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GP workloads are now at saturation point.

During recent years, there has been a widespread and shared belief, amongst many GPs and others working in Primary Care that workloads have increased exponentially. The Government has failed to resource adequately for this and, as such, not only is this having an impact on the health and wellbeing of GPs, it is also at times affecting their ability to provide safe and consistent levels of care.

It is now commonplace for the media to sensationalise issues occurring within Primary Care concerning the supply and demand of services and the impact that this has on other frontline services. Most GPs want the best for their patients and, as such, the increase in workloads has been raised repeatedly and consistently with the Government, only for these concerns to be rebuffed, by both NHS England and the Department of Health, with promises of thousands of extra staff in Primary Care by 2020.

Despite the attractiveness of thousands of more staff in 2020, a new study in the Lancet led by researchers from the BMA and the Royal College of GP’s, provides clear objective evidence of what GPs have been saying for years and demonstrates that action must be taken now.

The key messages from the study, which covered over 100 million GP and Nurse Consultations at 398 practices in England during 2007 and 2014, include:

– ‘There is a substantial increase in practice consultation rates, the average duration of the consultations being given and the total patient-facing clinical workload.

– GPs are facilitating more consultations than ever before for patients who are living longer, who often have multiple long-term conditions resulting in a complex presentations of symptoms that cannot be dealt with in the previously allocated time.

– Due to the change in nature and volume of workloads, GP practices and their teams are working harder than ever before, but struggle to provide basic levels of care as services are overwhelmed.’

The impact of inaction in the face of such significant objective data could be disastrous not only for staff but for patients also. With many GPs now facing the prospect of burnout or feeling the impact of being overworked, over tired and exhausted the results could be damaging for patients especially if this results in substandard care, harm or misdiagnosis.

Compounding these issues are figures released from Health Education England, who have revealed that one third of GP training places still remain vacant. Despite this representing a 1% increase on last year’s figures these results are second lowest recruitment results of all the specialities. This is not unsurprising as in 2015; GPs in England reported having the lowest job satisfaction rates since records began in 2001.

The solution for many of the problems reported across the NHS, according to the Government, is a greater shift towards ‘place based care’, a new model being explored to reduce the burden on the acute care system. However, without a serious focus on patients’ and communities abilities to self-care and make the most of non-traditional services, such as the extended pharmacy offer, the ‘place-based model’ will only once again serve to shift the burden from acute to primary care and resulting in further pressure to under-resourced and overworked GPs, and once again endanger the whole system of collapse.

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Fallout from EU Referendum.

On the 24th June 2016 the people of the UK made the decision to leave the EU, a decision that has since sent shockwaves across the entire global community. Politically, this has sent the country into chaos with changes and challenges of leadership across the three main political parties. Economically, the impact is widely expected to result in recession in the UK, which could then have a knock on effect and force other EU countries down the same path.
With the decision to leave predicated on strong views concerning NHS Funding and Immigration policies, it now seems ironic that these two issues, along with economic gloom, once again plunge the future sustainability of the health service further towards uncertainty. Furthermore, with the ‘Leave’ campaign distancing themselves from claims that were made indicating that funds previously sent to the EU could be reinvested into the NHS, this is an uncertain time for many of the 110,000 EU healthcare workers who already work tirelessly to deliver more with less resources.
Previous estimates relating to shortages in both the future Medical and Nursing workforces may potentially pale in comparison to the reality, especially when one considers that the UK has traditionally tried to fill existing gaps in healthcare workers from abroad. A huge majority of these workers – 10% of Doctors and 20,000 Nurses, have come from other EU countries. With already rising social unrest and concerns over existing immigration policies the current challenge of motivating, recruiting and retaining an already disenfranchised GP profession will continue to escalate, especially if no help is perceived to be coming from anywhere other than inside the UK. The GMC is currently exploring how doctors from the EU will be granted access to the UK medical register once the UK is no longer a member state. As it stands, the EU vote will have no impact on the current registration of any doctor on the register, but there may be implications relating to regulation in coming years.
In the aftermath of a heavily sensationalised and manipulative leave campaign, many of us now ask if it was right to trust such an important decision to the people, especially when the outcome now stands to jeopardise so much. Should this have been left in the hands of people with the power, knowledge, experience and understanding to assess the impact on our services, our economy and our health care system? It’s too early to be able to ascertain with any great certainty, but one thing is for certain there is an ageing population. By limiting free movement of skilled workers, we are widening the gap concerning demand and supply for our health care services and we are pushing our already heavily burdened finances a step closer to the brink of destruction.

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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.

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CVD risk calculations error

Following a statement issued by the MHRA, an investigation has been launched into how a digital calculator (QRISK2) used by GPs to assess the potential risk of cardiovascular disease, has resulted in incorrect risk estimation scores being calculated. The SystemOne’s version of the QRISK2 calculator is used in more than 2,500 practices across the country and it is now thought that incorrect scores could have been determined for potentially hundreds of thousands of patients, dating as far back as 2009.

The MHRA confirmed that it was only the interaction between QRisk2 and SystemOne that have caused the alert and this must be reiterated to patients when concerns are being raised. Having said that, this is a major system error, one that could potentially result in a loss of confidence in the tool and one that could create a lot of additional work to already excessive GP workloads.

The risk to patients can vary and includes:

– Thousands of patients may have been prescribed statins when they are not indicated.

– Patients who should not be on statins may suffer unnecessary side effects from being on them.

– Patients may choose to stop their statins because of a loss of confidence in the decision making process. This may cause cholesterol to return to dangerously high levels in just a few weeks.

– The risk of a cardiovascular event from not being on a statin, when in actual fact one should have been commenced.

The numbers of patients affected by use of the tool are thought to be low because this is a tool to aid to clinical decision making. Therefore, the hope is that only a small number of patients will require changes to their CVD management plan. If only one patient is affected by a software system error this, however is one patient too many. GPs and the company that manufactures the SystemOne software system, TTP, are therefore working frantically to enable practices to identify patients to ensure that they receive accurate risk estimation scores and treatment where necessary is altered accordingly.

TTP have temporarily, but only recently suspended the use of their tool until the glitches within the system have been identified. The MHRA are working closely with the company to get to the root cause of the problem. One thing is certain, it is going to take a lot of time and reassurance from TTP before many GPs find confidence in this particular brand of the tool, especially in the face of so many other competitors whose end product is much more reliable. In the meantime GPs are advised that if it is necessary to use an algorithm to assess a patients risk then QRISK2 is available at www.qrisk.org

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Leadership I – GPs as Leaders, what’s your style?

The evidence for strong leadership at every level of the healthcare system has never been more compelling with research proving that good leadership skills can have a positive impact on effective team working, the health and wellbeing of team members, quality of care, patient experience and patient outcomes. During recent years huge amounts of money have been invested in leadership development across the whole spectrum of the NHS aimed not only at those who manage services but with particular focus towards clinicians.

GPs have an intrinsic leadership role within health and social care services and therefore are essential in the effective delivery, running and future delivery of these services. Both ‘The NHS Five Year Forward’ and ‘General Practice: Forward View’ recognise how significant this role is and therefore it is essential for GPs and others within Primary Care to embark on leadership development programmes. Development within Primary Care should now begin to match pace and scale of colleagues within Secondary Care who are much further along the road in relation to the importance placed on leadership development.

Indeed much can be gained from developing GPs as leaders in as much as it enables resilience, adaptability and collaboration in the face of the difficult working conditions that are faced daily. With services being delivered through more interconnected and interdependent organisations in order to nurture, develop and maintain these relationships, collaborative and transformational leadership skills are required, as health care moves across traditional boundaries.

The reality is that the people in the system know it the best and therefore it is essential for them to get involved and lead the way. The reality for GPs however, are that full clinics, numerous home visits, unnecessary workloads, staff shortages and extreme demands on the service result in very limited non-patient facing work being completed. In a system that has no time it seems incredibly ill conceived that the very people who need time, energy and resource spent on them to develop them as leaders cannot be released because this will leave no one else to do the work. How will we ever get the best out of GPs, get them to think differently and enable them to use their skills and their knowledge to get the best out of people, services and the most from their patients without running them into the ground?

Recognising how difficult it is to get time away from work to focus on leadership development, this is the first of a series of blogs on the topic. In this first series you are asked to consider;

  • Which leadership style you most closely associate with?
  • Which leadership style do you use in your daily work life?
  • Which leadership style is your dominant preference?

Leadership styles describe a person’s habitual behaviour when confronted with any number of managerial situations. They can be influenced by personality, values, preference, culture, team/organisational culture, the response of others and behaviours learned from others such as mentors or colleagues. The concept of leadership styles is based on work by psychologists Litwin and Stringer at Harvard University. Each of these styles has pros and cons when being used, especially if the behaviours that arise have damaging effects towards patients or colleagues. No single style is effective in all situations but rather leaders need to ensure they’re able to adapt to different situations with different styles to get the most out of people and not just a quick win.

 

Leadership style and definition

These styles are effective when….

These styles are least effective when…

Directive:

“Do it the way I tell you”

Effective when the primary objective is immediate compliance

– Applied to relatively straight forward tasks

– Used in crisis situations

– Deviations from compliance will result in serious problems

– All else has failed with problem employees

– Applied to complex tasks

– Used over extended periods with self-motivated employees

– Used with individual specialists or talented people who are expected to be creative

Visionary:

“This is where we are going and why”

Effective when the primary objective is providing long-term direction or vision

– A new vision or clear direction and standards are needed (e.g. in times of change)

– A manager is perceived to be the “expert”

– New employees depend on the manager for active guidance

– The manager does not develop employees

– The manager is not seen as credible or if used with experienced employees who are themselves knowledgeable

– Trying to promote self-managed teams

Affiliative:

“It’s important we all get on”

Effective when the primary objective is creating harmony

 

 

– Used as part of a repertoire that includes Visionary, Participative or Coaching styles

– Tasks are routine and performance adequate

– Giving personal help

– Getting conflicting groups/ individuals to work in harmony

– Employees’ performance is inadequate and negative performance feedback is required

– The situation requires direction and control

– Employees are task focused

 

Participative:

“What do you think”

Effective when the primary objective is building commitment and generating new ideas

 

 

– Employees are competent

– Employees possess critical information

– Employees have clear ideas about the best approach to take

– Visionary style has already been used to create and champion a clear overall direction for the team

– There is a crisis, and there is no time to hold meetings

– Employees are incompetent, lack crucial information, or need close supervision

 

 

 

Pacesetting:

“This is the way to do it”

Effective when the primary objective is accomplishing tasks to a high standard of excellence

 

 

– Employees are highly motivated, competent, know their jobs, and need little direction

– Managing “individual contributors”

– Quick results are required

-Developing employees who are similar to the manager

– The manager cannot do all the work personally, and needs to increase delegation- Employees need direction,

– Employees need direction, development and co-ordination

 

 

Coaching:

“Here is an opportunity to practice”

Effective when the primary objective is the long term professional development of others

– Employees acknowledge discrepancy between their current level of performance and where they would like to be

– Employees are motivated to take initiative, be innovative, and seek professional development

– The manager lacks expertise –

– Employees require much direction and feedback- There is a crisis

– There is a crisis

 

(The Hay Group, 2015)