Unified DNA-CPR

End of life and palliative care symptom control can be some of the most fulfilling aspects of the GP role, but huge variations still exist across the whole of the UK. Getting it right every time for every patient is the ultimate goal in these situations, and supporting people to live well before dying with peace and dignity in a place of their choice can be incredibly satisfying for all involved, despite the bleakness of the situation.
A number of strategies have arisen in recent years to help GPs and other professionals to facilitate the wishes of patients approaching the end of their lives, and they have ensured that care is uniquely tailored to the patient. This has resulted in their needs increasingly being met and care is often managed in a much more collaborative and coordinated way. Ironically, the ultimate goal of healthcare, which is to save lives, can be a barrier in these circumstances and can prevent patients from achieving a peaceful and dignified death, especially when we consider the issue of CPR.
Discussions relating to resuscitation can be one of the most sensitive and difficult that GPs, patients and family members may ever have to be involved in. It is essential to identify patients for whom cardiopulmonary arrest represents the terminal event in their lives and for whom CPR will fail or is inappropriate. It is also essential to identify those patients who would not want CPR to be attempted and who competently refuse this treatment option. Some patients may wish to make an advance directive about treatment. Such directives must be respected as long as the decisions are made by patients with the mental capacity to do so. These decisions should be informed, current, made without coercion and should apply to the current clinical picture. All of these variables have to be considered and should include the patient where appropriate. With emotions high in these situations, unsurprisingly there are still many reports detailing when patients have been excluded and decisions made in their best interests, with some of the worst cases reaching the media. This does nothing but create a culture of fear and results in further anxiety around such discussions. There needs to be convincing reasons not to involve patients in these discussions, or as seen with the Tracey Judgement, there is a risk to patients under Article 8 of the European Convention on Human Rights.
Once the decision concerning CPR is made, it is absolutely essential that inappropriate, futile or unwanted attempts do not occur. This is not to say that decisions cannot be reviewed and amended accordingly, if it is appropriate to do so. Variations in local policies can cause further misunderstandings and can lead to distressing incidents for patients, families and staff. The increased movement of patients and staff between different care settings makes a single integrated and consistent approach complex and difficult to achieve. The caution for Locums is that this can be very confusing, especially if they work in one area of the UK where there is a unified approach in place and then they choose to work in another area, where this approach is yet to be implemented and the policies once again differ significantly.
The introduction of the ‘Unified-Do-Not-Attempt-CPR-Form’  represents a significant step in the right direction for standardising the approach relating to decisions concerning CPR. The concept is quite simple but very effective and just involves the appropriate professional completing a resuscitation form. Ideally this form should be initiated in the Primary Care setting, and therefore should be a GP, but it can be commenced when the patient is still in the Secondary Care setting. Its significance comes from the fact that once the decision has been made it doesn’t mandate the process be revisited just because the patient may move between different settings prior to their death. Of equal importance, is it is recognised by the Ambulance Service and will therefore prevent inappropriate CPR if the service is contacted, when previously Paramedics would have been duty bound to act. The paperwork is transferable to all services.
It isn’t without its criticisms. The decision is only applicable if the lilac form stays with the patient at all times (or can be easily found) regardless of their setting. There are reports that this is much easier said than done, and forms often get lost and need re-writing. The fact that it is currently only available in a paper format when most services are working towards an Electronic Patient Record is also another area of weakness and a potential pitfall.
The introduction of the Unified DNA-CPR Form is in varying degrees of implementation across the UK. Due to the positive impact the process can have on patients and their families, there needs to be increasing amounts of pressure from all healthcare professionals to ensure that there is rapid roll out in those areas that are lagging behind, or have yet to embrace the idea.


CQC – A hindrance or a help?!

For many employed within Primary Care the very mention of a pending CQC inspection is enough to trigger anxiety, panic, fear and frustration. These emotions can be felt by every member of the team regardless of their professional roles and responsibilities, even more so when there is an overwhelming feeling that we just don’t have the resources to do what we do currently any differently. With recent news that the Organisation intends to increase the amount of unannounced visits over the next couple of years many are left pondering whether clinical staff will ever get an opportunity to see patients again or just be forever lost in a constant and never ending sea of paperwork?
The CQC prides itself on monitoring, inspecting and rating health care providers, making bold claims that this is done in partnership with the teams who deliver those services. A rating is given in accordance to how safe, caring, effective, responsive and well-led that service is and then this is published nationally. Why then, when most of the Primary Care workforce take such pride in our work and when nobody gets up in the morning to go to work and do a bad job, is this Organisation able to illicit such negative emotions in the run up to an inspection? Why does the very mention of the Organisation unite the profession into calling for its immediate dissolution?
Here at we have put together a few potential reasons why:
– The amount of preparation and work required for a Practice to survive an inspection is substantial, and heavily bureaucratic. Despite what the Organisation claims, it is not always reflective of a diverse and modern health care system with many inspections being reported as being undertaken with an autocratic ‘we know best approach’ rather than a collaborative approach to dealing with real issues.
– The inspections are dependent upon data being readily available, up to date and correct in order to make a rating. Often, data comes from multiple sources, is difficult to collate and across England transparency in dealing with data and presenting it varies significantly, with the reasons why being multifactorial.
– Poor ratings often result in job losses and staff replacement, rather than addressing root causes of problems and working with leaders to resolve the system problems which are often out of the control of the staff leading the services.
– CQC inspections are often the ‘final nail in the coffin’ for struggling Practices and can destroy the last vestige of hope and morale currently keeping that Practice afloat. Surely an injection of resource, support and leadership is much more effective than an injection of inspectors telling disillusioned staff what they already know? If this results in the closure of a Practice then this causes additional pressure to other Practices who have to pick up this work and as such, care if often compromised.
– Ratings should not be issued on the basis of a single visit and some consideration should be given to how responsive that Practice is in dealing with any identified issues and what systems and processes are put in place to deal with them.
– Some GPCs have called for the CQC regime to be abolished and replaced with a proportionate and fair system that empowers and supports Practices to improve without recourse to an unachievable action plan.
– The CQC does not take into account resource allocations when considering ratings. When the BMA reviewed CQC ratings from 2814 GP Practices in England from 2015 they found that practices with the highest ratings received more funding per patient.

  • Practices rated as ‘outstanding’ received on average £152 per patient
  • Practices rated as ‘good’ received on average £140 per patient
  • Practices rated as ‘needs improvement’ received on average £128 per patient
  • Practices rated as ‘inadequate’ received on average £111 per patient

The correlation between performance and funding per patient are not shock findings, they are common sense. The CQC does not take this into account when issuing ratings, but maybe now that so much importance is being placed on finances driving our services influencing their sustainability, this is the time that funding should be published. This may in some way act as some consolation that at least people may have some ideas of the real pressures that Practices face.
For Practices who have an inspection pending then the BMA have released advice and guidance in relation to this and this can be accessed via this link


Medical Revalidation – Under the Microscope

Revalidation started on 3 December 2012 and the vast majority of Doctors are now reported to have undertaken the process at least once. Opinion on Revalidation is extremely divided and this can be a contentious topic of discussion, especially when one considers how much time, energy and effort GPs and their partners have to invest in order to work through the process and demonstrate the requirements. It is absolutely essential that GPs provide up to date and evidenced based treatment to patients. Nobody can argue that this should be done by competent, compassionate and resilient GPs who are caring and sensitive in their approach to patients and their families. What many GPs are disgruntled about is where they are finding the time to complete Revalidation. With constant pressure from rising workload demands, attempts to ensure quality is never compromised and the rising expectation to undertake non-patient facing work and additional roles, many GPs are having to tackle Revalidation in the evenings after an exhausting day in the Surgery or during their downtime.

If Revalidation creeps into social and leisure time then surely this will have an impact on the resilience of GPs, their ability to deal with stress and may bring about one of the conditions the process has been brought in to root out, unstable Doctors! For Locum colleagues the process can be even more daunting with concerns being raised in relation to finding not only time, but a Responsible Officer to undertake the review. One only hopes this process is not having an impact on the current poor recruitment and retention rate across the whole of the medical profession. Is it just becoming too difficult to maintain one’s licence in the face of just wanting to treat patients?

Two significant reports have been published in recent months that aim to review the effectiveness of the process for both patients and for colleagues. The hope is the reviews will help to identify what doesn’t add value and what needs to improve.

The first report, a GMC sponsored evaluation, is a report by an independent collaboration of researchers referred to as UMbRELLA. The survey reveals some encouraging feedback that the process may be having a positive impact on practice especially when used in line with appraisal. Other important findings include:
• 90% of doctors have had a medical appraisal in their career; of this group, 94% have had an appraisal in the past 12 months
• 42% of doctors agreed that appraisal is an effective way to help improve clinical practice
• 32% thought that revalidation has had a positive impact on appraisal, with a small number saying that the impact has been very positive
• Doctors who got feedback from patients said it is the most helpful information to support reflection on their practice
• Some specialty doctors have highlighted difficulties with collecting patient feedback.
The Department of Health commissioned the second report and the main findings include:
• Revalidation has led to important changes in the way that medical performance is managed and assured
• It has helped to integrate sources of information within organisations, therefore giving the Responsible Officer the authority and scope to bring together information on performance and to act upon it
• There are issues around variation, especially from organisation to organisation, and as such there are still considerable areas of the process that could be more efficient and effective.
In short, the jury is still out as to how much value this process adds to safer and better quality of care for patients. The process is full of good intentions but there is still considerable work required to make it user-friendly and less time consuming. Currently, countless hours are not accounted for when referring to guidelines online, discussing cases with colleagues and referring to the BNF. One useful tip is to ensure that you use the GP Notebook  CPD tracker when you are quick referencing guidelines during Surgery, as this may add up to a few hours through the course of the year.