One appointment, one issue

[monkeymamma]

I genuinely think this policy (at our GP surgery and I assume widespread) is deeply harmful to patients.

I was given an appointment today with the paramedic - no idea why not a GP - to talk about worsening symptoms (painful, bloated belly, difficulty urinating, sickness, reflux, dizziness). I mentioned that the symptoms are making it hard to know what to take for migraine (chronic sufferer). She snapped ‘that’s a separate appointment.’

The thing is, it’s not really is it? The symptoms I’m having are clearly hormonally driven (worse/unbearable around ovulation) but she didn’t ask about that or really anything about me as a person.

And how do you decide which symptoms are connected to the issue you’ve booked in and which aren’t? Aren’t they going to miss really obvious things if they refuse to understand what is going on with the patient as an actual person, as opposed to a single symptom or problem?

It really is an issue - you can see why they brought it in as a principle, to stop people using their time with a GP to run through lists and lists of minor gripes.

But the body is holistic and medicine should be likewise. I often have this conversation with a friend of mine about how the lack of joined up thinking contributes to fractures within services - all of which are at overall detriment to the patient. We like to have this whinge as we both worked in the NHS for well over a decade each - doesn't stop staff being dedicated and professional, but there are some areas that just don't operate effectively for the patient.

I hope you get the care that you need and are feeling better very soon.

It’s crazy and dangerous

You're right OP, in your case the two issues are connected and it's relevant to ask about current medications and how they interact with the matter you are there for. You weren't bringing up a separate matter like an ear infection or a broken toe.

Edited to add: my gp was treating my peri and asked about other symptoms, i said constant stuffy nose and my RSI had got almost unbearable. He said both matters were hormone related and gave me an increased hrt script and some anti inflammatory nasal spray. Thing is it didn't cost him more than 2 minutes and meant i'm more productive at work, and i won't have to make further appointments down the line that will cause more backlog at the surgery.

I agree it’s dangerous.

Patients might not be best placed to connect symptoms either. You might find something that seems unrelated is actually really important, but as you can talk about it, and doctors generally don’t know the patients well enough to connect dots, it never gets discovered.

I had an appointment where I complained about irregular periods. I also mentioned bloating and was told one complaint per appointment.

This was utter madness.
The two are connected and can be symptoms of the same condition.

Can you book a double appt?

Yes, if you need an interpreter.

Are you sure you saw a paramedic and not a physician associate ?

Neither should be diagnosing you

Don’t see a PA or paramedic see a GP

Obviously I don’t know who OP saw, but I’ve seen/spoken to a paramedic twice at our surgery.

The first time she examined me, did some basic obs, then went and got the GP who then repeated it all.
The second time she prescribed antibiotics for a UTI over the phone - I think some paramedics have additional training to allow prescribing for things like that but not more complex issues.

I read a paper on use of GPs a few years back.

Couple of thing stayed with me:

Lots of people don't want to "bother" their GP unless it feels very important, which is often when they have a number of different concerns built up.

People with embarrassing or mental health problems often will start talking about something else (eg backache) until they feel comfortable, then will bring up the real concern after that.

This one isn't relevant but stuck out - on average most GPs interrupted the patient before the end of their first sentence!

Ten minutes. Seven if you are a regular and they consider you a bit batty and/or a pest.

It is not good enough. A bit longer and they might save themselves more appointments.

I do find they can be trying to see so many people in one day it cannot help them do their job properly.
Some surgeries intake is wide. Too wide. And too many work part time and not full time.
One of the issues is that they are businesses. And so want to make money by giving you tablets ( they get money from the NHS if the practice meets various tablet targets), but spend less on actual staff.

It has to change. There has to be a better model.

It is bonkers. I have been a bit unlucky healthwise over the last few years and am under the care of: cardiology, rheumatology, neurology, gastroenterology, orthopaedics - all of the problems interact and influence the progress of others.

It fits comfortably with the surgery for one item to be addressed at a time, but it is clearly nonsense. and the knee jerk reaction of passing people on to lots of different specialities is needed on some occasions but causes fragmentation of care which is exactly what the GP is supposed to be managing. They are supposed to have an overview and cannot do that if they insist on only addressing one problem, especially as further appointments are so few and so far apart.

And on the subject of booking with a GP and then seeing someone who is not a doctor ...... words fail me.

I had a 111 callback from a "doctor" who turned out not to be. Half way through the conversation I clocked this as she was proposing to prescribe something that was incompatible with another of my meds - I asked her directly if she was a doctor.

I think the way your GP surgery is applying the policy is ridiculous. I think it's fair enough for GP surgeries to ask patients not to raise two or more unrelated issues at the same appointment (eg if you want a mole looked at and also want to discuss heavy periods you should make a double appointment/two separate appointments). But where conditions are related to each other, patients need to be able to discuss them all at the same appointment. If your symptoms don't improve very rapidly with whatever treatment the paramedic prescribed, I would go back and insist you need an appointment with a doctor. Be prepared to make a formal complaint if the practice tries to refuse.

I agree totally. I have an appointment later this week due to suspected coeliacs disease. Typically my endometriosis is also now flaring up and I'm having lots of mid cycle bleeding. Getting a face to face ever about my endo is nigh on impossible and generally get fobbed off with a pharmacist call (who always sheepishly admits they don't know what to advise about endo and HRT).

I could try and shoe horn it into my appointment but I suspect they will use the endo as an excuse not to explore the coeliacs. Honestly it's so hard sometimes, I'm just trying to feel as well as I can function!!

It is harmful to patients and it is totally inefficient and wastes a shit-ton of money.

So many studies have shown that if you do the 10 minute one-issue model, people keep coming back over and over, progressively deteriorating between appointments, so that by the time all their issues are dealt with they are far more complex than they would have been if they had just been dealt with properly on day one. Every bit of evidence clearly demonstrates that the only way to save money and ensure people are kept healthy is to give them as much time as they need in an appointment, covering every possible issue. The 10 minute model is wasteful and inefficient and GPs hate it. I can't understand at all why they persist with something so stupid.

For me this was a benefit of not having face to face appointments in covid. Before then my doctors would discuss 2 symptoms and no more. If you were lucky you might get a double appointment so 4 symptoms. I had 20-25 which led to various outcomes depending on how you group them. Everything from a vitamin deficiency to cancer and AIDS.
Had a telephone appointment in covid times. Explained this to the dr. She sent me a link to upload a document too. I wrote it all down. Uploaded it. She called me back a couple of days later and arranged full bloods.

Of course even telephone appointments these days aren't that helpful.

That makes sense

I wonder if we could have a future with fewer doctors e.g.

Triage by paramedics
AI enabled Physician Associates to refer you to a specialist as required
Everything else / chronic conditions handled by pharmacy or specialist nurses

A few GPs left to supervise / pocket the money

Back in April the University Medical Centre at the Radboud in Nijmegen (the Netherlands) organised a 48 hour diagnosis hackathon for exactly this reason. They took the files of 33 patients with long term undiagnosed conditions and put them together with specialists from different departments to actually talk to each other. They made breakthroughs in multiple cases because they were able to join the dots.

Pretty much everyone I know who has a complex/immune issue started with "weird" disconnected symptoms. Back in the days GPs knew their patients, one diagnosed my gran because her hand "looked different"-she'd never had put that on a form.
When I had pregnancy issues, I could have gone just saying my stomach hurt, but it was mentioning the pain in my back/shoulder that alerted the doctor to the real problem.
Plus, it is so hard to get an appointment-the hospital referred someone back to their GP in August, and they won't get to see them until mid November (not joking, they've been cancelled on 3 times), it's very likely you will have more things to talk about, particularly as you get older, but of course many young patients have multiple issues.

I was talking to a retired GP who said he was totally disillusioned with the current system. He explained that diagnosis of some quite serious and complex conditions needed him to actually see the patient.
Some tell tale signs might not have been noticed by the patient, but would emerge with a proper hands on examination by a doctor.
He worries that these signs could be ( and probably are) missed by telephone consultations or less qualified medical staff.
Although he agrees with triage over the phone, for very basic obvious things he thinks that anyone with significant unexplained symptoms, particularly over longer than a couple of days, should be seem by a registered GP who has had full training and experience in diagnostics over a wide range of fields.

It's not a separate appointment unless you have a separate body.

Not like you asked about a stomach issue and an ingrowing toenail.

IANAD but surely it's all linked to the endocrine system, OP @monkeymamma so all the issues could well be part of a hormone imbalance one way or another. Little things like the adrenal gland and ovaries can cause a lot of problems.

https://my.clevelandclinic.org/health/body/21201-endocrine-system

I also wondered this for a different reason

A paramedic is usually very good.

I wouldn’t put it past physician associate to use the term “paramedic” because of the backlash against physicians associates.

My GP has wholeheartedly embraced AI and online triage.
The won't even book an appointment any more unless you go online. If you are elderly or have additional needs, the reception now fill in the online form for you instead and you hope they call you.

It is horrendous. I've not seen an actual GP in several years.

I end up putting through many more triage requests than I ever would have when we used to actually have access to humans as they keep getting closed without resolution.

Reception staff seem to triage now, I've been given dangerous advice, and actually had a pharmacist call them to have a go.

I'm due an hrt review and a smear, the same team do both, excellent chance to get 2 things sorted quickly with 1 appointment. System won't allow it. It's ridiculous.

The whole system needs overhaul. It's a huge money pit.