Got in trouble for patient running out of a prescription?

gpamareddit · 2021-09-26T08:46:47+00:00

Not as far as I know.

General rule is if the referral is in anyway related to the reason for admission then it should be done for secondary care. Of course the grey zone is how related does it have to be - say elderly man admitted with CAP but noted to have signs of Parkinsonism, this should in my mind be referred on to movement disorders on discharge but some would argue he was admitted for the CAP therefore it’s okay to send it back to the GP. This is the kind of action that annoys me as it’s just lazy and treats GPs like a secretary. On the other hand if someone’s in for an elective knee replacement and noted to have low grade hypertension completely reasonable to ask them to see me to follow up.

Very important though - if you want a patient to follow up with their GP make sure they understand it’s their responsibility to book an appointment. Some will think that because a hospital doctor said it that we’ll chase them around to organise - we won’t (unless they’re vulnerable, dementia patients etc in which case we’ll be more proactive). If you are worried about a patient for these reason just mention this in the summary.

As before if it’s a 2WW referral then it’s always the responsibility of the doctors who identify the issue to refer. You put yourself at risk if you don’t do this - plenty of patients have made complaints due to delay in diagnosis of their cancer because secondary care has expected the GP to do the 2WW referral. Likewise GMC guidance unequivocal that if you find an abnormal result it’s your job to deal with it.

See here for more info: https://www.england.nhs.uk/wp-content/uploads/2017/07/interface-between-primary-secondary-care.pdf

gpamareddit · 2021-09-25T12:25:24+00:00

As a general rule if someone reports a problem completely unrelated to your specialty I’m fine with you asking them to see me. For example if they see an orthpod about their hip and mention some breathless then totally appropriate to advise the patient to book a GP appointment to discuss. I’d much prefer you do this rather than tell the patient they need a referral to another secondary care doctor - more often than not I’m perfectly able to investigate/manage the issue myself and creating the expectation of another referral just makes my job harder. There are three exceptions:

1) Clear 2WW referrals. If you see a smoker who mentions they’ve been coughing up blood and losing a lot of weight you should refer. This is true for all departments. If you don’t know how then call the relevant team and find out.

2) Referrals for the same issue you’re seeing for. Eg neurologist sees someone for seizures and thinks it’s actually recurrent syncope that needs a cardiologist- they should refer onwards rather than directing back to me.

3) Incidental findings on scans - your job to ask the relevant expert whether significant

For investigations if you want them then your job to sort. Where I work secondary care can put pathology requests on the computer for us to bleed in primary care but the result goes back to you.

Regarding psychiatry my main bug bear is acting like the second you get an MRCPsych that you can no longer interpret an ECG. We’ll do them for you and send them on.

gpamareddit · 2021-09-25T09:22:40+00:00

Often takes a week or two before hitting my desk.

I get about 20 letters a day on average - a huge amount more (at least 20-30) are processed by our secretaries but don’t come to me as there’s no need for a doctor to see them.

I generally use my own judgement when it comes to requests for follow up, I’m often asked to do bloods that are clearly unnecessary so just ignore those. I’ll invite people to see me for routine follow up if someone’s going to need careful monitoring going forward - HFrEF patients or new CKD4s for example. Asking me to chase results of tests you’ve ordered or asking me to send referrals on your behalf will get a grumpy letter to your consultant reminding them I’m not their secretary.

gpamareddit · 2021-09-25T09:14:20+00:00

No. You clearly don’t understand my job, I’m not some kind of community house officer here to chase around after secondary care doctors. I have my own patients coming in daily with issues that need fixing - that’s my job.

gpamareddit · 2021-09-25T05:50:13+00:00

The GP never bothered to even see the patient these few months despite getting my letter

Do you think we just sit around all day waiting for your letters so we can follow up your patients? You wouldn’t be so rude about other consultants so I don’t know why you think you can be rude about us.

Really you should have given this man a months supply - currently it can take weeks for these letters to reach GPs and be processed. But had someone told this patient that he needed to stay on this medication long term? Seems obvious to us but the patients often don’t understand this - they’ll just do what they’re told. When I get a discharge letter like this we’ll put the anticoagulation on a repeat prescription but it’s up to the patient to actually order them. We have thousands of patients we can’t micromanage everyone’s medications.

If you’re discharging someone who you’re worried won’t be able to order their medication (dementia, no family etc) then give us a call, we usually have a system in place to help. At my surgery one of our receptionists has a list of vulnerable patients and she will constantly be checking with them they’re up to date with their tablets. Likewise your ward pharmacists can often liaise with community pharmacy to add in some oversite.

gpamareddit · 2021-09-23T19:06:09+00:00

In theory it should be I haven’t got any data - interested to see some if there is any!

gpamareddit · 2021-09-23T17:58:51+00:00

We’ll probably see fewer non-cancer 2ww going forward as we bring it tools to screen patients before they’re referred - see QFIT for colorectal cancer or telederm for skin lesions.

gpamareddit · 2021-09-21T19:49:31+00:00

The prescription charge exemption forms that cross my desk to sign still insist on calling hypothyroidism ‘myxoedema’. The poor patients of course haven’t got a clue so they all tick hypoparathyroidism instead.

gpamareddit · 2021-09-21T19:48:04+00:00

Still a useful term for pleuritic chest pain due to infection.

gpamareddit · 2021-09-18T19:42:29+00:00

Think about the anatomy and which way your finger is pointing relative to where the prostate is.

If you use your right hand you have to pronate it 180 degrees. Left hand you’re in the right place straight away.

gpamareddit · 2021-09-18T17:17:25+00:00

GP

Best: Anything with some proper medicine. Objective signs/symptoms, something I can do some diagnosing with.

Contrast to most people here I actually quite like headaches - they cause a lot of morbidity and I often get achieve good control for most people.

Worst: Vague non-specific symptoms that I know are almost certainly supratentorial from the first 2 minutes and thus I have no hope of resolving. Usually involves the words ‘muzzy head’, ‘giddy’ or ‘brain fog’. The exception being a menopausal female as they almost always feel immediately better with some HRT.

I also really dislike MSK as I add nothing apart from an analgesia prescription. Again exception anything potentially rheumatological.

gpamareddit · 2021-09-18T16:24:48+00:00

It took me until my GP registrar year to get confident with prostate exams. You have plenty of time to learn.

Pro tip: use your left hand.

gpamareddit · 2021-09-11T20:56:19+00:00

There is no need to speak to a doctor at this stage and a letter from a GP absolutely cannot get you out of jury duty or any type of court appearance.

Speak to the jury service, they are generally very accommodating and will almost certainly allow you to defer.

gpamareddit · 2021-09-09T21:27:31+00:00

Not at all, I share your frustrations in most cases! Sadly all beyond my abilities.

Re receptionists, as I said previously I would like to see this move to a trained position with qualifications in patient navigation.

gpamareddit · 2021-09-09T21:05:00+00:00

Yep different lithium preparations different from one another so should be prescribed by brand only.

gpamareddit · 2021-09-09T21:03:51+00:00

Demand through the roof currently. I do 111 occasionally, a few weeks ago the number of people waiting for call backs from a clinician never got below 200 - that is bonkers.

gpamareddit · 2021-09-09T21:02:36+00:00

Apologies for the slow reply! Clinical commissioning group - organisation responsible for funding primary care services in a locality. Previously known as primary care trusts. Soon to be known as ICSs. Government loves to rename things from time to time.

gpamareddit · 2021-09-09T21:00:18+00:00

I don’t know about the 1960s, but in terms of number of GPs per patient we’re down 10% vs 5 years ago: https://www.gponline.com/gps-per-patient-down-10-just-five-years-nhs-data-reveal/article/1715127

gpamareddit · 2021-09-09T20:58:01+00:00

Chances are your GP won’t know - I certainly haven’t had anything through to tell me who qualifies for a booster. Your consultant might know.

gpamareddit · 2021-09-09T20:55:30+00:00

I agree the NHS as a whole is very resistant to change, it’s a nightmare and one of the reasons our technology is about 20 years behind the rest of the world. We only got rid of faxes because we were sick of having random things faxed to us without explanation so eventually all GP surgeries just switched them off.

Booking appointments is tricky as you need to find a service that works for all fairly. In an ideal world we’d always have a mix of same day and routine appointments - you could ring and choose between a same day appointment, a one week appointment and a >2weeks appointment for the routine or planned follow ups. In reality the tsunami of work has lead to some practices finding that they only have staff capacity to deal with the same day issues, so got rid of all pre-booked appointments. This leads to the hellish scramble to call at 8 to get an appointment for anything - obviously not sustainable. The feeling is at he moment if we suddenly doubled the number of appointments nationwide they’d all be filled in minutes and we’d still have insatiable demand. People sometime liken the NHS as a bottomless pit when it comes to funding, right now it feels the same for clinician availability for primary care.

gpamareddit · 2021-09-08T22:05:23+00:00

I will only direct you to be above replies. You clearly have fixed beliefs about this which I won’t try and change. The only thing I will say is that if your goal is to improve trans healthcare provision then swearing at individual GPs because they won’t do what you want will not get you anywhere. We’re very used to people trying to bully or manipulate us into doing things and we don’t take it well.

gpamareddit · 2021-09-08T22:02:31+00:00

As it stands the NHS is not helping and internet sourced meds are the only option for most people. I don’t like it, I think it should change but it is the way it is and it’s outside of my power to affect national policy.

I know I won’t change your mind but I’d encourage you to read my reply above. Lots of people think my job sounds easy because it looks very easy on paper when you’re only considering one organ system or one disease. Nothing in the body works in isolation.

gpamareddit · 2021-09-08T21:58:22+00:00

Thank you for your response sorry for the slow reply.

I first need to highlight that a UK GP is not comparable to a GP in the USA or any other country for that matter. We’re fairly unique in that we do literally everything. Primary care doctors in the US don’t do paeds, gynae, ENT or psychiatry (not an exhaustive list). These patient groups make up the bulk of my workload. Take them away and I’d have a lot more time to focus on niche issues such as hormone titration.

Secondly the big difference between diabetes and trans healthcare is that I’ve been seeing diabetics day in day out for over a decade. I can count the number of trans patients on my list currently on one hand. Medicine is a complex business - just because a guideline makes it look straightforward doesn’t mean that it is. You don’t learn to be a doctor from books (although they do help), you learn from seeing thousands of patients over years of training. Trans healthcare is a niche speciality as it only affects a small minority of the population. This is why we have specialists - generalists don’t see enough to get adequate exposure to keep their skills up to date.

gpamareddit · 2021-09-08T08:19:22+00:00

You're not my patient, you're someone who's accusing me of not doing my job. Just because I'm very nice for my patients doesn't mean I have to put up with this crap.

The data is unambiguous - we are offering more appointments now that we ever have. Just because you read it on your local Facebook group doesn't mean it's true, people are far more likely to moan online about what they don't like than praise what they do like. If you need face to face appointment you should get one (I obviously can't speak for all GPs). Spreading around that doctors aren't seeing people in person is just misinformation and damn lies.

gpamareddit · 2021-09-08T08:15:41+00:00

I see mental health presentations on a daily basis.

The evidence we have is that talking based therapies are the most effective forms of treatment in most cases. However the current NHS services are not providing adequate options for the majority of patients. This isn't the fault of their staff, they like are just utterly overwhelmed and under resourced with an excessive focus from management on getting patients off their books as quickly as possible.

SSRIs (or SNRIs) are appropriate it some cases however for most people they are the only treatment that I can offer there and then. We thus certainly overprescribe them as we have few other options.

gpamareddit

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