Patient care, technology, and the new frontline

15 May 2020

Finally, a diagnosis

The letter we had all been dreading arrived in our electronic inbox on Monday. It sat, initially innocuously, among 72 others – its malevolence still contained.

One for all the partners to read, it told the news we had expected: after a long inpatient assessment, Mary’s lung cancer had finally been diagnosed and she was being discharged home for palliative care.

I hope you are like me and are blessed with great partners and colleagues. Within minutes of reading it, my colleagues Alan, Marie, Naomi and I were already two steps ahead with our planning.

To us, Mary is not the lung tumour in bed three: “Please get pharmacy to hurry with her medications - we need this bed free”. She, to us, is Mary.

Mary

Mary is a fit 72-year-old lady who never married. She lives with her partner of 23 years, but he is 82 and becoming frail.

She didn’t have children and relies heavily on her niece, Betty. There are tensions and fights with various family members, but we will have to attend to them, too, responding to their exacerbations of long-term conditions such as mental health and chronic pain.

Mary was successfully treated for lymphoma 20 years ago and her frequent attendances to our surgery after this were shaped by fears of recurrence. We also diagnosed and cared for Mary’s brother eight years ago, so we know she will be influenced by her experience of his treatment and death.

Mary loved fashion and was always very stylishly dressed when she attended me in surgery. Not extravagant or dressed up, but more how my mother would describe as “well turned out.”

Care and comfort

In one of my favourite poems, ‘Let me die a young man’s death,’ Roger McGough pleads the reader for:

 “not a clean and in between
 the sheets holy-water death”

However, knowing Mary as we do, if she is not “Clean and in between the sheets”, we will not have been true to her.

Her appearance is very important to her and she will want to be clean and well turned out, so knowing that her niece will be able to do her hair (she is a hairdresser) is important.

Of course, as expert medical generalists, we will manage her syringe driver, dyspnoea, pain and all other symptoms well. To me, though, it is this real intimate, personal knowledge of our patient that makes general practice such a rewarding and privileged job.

Our relationships with our patients

Relationship-based medicine is a key priority for RCGP Chair Professor Martin Marshall during his three-year tenure, and I think he is onto something very special.

As we can see with Mary’s care, it is not just pharmacology and chronic disease management that we need to be good at, and I wonder how we would have gleaned some of this personal information without meeting Mary face to face over the years.

Beyond the pandemic

As we start to look beyond COVID-19, RCGP is working hard behind the scenes to influence government on how our profession should look after the crisis.

Which ways of working helped us and our patients? What things didn’t we like so much?

I was very honoured on Monday night to host a special meeting on the subject that included our Executive, Council, Members Forum, First5 Liaison Group, Federation Chairs and invited guests to feedback into these important questions.

A valuable debate

The debate was very informative and helpful; thank you to everyone who participated.

Several themes recurred, and they centred around how technology had been very helpful, but our current situation cannot be considered the ‘new normal’.

The difference between telephone triage and telephone consultation was emphasised as was the risk of inadvertent health inequalities to patient groups who didn’t have good access to the technology.

Our relationship with our patients, and continuity of care was highlighted as important, as was how this had been achieved over years of work and contact.

Multidisciplinary teams

The most striking theme to me throughout the evening was the importance of multidisciplinary teams (MDTs).

Talking about MDTs now seems like another world ago, but the variety of different ways MDTs can offer solutions to the myriad of challenges we face became ever more evident over the discussion.

There is still time to feedback into this debate, so if you have any suggestions please  get in touch with me.

Feeding back to the Government

I was delighted to take this feedback straight to the top of government on Wednesday, when we met health minister Robin Swann for a teleconference. It is hard to believe that the above photograph with myself and our Deputy Chair Policy Ursula Mason was taken in February. 

When we exited his office that morning, we bumped into Department of Health Chief Medical Officer Dr Michael McBride who in retrospect was approaching the minister to make COVID-19 become a notifiable disease.

Little did any of us realise how much all our lives would change after that day. 

The minister was genuinely very complementary about general practice and how we showed incredible flexibility and ability to adapt to the crisis to meet our patients’ needs. He specifically asked to pass on his personal thanks to all GPs and I do so with pride here.

Some much needed support

We were able to raise with the minister some specific issues about the need to incorporate flexibility of funding into the MDT projects, but our most important message was the opportunities MDTs offer to support our patients and practices.

The mental health practitioners and social workers are needed in our practices now, and we highlighted to the minister that our adaptability as a profession would ensure these new team members could go to work right away and start to meet the demand of the impending tsunami of mental health issues affecting our patients.

Technology in general practice

Thank you to everyone who participated in our technology survey which received over 100 responses. It found that 40% of GPs still don’t have access to remote working and many had difficulty accessing a laptop.

Access to remote working is important and having good IT systems in place will ensure GPs can still work, even when unable to get to the surgery. The survey is designed to open a bigger conversation about technology and how it can be used as a tool to provide best care for our patients.

On the back of this work, we will be able to lobby and raise bigger issues with government about “macro” technology issues such as fast broadband speeds, 5G rollout and Voice over Internet Protocol (VOIP).

We can also lobby for other specific projects which will help patient care, such as electronic prescribing, photo dermatology and mobile notes access for home visits. Read our statement on our call for government to implement a dedicated technology plan.

Abortion guidance

At the start of the month, we had a good meeting with Professor Colin Melville, Medical Director and Director of Education and Standards at the General Medical Council (GMC).

The new Abortion (Northern Ireland) (No. 2) Regulations 2020 came into effect on 14 May 2020 and we recognise that this issue generates a range of opinions from all our members, as well as our society. Our discussion with the GMC was to ensure that we act within the law and rules as outlined by our regulator.

GMC has clear guidance to help professionals with personal beliefs. We raised the issue that these documents are not very visible from the main website and they have taken on board our feedback.

Services continue to be delivered in Northern Ireland and more information can be found on the Informing Choices NI website.

The new frontline

Our care homes are now very much the frontline of the COVID-19 battle. Please continue to reach out to our care home colleagues and be as proactive as you can.

I had a good chat with Johnny Burns, Chair of Causeway Federation, about his experiences with Causeway Federation’s Anticipatory Care Service Model last week.

What I liked about this model was the continuity of care it afforded to the patients and staff in the home, how the Trust recognised its responsibilities, and how this translated into additional resource for services, such as extra speech and language support. Whenever we emerge from the pandemic, it is likely our relationship with care homes will be different.

There is good evidence to suggest care homes that are provided by a sole GP practice provides the best care and we will support our local medical committee (LMC) colleagues to negotiate what is best, should this opportunity arise.

World Family Doctor Day

As you can see, the importance of good primary care during COVID-19 is being recognised by governments around the world.

Next Tuesday, 19 May, is World Family Doctor Day and will be promoted by the World Organization of Family Doctors (WONCA). Your membership of RCGP automatically makes you a member of WONCA and its website is well worth investigating.

RCGP has good access to international work, including a Junior International Committee.

Travel is restricted at the moment, but if any of our First5 members are using this time to plan to work in family medicine abroad, please get in touch and we will help you by using our contacts to broaden your horizons.

Dr Manning's thank you

The President of WONCA has recorded a special message of thanks for all family doctors. It features the Chief Executive of WONCA Dr Garth Manning. Garth lives in Belfast and is a graduate of Queen’s University.

 

He has a very interesting CV, having delivered primary health care development projects around the world. It is terrific to know that Northern Ireland is providing global leadership in primary care through our British Journal of General Practice, and WONCA, and I have no doubt that when MDTs are fully established, they will truly be the envy of all other countries.

GPNI webinars

Finally, GPNI is hosting another in its series of excellent webinars on Wednesday 20 May entitled 'COVID-19 primary care update and what happens next?'

I am delighted to have the opportunity to join with Dr Margaret O’Brien (Head of General Practice, General Medical Services, The Health and Social Care Board ), Dr Alan Stout (Chair of The Northern Ireland general practitioners committee (NIGPC)) and Professor Charlotte McArdle (Chief Nursing Officer Northern Ireland) to answer your questions.

These sessions are always well attended, so if you can send in your questions in advance to GPNI, it will help to ensure your voice is heard. 
  
I hope you have a restful weekend – please get in touch and tell me your stories and what is important to you.

Email: ChairNI@rcgp.org.uk
Twitter: @laurence903


Post written by

Dr Laurence Dorman, Chair of RCGP Northern Ireland

Dr Laurence Dorman took office in November 2019 after three years as Deputy Chair of Policy for RCGPNI. A GP principal in Mourne Family Surgery, Kilkeel, Co Down, since 2007, he is the fourth generation of GPs in his family. He was also, until recently, the Chair of Newry and District GP Federation. 

Laurence has particular interests in new ways of working in primary care, cancer care, and inspiring the next generation of GPs. He set up the successful 'Dear Colleague' initiative to improve the interface between primary and secondary care and has been a Strategic Advocate for Interface and Communication since September 2017.

During his time as Chair, he wants to support College members to ensure that the future of GP services is protected, supported and sustainable.

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