Enfranchising our patients

Blog kindly submitted by Dr Jonathan Mills and Dr Unniparambath Prabhakaran.

With the recently held (and somewhat unexpected) general election in June, this provided an opportunity for us to reflect that as GPs, how we encourage our patients to exercise their democratic rights, and are we aware just who can vote?

Whilst voting can be straightforward for many people who have registered, as GPs we should be mindful of those who are disenfranchised by the very nature of difficulty getting to the polling booth or posting a vote. This is particularly the case for those in care homes, hospital and psychiatric units, where physical health problems restrict participation, or the locked nature of some of the wards serves as a barrier to exercising the right to vote. In the 2010 General Election, psychiatric inpatients were half as likely to register to vote. If registered, they were again half as likely to vote compared to the general population (McIntyre et al., 2012). The majority of those unregistered were not aware of their eligibility to vote or the registration process.

Historically, inpatients in psychiatric settings were disenfranchised in UK general elections as ‘lunatics’ and ‘idiots’ under the Representation of the People Act 1949, before the electoral Administration Act (2006) granted psychiatric inpatients a right to vote whether they were informally admitted or detained under the civil sections of the Mental Health Act 1983 (MHA). Thus psychiatric patients have a right to vote personally, or by proxy, and should be encouraged to register to vote and exercise that right should they choose. For clarity, patients who are sectioned under civil sections of the MHA (this also includes prisoners remanded to hospital under the MHA on Sections 35, 36 or 48) are entitled to vote (Royal College of Psychiatrists, 2015). However, prisoners detained after conviction of a criminal offence who are ordered to hospital be the courts and those who have impaired capacity (which includes dementia) do not in themselves demonstrate legal incapacity to vote, and these individuals should be supported if they intend to register and vote (Royal College of Psychiatrists, 2015).

A GP may have patients in the community under care of psychiatric teams, subject to mental health legislation (such as Community Treatment Orders) who are also entitled to vote, despite restrictions to their liberty such orders may pose.

Similarly, patients who are homeless can make a ‘declaration of local connection’ should they spend a significant period of time at a particular address or location. Those in residential and nursing homes may lack the physical ability to go to a polling station, or even to physically mark a ballot paper, but again this should not be a bar to choosing their representatives. Care homes should be encouraged to help residents register and vote. Where someone is unable to vote but wishes to do so, remind them they can nominate a proxy to enable them. As GPs, we work under the premise that adults have capacity until proven otherwise, we should also work under the assumption that patients have capacity to register and vote.

McIntyre J, Yelamanchili V, Naz S, Khwaja M, Clarke M. Uptake and knowledge of voting rights by adult in-patients during the 2010 UK general election. The Psychiatrist 2012; 36: 126-130

Royal College of Psychiatrists, Voting rights for mental health patients, (2015), available via http://www.rcpsych.ac.uk/mediacentre/pressreleases2015/votingrights.aspx Last accessed 18/7/2017

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Working abroad

Here is this month’s Clinical Scenario from RCGP Learning in conjunction with Doctors.net. Several of my peers from VTS training have either worked or moved permanently abroad since qualifying and this seems to be the case nationally. The pull of family needs here and the appeal of working abroad is a very real one – let us know your thoughts on the comments page which you can access from this link http://elearning.rcgp.org.uk/mod/pageplus/view.php?id=7485.

Dr Anderson has just completed his GP training in the UK and has been doing some locum work. He has seen an advertisement for a GP post in rural New Zealand and thinks that he might apply. However, his mother has a long-term illness and he is worried that, if he does go to work abroad, he might not be able to return to work in the UK as a GP should his mother deteriorate and need his help.

Suggested points for discussion

  • What are the rules about UK-trained doctors returning to work in the UK after some time abroad?
  • How might Dr Anderson maintain his right to practise in the UK whilst working abroad?
  • Would these rules be different if Dr Anderson was trained in New Zealand and wanted to come to work in the UK?
  • What other factors might influence Dr Anderson’s decision?

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Difficult decisions

Did you see the brilliant August Special Edition on Difficult Decisions? In case you missed it, there is a wealth of discussion around many different difficult decisions which regularly affect us.

I was really interested in the article ‘The ethics of GP commissioning’ by @gentlemedic, a Clinical Lecturer from Oxford University and Dr Cox, GP with special interest in Ethics and medico-legal work. I work for our local CCG and have to advise with a much wider population view so was particularly interested in this discussion, but also the ethics around the decisions we make to manage the care of our individual patients or practice population.

The great @DuncanShrew writes about the impact on us, of all the decisions that we have to make which was certainly a message which rang true with me. I have heard it said that as GPs we make a decision every 10-20 seconds  – whether to pursue that mention by a patient of chest pain in amongst the other plethora of symptoms, or in amongst a list of 80 medicines management is it ok to re-issue this medication, or whether to read the urgent screen message whilst the patient is in with us or wait until they have left. I remember on more than one occasion of getting home from a long day, my husband has asked if I would like a cup of tea and I have genuinely struggled to answer. Decision fatigue is very real for me.

The article ‘The psychology of uncertainty in difficult decisions‘ is a fascinating closer look at our reactions to the horribly uncomfortable moments of just not knowing what to do easily referred to as ‘WDYDWYDKWTD moments’ (What do you do when you don’t know what to do). The fear that if only a better doctor was seeing this patient or looking at these results because they would obviously know what to do. I recognise that I had these a lot as a trainee, and in no way do I now know all the answers, but having strategies for how to manage the situation is so very helpful. I couldn’t really understand this when my supervisor told me to learn how to manage the situation, it felt like a cop out, that actually we should just work harder to know all the answers. The realisation that we can’t and that our role is also to risk assess is both helpful and daunting. This article is a good opportunity to consider why we feel the way we do in those WDYDWYDKWTD moments. The following article then considers sharing this uncertainty with our patients.

There are also lots of shorter scenarios posing difficult decisions which are produced in partnership with RCGP and Doctors.net with the opportunity to post your thoughts in the discussion afterwards. These are available at http://journals.sagepub.com/Ino/tenminutescenarios?pbEditor=true 

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Latest RCGP Forum Clinical Scenario

A really meaty scenario this month, which has left me feeling very grateful for all the partners in our practice happy take concerns on board.
Don’t forget that you can catch up on all the previous scenarios and discussion too, great for CPD or discussion points with your supervisors.
Medicines reconciliation
 
A GP colleague asks for your advice. Six months previously, he had joined a new practice as a partner. One of the other partners left the practice two months ago after an argument with the senior partner. He is concerned that reception staff are asked to add medications from discharge summaries to patient electronic records. He had noticed a few mistakes that could have been serious. He felt strongly that the whole medication reconciliation system for patients discharged from hospital needs an overhaul. He mentioned this to a couple of the other GPs in the practice who agreed with him, so he brought it up at a practice meeting. The senior partner instantly dismissed his concerns without discussion saying that there had been no major issues with the existing system and there was no reason to change a system that was working ‘perfectly well’.
 
Suggested points for discussion

 

  • What proportion of medication errors relate to errors in medicines reconciliation?
  • How would you advise your colleague to approach this issue in his practice?
  • How could your colleague explore this issue further to find evidence that change is needed?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (August 2017) forum discussion within the OLE:
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Equal Pay

With the BBC releasing today details of salaries of their top earners and having pre-warned us that only one third of these will be female, this month’s Clinical Scenario is especially relevant. It is worth considering this situation from the point of view of the salaried GPs, the partners and as trainees about to apply for jobs.

Equal Pay
Alison is a female salaried GP who has been working for a practice for 10 years doing 4 sessions per week – 8.30am to 6.30pm on a Monday and the same hours on a Thursday. The job is convenient for her as it is close to home and she can easily fit child care around her hours. She is paid £30,000 per year. The practice appoints a new male salaried GP. He works 3 days a week, 8.30am – 6.30pm on Mondays, Tuesdays and Fridays. One day, in conversation over coffee, he mentions that he actually had two job offers and chose to come to this practice purely because their sessional rate was better. He said he was being paid £9,500 per session. He has no additional duties or qualifications compared to her and is newly qualified as a GP. Both GPs are responsible for paying for their own indemnity.
Suggested points for discussion
  • Is the practice allowed to pay salaried GPs doing the same job different rates of pay?
  • Which pieces of legislation might be applicable to this scenario?
  • How might Alison manage this situation?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (July 2017) forum discussion within the OLE:

Drug Monitoring – Primary and Secondary Care Interface

This month’s Clinical Scenario on the RCGP forum is about drug monitoring. It is a really interesting scenario with lots of discussion points. In a time of trying to improve our resilience, it’s cases like this which rightly or wrongly, make me worry. If a complaint came through – what would you do? Do you have a clinical governance process in your practice to review cases such as this? See what you think….

Drug Monitoring
A patient of yours is seen in the rheumatology clinic and diagnosed with rheumatoid arthritis. The consultant initiates methotrexate treatment and organises baseline monitoring blood tests. When checking patient blood results after morning surgery one day, you discover that this patient’s white cell count is 2.9 x109/L. You review the patient’s notes and see that the rheumatology consultant prescribed the methotrexate, requested the blood test and copied you in to the results for information. Therefore you do not act on the result.
 
Two weeks later you receive an out-of-hours report stating that the patient was admitted overnight with a multi-lobar pneumonia. You telephone the rheumatology clinic to discuss the case and discover that the consultant has been on annual leave for 2 weeks and unfortunately the initial blood results were not acted upon. The patient required hospital admission, which led to financial difficulties for the patient as he was self-employed. When you next see the patient in your surgery, he is very angry with you, asking why you did not contact him about the abnormal blood test. The patient is keen to highlight that the correct advice from you could have prevented his illness.
 
Suggested points for discussion

 

  • How might you address the patient’s concerns?
  • How would you discuss this case with the rheumatology consultant?
  • How might you raise your concerns outside the practice to try and prevent this situation from occurring again?

 

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (June 2017) forum discussion within the OLE:
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Busy Blog

There has been lots happening at InnovAiT since my last blog.

Great news that our Spring Podcast is now available. I enjoyed listening to it whilst in the car today! The recommendations from NICE on multimorbidity are discussed which reminded me how crucial we are for our complex and frail patients. In a week where five CCGs have reportedly proposed raising their thresholds for diagnosis of Autism due to service capacity difficulties – it was very topical to hear the discussion on Autism and Asperger’s. I am also delighted to support the STOMP campaign of stopping the over-medication of people with Learning Disabilities which is discussed in more detail in the podcast.

You may have seen the recent National media coverage around GP workload originating from an article in the BJGP supported by the brilliant Professor Chantal Simon. It has helped raise awareness of just how intense it is to be a GP in the current climate. Having positive stories of how hard we are working to do the best by our patients really helps me to feel proud of what we do. It also serves as a useful prompt for me to look at how we are doing within our surgery for capability and work-life balance so that we can continue to offer great care.

We are inviting your contributions for the ‘Difficult Decisions’ Special Edition to be published in August. If you are a keen writer, have something to share or just fancy having a go, you could submit a blog, case study, your top tips or produce your own podcast. We hope to compile an online collection of your thoughts on areas such as Ethical Dilemmas in genetics or perhaps palliative care, how to advise on the best treatment option for a patient – such as a multimorbid patient as discussed in the podcast, or even how best to achieve a good work-life balance – does something always have to give? Take a look at the website for more information – but be quick – the closing date is 30th June.

Our latest Clinical Scenario is also now available. This month’s discusses when your practice staff ask for your medical opinion. See what you would do and join in the discussion…….

Your practice manager, who is a heavy smoker, asks for your advice about a painless lump that she has noticed in her neck. On balance, you decide to agree to an examination and find that there is a firm non-tender swelling of the right submandibular lymph node. Her right tonsil is also enlarged, although she denies any throat pain. At your recommendation, she goes to see her GP, who refers her to the hospital under the 2 week wait.

Suggested points for discussion

  • How would you respond to a member of staff at your practice asking you to provide a medical opinion?
  • What are the ethical arguments for and against giving an informal medical opinion to a work colleague?

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Diverticulosis

Diverticular disease feels so common place that it’s easy to be slightly nonchalant about it. However, the impact it has on the population is significant and even more so for those patients who develop complicated diverticulosis such as abscesses, fistulae or perforation. Interestingly you are more likely to have these if you smoke or take NSAIDs.

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At a time when the importance of antimicrobial stewardship is increasingly recognised, the decision to prescribe a broad-spectrum antibiotic cannot be taken lightly. Having a solid understanding of the clinical features of acute diverticulitis can help with the decision of when to issue.

The article in this month’s InnovAiT by Dr Whatling gives a fantastic overview for what we all need to know in primary care.

To follow the digestive theme in this edition, there are articles on acute gallbladder disease and benign ano-rectal disorders. Amongst other helpful tips, the latter has a good reminder of haemorrhoid staging and when to refer.

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Health Anxiety

In a googletastic time, anxiety about one’s health can be increasingly difficult to support as a GP. The journey as a doctor to understand that the patient is presenting due to their health anxiety, can be a drawn out and difficult one. It can probably only happen well with continuity of care, confidence and a good relationship with the patient. There are many pitfalls along the way.

Here is this month’s clinical instalment available for your thoughts, comments and reflection. See what you would do….

Samantha is 34 years old and a single mother. She has a past medical history of a meningioma that was completely excised 15 years ago. She has been discharged by her neurosurgery team. Two years ago, she presented with recurring headaches. She was seen by a specialist neurologist, had brain imaging, and was reassured that her headaches were tension type headaches and not a recurrence of her tumour. She subsequently asked for a second opinion and was seen by another neurologist who repeated all her tests and came to the same conclusion.

She has always attended the GP surgery frequently, but over recent months has been making appointments every week about her headaches and calling the surgery asking to speak to a GP in between. She is convinced that she has a recurrence of her ‘cancer’.  She is also making frequent appointments for her son, who is well and has no persistent symptoms or abnormal examination findings, and demanding that he is referred for specialist investigation to make sure that he ‘doesn’t have anything nasty’.

father comforting son in tears

Suggested points for discussion

  • How might you manage this lady’s headaches?
  • How might you manage her health-related anxiety?
  • Is her anxiety about her son a safeguarding issue?  If so, how might you manage that?

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Clinical Scenario Forums

You may remember a previous blog letting you know about the new Clinical Scenario forums available on the RCGP  Learning site in conjunction with Doctors.net.

These are now up and running with lots of scenarios to consider how you would handle them. If you have a Doctors.net login you can comment too. It is useful to consider different options of how to manage a situation and these are discussed in the comments below each scenario which can all be used as CPD for your eportfolio.

This month’s, shown below, is around overuse of medication. My thoughts on reading it, was relief that I (hypothetically) recalled the patient and having issued the medication – it didn’t just get buried in amongst the many others. Depending on how well I knew the patient I would either give her a quick call or reject the request asking for more information as to why she needed it, but also copy it into the journal notes that this had happened so that if anyone else received a request they would know. But what do you think? Am I being too keen? Should it be a simple reject and the onus is on the patient to get back in touch? Or perhaps, as it is the first real extra request just send it on? Do comment on the site, or tweet us.

Overuse of medication

While reviewing a batch of prescription queries in the Electronic Prescribing System, you come across a request for a month’s supply of 40 mg citalopram tablets. It is for a woman who you saw last week and it strikes you as odd as you recall issuing her with some medication then. The prescription is not on repeat and so is not flagging as being overused but the date of the last prescription issued is just a week ago.

You check back in her notes and find that she had her usual prescription a month ago, another from you a week ago as she said she needed them early as she was going on holiday. Therefore this is the third request in a month for antidepressant medication.

Suggested points for discussion

  • What would you do in this situation?
  • What safeguards can be put in place to prevent patients at risk of suicide from making extra prescription requests to stockpile medication?

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