, and plans about how these can be met”. It would appear that this tool takes into account (to a greater degree than the LCP) the uncertainty that surrounds the accurate identification of patients who are dying and allows for a more flexible management plan.
With an independent review of the LCP currently being undertaken by the Department of Health there is likely to be further scrutiny and debate. As GP Trainees you will be caring for patients, and their relatives, who require end of life care and who will have their own views and thoughts about tools such as the LCP. It is important that you are able to recognise how patients’ concerns may be shaped by personal, local and national factors.
Further resources can be found here: RCGP, The Marie Curie Palliative Care Institute and and the BMJ (care of the dying patient in the community and hospital). Local information: National End of Life Care Profile for Barnsley PCT (2012) and Barnsley Hospice.
The recent report from Grant Thornton highlighting the alleged cover up by the Care Quality Commission (CQC) of the deaths of babies in Furness General Hospital has thrown the process of “whistleblowing” within the NHS into the spotlight.
The British Medical Association (BMA) defines whistle blowing as “the popular term applied to a situation where an employee raises concerns to people who have the power and willingness to take corrective action”. There has also been a recent article in the BMJ examining the issues which surround whistle blowing.
As trainees you may be involved in, or become aware of, events which you feel require escalation. Whether this occurs in hospital, or in general practice, the process of raising concerns is likely to be a difficult one. I hope that the links included give you some guidance as to the best approach: RCGP – NHS Whistle Blowing and GMC – Raising Concerns. You can also find a thought-provoking post about whistle blowing from NHS Consultant Philip Berry on his blog “Illusions of Autonomy” which illustrates the dilemmas you may face.
The slides from Prof Nigel Mathers’ presentation on Long Term Conditions can be found here. I can honestly say that this presentation was a revelation to some of the GPs and GP trainees in the audience and has really stimulated some discussion and thought as to how we can work along side our patients. Other presentations available include an Overview of General Practice (Dr Mark Purvis), First5 Kick-start Your Career (Dr Katharine Rowell) and Employment Law (Paul Gregory).
There has been a strong focus on urgent and emergency care in recent weeks. A large part of that focus has been targeted on access to GPs, especially out of hours provision. NHS England have now published their evidence base which they claim has “identified areas for improvement in the current system”. They have also published their own possible solutions.
As GP trainees you will all be involved in providing out of hours, and urgent care, in the Practices where you work. You will also be directly affected by the outcomes of the review. So, why not take a look at what is proposed and consider completing and sending back the NHS England survey. This topic covers a couple of the curriculum headings: Patient safety and quality of care and The GP in the wider professional environment.