A simple story that illustrates why sick patients need a local GP

31/12/2011

Here is another story about caring for a patient at a distance

On a Tuesday in July 2011 I was taking the midday phone calls. A patient who had been seen that morning by one of my colleagues rang for further advice. My colleague had diagnosed a likely pyelonephritis and prescribed antibiotics, and sent a urine specimen to our local hospital for analysis. Pyelonephritis is a serious condition which not infrequently needs hospitalisation. The patient, under thirty and otherwise a fit and healthy person, was having shivers and felt the need for further advice. I told the patient that the ‘shivers’ might be due to a temperature and what to do about that, but that it might also be due to rigors due to the infection spreading to the blood. I advised that he/she continue taking the antibiotics, and take medication to lower his/her temperature, and to ring again if the shivering persisted or if he/she became more unwell.

The next afternoon at about 3pm the patient phoned again. The patient was still quite unwell. As it happens, I had been invited to speak to a group of mainly pyschotherapists about this blog, this Protest, and I was getting ready to leave for this meeting. I could see that the patient lived 2 blocks from the surgery and I thought I could drop by on my bicycle on the way to the meeting. I told the patient that I felt he/she needed to be seen. The patient said he/she would come to the surgery; I said to come straight away.

It took the patient 45 minutes to arrive. I assessed the patient, spoke to the duty medical team at our local hospital; we would continue to manage the patient at home, but if he/she got any worse, hospital review and possible admission would be necessary. I gave the patient a letter, in case he/she needed it.

The patient then said that he/she had moved address, and now lived in Hackney, a neighbouring borough. The patient had had to come to the surgery by minicab, hence the delay in getting to the surgery. The patient said: ‘This really does not work for me. I’ve moved but did not want to change doctors, but this does not work.’ What the patient meant was that getting medical care under his/her present circumstances was difficult, due to the distance.   In fact, it did not work.

I told the patient that this had been my experience: looking after patients at a distance becomes more complex, and often unworkable. It works fine for patients who are well and do not need medical attention, but does not work if the patient becomes ill. I told the patient I was about to speak to a group about this problem, and the fact that the Health Bill was seeking to abolish practice boundaries and allow patients to register with a GP of their choice, regardless of where they lived. The patient said this did not make sense. I agreed. I encouraged the patient to find a local GP.

The next day the results of the urine test came back: the patient did in fact have a urinary tract infection, and the antibiotics she had should have treated the infection. I spoke with the patient on the phone; there had been an improvement. I warned him/her that if this recurred, he/she would need further investigation.

This is a simple story. It illustrates the problem well. The patient had delayed registering with a local GP because there were problems (limited choice given his/her new address). When he/she became ill and needed to see the GP, the practical issues became evident.

A core part of our work is looking after people who are sick. Sick people are less mobile. There is no getting away from this very basic fact. That is why patients need a primary care practice which is local, not distant. Distance is a barrier to care.


Surely, nobody would be that stupid. Illustration 1

14/05/2011

Let me illustrate the mechanics of providing standard primary care to a patient who is relatively well. This is a real patient, this really happened, and recently. This type of consultation and follow up is the bread and butter of general practice.

The patient is a professional lady in her late twenties. Let’s call her Alice. It takes her 5 minutes to walk to the surgery. She attends on a Monday morning with symptoms that may be a urine infection. She had a urine infection several months ago, and she is getting some lower abdominal discomfort; she wonders if this is another infection. I take a urine sample, dipstick it (that means putting a test strip into the urine; the results can give us a sense if there is an infection); the test is equivocal. I prescribe the recommended first line antibiotic treatment in this situation, and send the specimen off to the hospital for testing (this gives us a definitive answer). I advise the patient to ring later in the week (on Thursday or Friday) to check on the result.

Our specimens all go to the Royal London Hospital, and the results come back to us electronically and appear in our pathology inbox. We check through the results on a daily basis.

On Friday afternoon at about 3pm, I check the results and come across the urine result for Alice. It shows that she does indeed have a urine infection, but that bacterium causing the infection is resistant to the antibiotic I prescribed to her on Monday. So I ring her to let her know. She is still having symptoms, and needs a different antibiotic (the result tells me which one will be effective). Alice will not be back home from work until about 8pm so will not be able to collect a prescription from us Friday evening because we will be closed. So I arrange for her to collect the antibiotics from a local chemist that is open until 11pm. I ring the chemist whom I know well; he takes the details; I generate the prescription and put it in a tray designated for this particular chemist. One of his staff will come the following Monday to collect the prescription.

Now lets replay this real-life scenario with Alice living outside the practice area, as she has moved. Let’s say she is living in Brixton which is a one hour journey by public transport (you might think that patients would not remain registered with us at this distance: not true at all, it happens all the time). Will Alice think it is worthwhile to travel one hour to see us (actually two hours because she then has to get back home). Maybe she won’t come to the surgery, maybe she’ll ring. Let’s say she rings: over the phone I am able to decide that she might well have a urine infection; but I can’t check her urine, nor can I send the urine to the hospital lab. I’ll just have to prescribe without sending a urine. Fine, but how is she going to get the prescription? Well, I can probably send a prescription to a local chemist but that will mean ringing the chemist (getting her to choose a chemist, look up the number online), requesting the item to be dispensed, and then sending the prescription in the post.

Now come Friday I don’t ring Alice because I don’t have a urine result to tell me that the treatment will not be effective. She doesn’t ring me (in real life Alice does not ring on the Friday, I ring her). Her discomfort persists, so she rings us again the following week. We would prefer to get a urine sample from her, but she is not keen because she is really busy and does not have the time to cross London to see us. So all I can do is prescribe another antibiotic and go through the same procedure.

Or rather than ring me in the first place, Alice might go instead to a walk in centre in Brixton or to A+E. They will probably not take a urine sample, but if they do it will go to back to the requestor (it certainly will not appear in our pathology inbox, only items from the Royal London Hospital reach us in this way). Our practice will be charged for the A+E attendance, and this is problematic as we are already overspent on our secondary care budget.

Now I hope it is clear that the first scenario is much more satisfactory for the patient, for the treatment and investigation as a process, and for me as the provider. The second scenario provides poorer care, with more time spent by me, and potentially an additional cost if she attends a walk-in-centre or A+E.

Why would you design such a system? Surely, nobody would be that stupid.

 


Distance from practice: some recent examples

30/01/2011

The following are some examples to illustrate why registering with a GP at a distance has its problems. These examples are all within the past 6 weeks.

1. A man in his late twenties consulted one evening. At the end of the consultation, having dealt with 3 separate health issues which he said he ‘had saved up’, it emerged that he had moved to south west London. I said he would have to get a local GP; he was reluctant: left to his choice, he would have opted to remain our patient. I pointed out that in order to see me he had to travel more than an hour each way. If he were unwell, what would he do? He said he worked in King’s Cross (about 30 minutes by underground, if there are no delays). But to see me he would have to travel 30 minutes further away from his home, and then over an hour to get home. Was this going to favour him seeing me when appropriate? He agreed that this probably was not a good idea.

People in this situation ‘save things up’ because they want to get it all done at once. The trouble with this is that it greatly crowds the 10 minutes we have; the quality of the consultation is lowered as it is hurried, we over-run and so the surgery is then running late which affects others.

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2. Patient L is in his/her 50’s. L has been a patient of our’s for years. L moved out of our area, about 2 miles away (15-20 mins each way), some years ago. L was removed from the list, but re-registered at a local address. We subsequently found out L was not living there. L was removed from the list last November but continued to come for repeats but did not register with a local GP. L became unwell in December; L had appointments to see us but did not attend because L’s problem meant that L felt unable to leave home. It was not possible to make a diagnosis over the phone; L needed to be seen in person. Had L lived in our area, we would have visited. L attended A+E on two occasions; on the second occasion, L was admitted with a serious condition, and also an underlying cancer.

We provided prescriptions after discharge (though not registered with us), and did our best to get L registered with a local practice.

[6.8.11: This patient has since died.]

This experience has made us more determined to insist our patients get registered with a local GP: for their welfare.

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3. Patient Q had surgery and needed daily dressings. Q’s address was near the surgery (less than 1 minute), but Q had moved 2 miles away, into a neighbouring borough (15 minutes each way by car, unless traffic). Our district nurses visit patients within our patch. They are overstretched as it is, and do not have the resources to see patients in neighbouring boroughs. Had Q been at Q’s registered address, Q might have been able to see our practice nurse, or have a district nurse visit. Instead, Q travelled to the hospital A+E to have it changed; quite an inappropriate model for care, and costly.

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4. Patient F recently had major surgery. When discharged from hospital, F went to stay with relatives about 2 miles away (travel time to surgery 15-20 mins each way by car). F probably had a wound infection; I diagnosed this over the phone. I would have preferred to have seen F, but cannot afford to go visiting as time does not permit. Not a desirable model of care.

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5. The A family, two parents, three children, moved out of the area, 5 miles away in a different borough. Mrs A has chronic diseases with reduced mobility, and hardly gets out. In recent years, most contact had to be on home visits (5 minute walk). Various services were in place for Mrs A; these services are run for borough residents and do not extend to where they live now. Left to their decision, the A family would have opted to stay with us. This would have led to disastrous care, a model of how not to do it. We had to insist they get a local doctor and in the end had to remove them.

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6. Patient S is in his/her 50’s and lives alone; S has a chronic neurological condition which reduces S’s mobility. S was rehoused about 2.5 miles away (travel distance for me 15-20 minutes each way by car). At the moment S is able to manage public transport and wants to remain our patient. I sympathise with S’s request; but I explain that if S becomes unwell, the GP needs to be able to get to S’s home easily. ‘That’s ok, doctor, I will call an ambulance,’ S says. I explain this would not be appropriate. I liaise with a practice local to S and he/she should be able to register with them. I assure S that if S moves back to our area, we will re-register S immediately, without delay.

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These are all examples from the past 6 weeks. In each case, distance is a very real barrier to care. In some cases, this barrier makes things unsafe. In all cases it leads to inefficiency and corners being cut. At a time when we are being asked to make efficiency savings, this government wants to introduce a policy that, in its very design, will increase inefficiency considerably and in some cases be unsafe.

I have only listed here examples of patients who have moved a relatively short distance outside our practice area. On the face of it, you might think this would not make much difference. In reality, it does make an enormous difference.

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Oh, it has occurred to me to mention 2 instances which highlight in a positive vein what goes right when patients live nearby. Both examples are from last week.

Patient T has a serious mental illness. Patient T came to the surgery seeking help (3 minute walk); T was assessed. My colleague spoke with the relevant mental health team and arranged an urgent assessment at home; T returned to the surgery again and saw my colleague; the community team came to the surgery to give my colleague the necessary papers to sign; the patient was admitted to hospital. This could not have happened if the patient lived 2 or 3 miles from the practice.

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Patient R is receiving palliative care at home and is in the terminal phases. I visited the home 3 times last Friday (less than 2 minutes walk). Family members came to the surgery at one point to seek help (less than 2 minute walk). This meant that things were put in place to maximise care for the weekend. This could not have happened if the patient lived 2-3 miles from the practice.

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Politicians, please take note. Please engage critical faculties. Do you want choice or do you want quality?