AIBU to think that most people want clinicians and our wider system to have real autonomy?

[GEEpEe]

So I have a medical issue. Repeated pilonidal sinus. Common on hairy men who sit a lot. I'm a GP and hairy so that is me.

Laser treatment has been shown to reduce the reoccurance rate in some patients but not enough for the NHS to fund the treatment.

It's one of those things where if you have the obvious risk factor of thick, plentiful body hair and when they operate, they're removing copious amounts of said hair from the tunnel created, lasering that individual seems to make sense.

But as clinicians, we are so tied to protocol about who meets the criteria for referral/treatment and I know myself that you get shit from higher up when you don't obey. I'm known as a maverick and rebel but all I can really do in most cases like mine is refer and make some sort of suggestion of such a treatment in the notes.

I could afford private lasering but I've been trying to "fight" the CCG to let clinicians make individual decisions about who might benefit from lasering to no avail. Now I've had quite extensive surgery and my wife is putting her foot down and saying I've got to get my whole arse lasered but that's another thread!

My question is wouldn't you prefer overall if your GP and specialists could make individual decisions about what treatment might work for YOU based on available evidence and personal values and goals rather than just stats from RCTs that make blanket rules about who can get what?

I know a lot of GPs who happily allow patients to sit with long term chronic conditions though so I'm sceptical about a lot of people's PoVs in this respect. I mean it is still common to hear GPs moan about menopausal women harassing them about their "women's problems" and how they should just get used to it like they did their periods so yeah... no..

Or all clinicians would feel greater sense of autonomy and accountability therefore whistleblow more often to highlight dangerous practice sooner.

Most people do not have misplaced concerns about their health. What can provoke health anxiety is constant dismissal of genuine complaints. If I can solve their issue in the surgery, people are generally happy not to go elsewhere.

Don’t suppose you are based in Dorset are you OP? Wish I had a GP with your attitude!

my DH is an oncologist and there is not enough money for his clinics to be equipped with chairs for patients undergoing chemo

Yet he gets a new iPad every year because they have so much money they can’t spend it, which is it @RunningAwaywiththeCircus?

No, london, I'm afraid.

@Alsohuman

Oh RLY?

Its habit like those bladders scanners in A+E that tell you how full someone's bladder is with no real accuracy but costs 1000s more. The old ones were perfectly fine alongside a history and palpation.

A bit*

Here's my one from this week
2009 I saw a derm who said I was a good candidate for ££££ drug, and it's there in print on the screen
2020 my condition has worsened, they send me to the allergy clinic. Oh no says the allergy clinic, I can only give you that for spontaneous urticaria, not hives. Can't do it, sorry
So allergy clinic has to make a second referral (I waited 6 months for this one), back to the derm and says I also need to see my GP
So I'm costing a derm appointment, a GP appointment and it's there, in writing I can have the drug

@GEEpEe, if you hadn’t used the example of your arse and made it clear you’re male, I suspect the responses would be very different. As it happens I completely agree with you. Some of the guidelines are completely bonkers.

My favourite example is lack of foot care for elderly people. Anyone who’s unable to pay a chiropodist three or four times a year has to put up with ever lengthening toe nails, callouses and painful corns. What’s the major cause of older people’s A&E admissions? Falls. I wonder how many could be prevented with free foot care?

Just to add to the idiocy, community care assistants aren’t allowed to do is. I remember one asking how it was she was allowed to cut toenails as a beautician but not as a care assistant. Needless to say, nobody could come up with a sensible answer.

@Alsohuman

I'm seeing I should have stuck with the tonsillectomy.

Get over to the Style and Beauty section and swot up on IPLs, G. There's no shortage of knowledge there and they are far better than waxing at reducing hair in delicate areas and can even be used on the face (some models, not all).

I have a male friend who is similar, went through two surgeries for it, got him to get a Phillips Lumea and life is now good for him in that department.

I rather suspect the families of patients treated by Shipman,
and Paterson, those at Gosport in the 1980s, Morecambe bay obstetricians, Stafford doctors and now East Kent obstetricians should have rather closer monitoring and more explicit guidelines.

Maverick behaviour and autonomy can be innovative but can also kill and maim. Governance has increased because of the public demand for increased accountability.

@CherryPavlova, this isn’t about governance, it’s about inflexible funding guidelines, some of which not only cost the NHS more in the long run but also aren’t in all patients’ interests.

I'll try one of those once I've healed a bit more. Think my SIL has one. Wont tell her my plans!

There is maybe 1 person a week who I think did not need an appointment and a bit of a waste of time. but are you given your maverick-help-the-undertreated stance the best judge of that. I would say your assertion is unusual.

Why can’t you buy your own lumea? They only have so many flashes in them. You seem determined not to put any effort or £££s into your own health. Why is that?

Alsohuman the two hand in hand. You cannot have autonomy for practitioners without strong governance to monitor what is happening. There is every evidence that bad things happen when the framework surrounding clinical decisions is not present or not followed.

Antibiotics being a good example. Some clinicians felt pressured to give them out like smarties whilst others resisted even when they were indicated. Firm prescribing protocols and sound governance have improved usage and made us all a little safer.

5zeds

Admittedly I've never considered it as a viable alternative because people used to say those things were crap. However, I do remember SIL saying hers is good so I will try it once I'm healed.

have to say my Lumea was useless. It languished in my drawer for a year then didn’t work when I excavated it

Because it says quite clearly that it needs to be charged every three months🤷🏻‍♀️

The nhs should be funding treatment based on personal benefit, rather than cost effectiveness in areas such as oncology. But individual clinicians shouldn't have the autonomy to decide, it still needs to be judged on fact based guidelines.

But frankly, when the nhs won't currently fund some cancer treatments because they aren't cost effective, lasering your arse is not a pressing concern.

Chronic pain is extremely complicated and in most cases impossible to cure, I don’t think it’s a case of people being happy to leave patients in pain, it’s that there is no known cause for their pain, so all we can do is manage it, unfortunately, many patients won’t accept this and refuse to properly engage with the chronic pain team and physios to make the lifestyle changes which could really help them and just keep going back to their GP asking for more and more tests which all come back normal. There’s also a huge psychological element to chronic pain, and unfortunately the mental health care system cannot support them appropriately either and again many patients become very resistant to any suggestion that their mental health impacts their pain so refuse help.