A way to streamline NHS

[FairytalesAreBullshit]

With most of us having access to the internet, I know this does exist privately, but maybe surgeries use the internet more to help patients.

Like the patient with a UTI, reflux, skin complaint emails in and the Dr goes ah yes, they need this. Or even a nurse practitioner.

The child with an irritating cough is triaged further with questions, then the typical linctus is suggested. Or the child with D&V is triaged further, if necessary, they're bought in when the surgery isn't full of unsuspecting victims to avoid transmission.

The patients with more complex symptoms get booked into surgery.

A lot of the time if you have several health issues, you fear the GP will have a nervous breakdown if you mention everything you want to ask. Plus a lot of us forget, so emailing ahead, the Dr has the full picture and can deal appropriately.

Or the patients with other chronic diseases, who pretty much know what is needed, say what it wrong and suggest this has worked in the past. GP decides if they need a face to face consult.

For a few patients, it's quite ironic but doing the littlest of things is a big deal, so being able to email the GP with 'ok this is happening,' they might be able to prescribe there and then, or want to see the patient.

Say blood tests have come back, a nurse practitioner could get the results, if we focus on TSH, low or high, patient is told that bloods have shown hyperthyroidism, prescription has been send to your chemist for meds you need to take at a certain time, plus a new bloods form will be posted, so they get retested in so many weeks.

Or the person with a borderline fasting blood sugar, nothing imminently wrong, please book in to have a GTT.

It could streamline how services work, it could make it easier for patients who work and commute. Say John went in and was found to have slightly high BP, they gave him a BP monitor for morning and night, email or write down results and bring back machine. GP / NP takes it from there.

I know some surgeries may use it, I think I read of a woman who ordered meds online for her husband, there was the example he said he had something he didn't to get anti biotics. You'd have to trust that it wouldn't happen often.

For those who love being at the Dr's Surgery, it could really transform things. So say you started a new med, all seems ok, there's no further in person checks required, all sorted quickly.

Leaving appointments open for those who really need to see a Dr ASAP.

They do have the telephone triage system, but with an email triage system, you can get it all on email, instead of losing your nerve as some do and getting cross as the triage Dr/NP is dismissive.

It could work well in hospitals too, with patients checking in with consultants / specialist nurses. Asking any questions they may have forgot or cropped up.

Maybe it's not as simple from an insurance point of view. But last example, Ellie is waiting for ENT surgery, has another bloody infection, Mum knows the signs well. Sorted quick.

Would you use it if it was available?

Some things done by letter do seem to take ages. Not doctor but hospital
I'm waiting for urgent spinal surgery (numbness, pins and needles etc). Saw a consultant 16 days ago and I'm not even on the waiting list yet as the letter hasn't been typed

We have e consulting, but they say not to use if complex issues - I get told just to see same doctor 4 weekly with phone calls or emergency appointments in between. If reception question have been told to explain have ongoing complex health issues . E.g if I say I have UTI they say to contact a pharmacist but as I'm in and out of hospital and regularly catheterised pharmacist and nurse won't see me , has to be a GP. Phone calls are quite good if GP knows me , or if it's just a small issue like needing more meds etc.

Local hospital uses telemedicine so you talk to a doctor via Skype, that's quite good for stuff like simple fractures but not great with anything else. I used it once when I had a minor break in foot and whilst it was OK it was a bit odd. I can see it working in some cases though.

The eConsult option allows you consult online but if the doctor sees anything on your questionnaire that they want to discuss further they will call you or ask you to come in if necessary. It means you only have to go in if its needed.
The practice still provides normal appointments and telephone consultations but having the ability to do this online (as well as booking appointments and accessing your records) means that it's more efficient for everyone.

I would use this service without hesitation. I can never get through to my GP to even get an appointment. It takes over 100 calls to get through on the phone. Any option of contacting them in an alternative manner is a winner for me. I have a job that makes it near on impossible to get an appt out of working hours and I have no option of taking time off to attend appts.

I'm not a doctor but I have used email a lot and work with people who are obsessed with it.

Days spent in pointless email trails of misunderstanding when a two minute phone call would have sufficed.

Online services are useful for booking and changing appointments, sending reminders and opting in/out of screening and other services or requesting a repeat prescription. Not so useful for a consultation because you can't ask a question of the words on the screen.

I think there's room for improvement and people need to take a bit more responsibility for a self care and using other services like walk-in clinics and pharmacies and I wish the doctor didn't send me a bloody letter when an email would do - but I don't think online triage is acceptable or appropriate. You need something much more responsive than that.

Being able to email and say "can you call me back on 07xxxxxxxx please?". Would be helpful. As would being able to book online for same day surgery :)

We spend ages trying to find ways round the fact that the only reason that you can have 10 minute GP appointments and just about survive as a nation is that GPS ARE REALLY GOOD. They are very very highly trained and experienced compared to primary physicians in some countries. That first contact is quicker and easier if it's done by an expert. If it's done by a less trained person, you have to build in all sorts of extra layers of safety that end up adding vast amounts of flummery and bureaucracy.

Having said that, the e-consult system sounds good, I'd like to know how GPs find it. Our practice is great and uses most of the things people have been saying are useful like phone contact and online prescriptions etc. They save a bit of time I think by just not getting involved with facilitating private appointments - they're not anti it exactly but you sort it out yourself. i have worked in a gP surgery that was very pro private work and the private stuff took an age to sort out.

If you google eConsult it comes up straight away.

Well dd was prescribed special order capsules.
The GP took 10 days to produce a prescription and failed to post it.
I popped in last night and collected it.
Phoned chemist today so they cd pre-order
They couldn't get capsules, only tablets
For tablets they needed a prescription that said tablets
They could not order and allow the prescription to follow retrospectively in case the Dr refused ( They couldn't order even though I said I'd meet the full cost if the Dr refused to change)
Spent 20 mins on phone getting Dr to answer
Explained and Dr had to phone me back
Dr was grumpy about extra cost and asked how many chemists I'd tried. Er none because I work full time and yr surgery shd have done the prescription in accordance with the published guidelines.
Told this was an exception.
Rang chemist to sy prescription agreed
Chemist couldn't act without prescription
Chemist persuaded to collect
Rang Dr to make sure prescription done and available - told it was (20 mins to pick up phone, them cut off). Another 20 minutes to get through.
Phoned back chemist
Chemist went to collect but prescription not there.
Left work at 4.30 to physically collect prescription
Got the third degree
Asked if mine had now been done (again requested on 10th April) and told no, you only asked last night.
Receptionist was arsy. Explained how much time this had taken and was told that's the way it is.
Said it shouldn't be and noted the NHS wasn't free and the service should be better
Told I had a bad attitude, actally I was shouted at. THIS IS THE NATIONAL HEALTH SERVICE and it's free.
No, it really isn't it's free at the point of delivery "and,I don't think it's me shouting actually"
Asked her to dance my apt on Tuesday because I'd be changing GP.
Told she'd had a busy day.
Well so had I actually and now I have go go to work tomorrow to get done what didn't get done today due to this.

I don't suppose the receptionist or my GP will work tomorrow because they have been so messed about. And no I won't get paid extra - there are standards of service I am expected to deliver for my customers.

I honestly don't think the system gets worse, more inefficient or more uncaring than this.

Did I say the prescription relate to dd's MH? The same MH CAMHS said didn't meet their criteria and on which we have now spent £5000 to support her recovery. And a GP cross examined me over an extra £50. They'd have spent a shedload more if wd hadn't been able to support dd.

I really don't believe this is about lack of resources. It's about a dysfunctional system that doesn't give a shit about the people. It needs dismantling.

It's a disgrace. A f***g disgrace.

Being able to email and say "can you call me back on 07xxxxxxxx please?". Would be helpful. As would being able to book online for same day surgery

That would all be lovely.

And when GPs get funded more than £130 per patients per year then we will be able to offer that to everyone. As it is, the various appointment systems are a deliberate way to manage a huge mismatch between supply and demand and make sure that those with sharp elbows and internet access don't always push out the elderly and frail who may be in more need of our services.

I physically saw a GP 6 times before he finally felt my stomach and realised I had stage 3 ovarian cancer. That doesn't include the 3 calls to NHS24 which saw me being told I had flu/swine flu/bad asthma. Self diagnosis and phone diagnosis can't replace face to face consultations.

What does the £130 pa cover please wickerlampshade Does it cover things like Scans, breast clinics, operations, cost of prescribed meds etc. Also do you get more for hitting vaccination, smear test targets, etc.

I earn a reasonable salary (my DH earns more). The breakdown I got with my tax statement this year said about ££4.5k of my contributions was allocated to the NHS. I'd like to know where the other £4,370 is going please? It didn't go on my dd' mental health. There was diddly squat for that so in the last couple of years I've now spent about £6.5k in addition to the £4.5k. I'll ask my MP where the rest is going then.

I'm sorry but I don't think I'm getting value for money.

Good question ohtheroses but don't forget that as a net contributor you will be subsidising those who are net takers from the system. And of course if you suddenly need an ITU stay you'll run through that 4.5k very quickly and no-one will ask you for more.

That's the total cost (average - every practice will vary) including bonuses for hitting smear targets etc. The basic funding per patient without such bonuses is about £60-80 per patient.

It doesn't cover rent/mortgage on the building, IT hardware (computers, printers etc) and IT tech support. And it only covers care given in primary care, so not scans, costs of blood tests, consultant appointments etc. And no, not the costs of medicines.

What it does cover, roughly divided into four areas:

Staff
Salaries and pension contributions for the doctors, nurses, HCAs, admin, secretaries, cleaner etc. This is by far the biggest cost and of course all the relevant NI and tax have to be paid.

Insurance
A full time doctor's litigation insurance will cost £12-15,000 per year and for the last 5-10 years has been rising by 10-20% a year, maybe £1-2000 for a nurse and less for an HCA. Plus all the insurance involved in keeping a building running (buildings, contents, boiler cover etc).

Costs of running the business
Accountant to do the tax return each year. HR costs including running a significant payroll and processing pension contributions under a ridiculously inefficient system. Security - burglar alarm and CCTV including all the relevant monitoring. Maintaining the premises and heating/lighting them. Any legal input that you need around employment law. The telephone system - we've just had to get 10 more lines to cope with demand. No extra funding for that.

Consumables
Printer paper/toner/ink. Couch rolls. The little cardboard tubes that go on a peak flow meter. Soap. Hand sanitiser. Replacing the curtains round the couches every now and then when they get manky. Cost of new couches when they get old/broken. Any redecoration needed. Loo paper. Toilet duck. Teabags and milk. Cost of washing the tea towels. Replacing the fridge when it breaks. Speculums and lubricant (sorry to be basic!). The bandages that I use after I put in or take out an implant. Needles. Syringes. Gauze. Pens. Any new office furniture. The electronic screen in the waiting room that calls in patients. Travel costs to do home visits. Obviously this paragraph could go on and on and on.

So, if you imagine a £12,000 patient practice, that gets maybe £1.5 million per year. If you think that sum has to pay 6 full time (or full time equivalent) doctors, maybe 2 nurses, 10 admin staff, a cleaner and all the costs listed above. Plus anything unexpected - if someone nicks all the metal off the roof and it has to be replaced (happened to a practice I know and their insurance wouldn't pay), the boiler needs replacing, the CQC introduce some arbitrary new policy that costs you thousands to implement etc etc etc. Suddenly being a GP doesn't sound like a licence to print money.........

Thank you for responding wickerlampshade.

So it's like other businesses then? Except that you are handed your running costs instead of operating in a competitive market. My husband has to find all those costs and more and yet doesn't get £130 per client.

You mention the £4500 will run out quickly if admitted to ITU, but what about the £4500's that have been paid in for the last 25 years and the next 10 to come. I work full time for £60k compared to the average figure of £78k published on my GPs' website and assume that £78k is the average of total salaries earned bearing in mind there is not one single full time GP at my practice. I work very hard to contribute and yet there seems no recognition at all that when the practice cocks up I have to leave work (an hour away), spend hours on the phone and then get the work done that should have been done whilst I was chasing a GP to make sure my daughter doesn't go without her medication.

My husband runs a business with very similar costs and a similarly professional occupation. If a client doesn't pay a bill there is a direct hit on his earnings, clients don't pay bills if service is poor. It is a fantastic way of ensuring service is excellent. I work in the quasi public sector and I have to say if I, or my staff, complained continually to our customers about our working conditions, that everything was the Employer's fault or the governments fault, careers would be over very very quickly.

I think GPs do a fantastic job (although I've come across a few dreadful ones) but I really don't think the present status quo can be maintained for very much longer. I'm happy to pay more but not when I encounter things like I did on Friday last week (see my previous post). I don't think we, as a family waste GP time, I think our GP wastes more of our time - than vice versa but at least 28 day prescribing seems to have been revised to twelve week prescribing.

It is really important that working people are facilitated to stay in work and encouraged to work and helped by the NHS to get better as quickly as possible so they can continue contributing. There is nothing in the system to prioritise working people, not so they get better care but let's be honest if one works an hour's commute away it is not helpful to give non working people the 8/9am appointments and offer a working person an appointment at 11.30am.

I would be perfectly happy to see a Continential/Australian style system implemented here where there is an upfront cost for those in work to see front-line staff. When we have had to use healthcare overseas it has been so much better both in the context of clinical care and attitude. I really do fail to comprehend the attitude within the NHS that it is doing the public a favour. It isn't, it's free at the point of delivery and I really believe that if it wasn't the culture would would change very quickly and it's the culture that desperately needs to change. So many people in the NHS have guaranteed incomes regardless of the levels of customer care they actually deliver.

It's rare that the doctors are every rude or unhelpful but the hoops we have to jump through and the obstructiveness are shocking at times.

So you'd be happy to take on a client on the understanding that they will pay you £130 for a year's service no matter how much they need you? No minimum hourly or daily rate? They can call every working day if they want to?

And FWIW practices in my area are having their budgets cut by 20-25% from next year. For no reason. So there will be less Drs and less nurses yet the expectations from the public will be the same.

But what about all the customers who don't need you? My DH has been to the GP four times in the last 28 years.

Other businesses don't get £130 towards their running costs for every client.

All I'm saying is that the present system isn't working. I'd happily pay you £300 a year but not if I have to go through what I went through last Friday.

I'd happily pay you £50 a visit (and I probably wouldn't get it back) but I'd expect phones to be answered, I'd expect reception staff to be more customer friendly, and for there to be more choice of appointments. I'd pay more tax but I want to stop hearing NHS staff complain to patients. I don't want to be treated by a nurse chewing gum or to hear the words "what d'yer want" if I approach a hospital desk.

And none of those things are recent. They were all happening 23 years ago which was when I was first pregnant and started using the NHS regularly. At least 23 years ago my GP gave me a slip for a blood test followed by a prescription for 365 thyroxine. Not my fault more work was created by 28 day prescribing.

Roses I'm sorry you've gone through all that with your DD. MH services have gone to hell in a handcart.

I read all the horror stories on here and think I must be so lucky to have the GP I do.

When you see someone face to face I think it helps build a sort of bond and respect. I'm terrified of hospitals (with good reason but not the point) but if my GP says it's necessary I trust her judgement and go in.

That doesn't sound like a huge deal but when it comes to MH issues having a professional you trust can make all the difference.

I don't think I'm in a unique position I've worked MH support and recently care and noted similar with other people. In an ideal world MH services would be better and able to take more patients but till then a lot does fall down to the GP's.

Don't get me wrong, ohtheroses the NHS is far from perfect. We'd all like to be able to offer a better service, but there just aren't the resources.

but on this point

But what about all the customers who don't need you? My DH has been to the GP four times in the last 28 years. Other businesses don't get £130 towards their running costs for every client.

and

I'd happily pay you £50 a visit

Private GPs in London charge around £100 for an appointments. That doesn't include any blood tests or prescriptions needed. So your £50 won't go far. Using that as a benchmark, we are funded to the level of under 1.5 appointments per patient per year. Many of our patients come twice a month - so for each of those, there needs to be over 20 like your husband who never come. The maths just doesn't add up

Every GP I know would gladly give up capitation (x amount per patient per year) if we could be funded on the basis of services actually provided. The reason the government doesn't do this is that it would be vastly more expensive.

Let me just say it again - what private business would offer their customers unlimited services for a year for a fixed rate?

As it happens, I'm not against more contribution from the public. There is a definite element of 'free at the point of abuse' but the problem is that it is often those who would be exempt that are the worst offenders. I'd like to see a charge for every prescription, pegged for kids at the cost of a bottle of paracetamol, to stop those who make an appointment when their child has a cold just to get the free calpol.

And by the way I have never chewed gum in front of a patient and would expect any member of staff doing that to be disciplined asap. There is no excuse for rudeness, but it comes from patients as well.