A Covenant and not a Contract

It has been an intense winter and in the three-way tussle between doing the day job, staying healthy and blogging it was always the writing that would have to give. It’s good to be back, though, and with renewed energy – although how long that lasts may well depend on which Government is elected on May 7th, and what they decide to throw at General Practice over the next five years.

It’s good to start afresh with a positive blog – one, oddly enough, inspired by the Care Quality Commission (CQC). I’m not the greatest fan of inspections, nor have I been impressed by the approach taken by the CQC as it has moved into doctors’ surgeries, but there are times when doing something you don’t want to do bears unexpected fruit.

One of the requirements of the CQC is that GP practices should have a ‘Vision and Values Statement’ that all staff should be familiar with. Knowing that we could be quizzed on such a statement at any time during an inspection, and that it would be hard to give the right answers if we didn’t actually have one, we set about to rectify the situation.

I confess to having an attitude more becoming of a teenager told to tidy their bedroom; just as an adolescent is convinced that they know where everything is in their own private world and so what is the point of tidying just to please Mum and Dad, so I knew that we understood our values and wondered what good could possibly come of writing them down just to tick a box.

It all felt very corporate. We looked for examples from others so that we would not have to reinvent the wheel, but they left us feeling flat and uninspired – they were other people’s values and not ours so they just didn’t resonate. It turns out, that when it comes to what really matters to you it’s best to invent your own wheel after all.

Then I remembered a line I’d heard about General Practice that had excited me and it was this: that the relationship between a GP and their patient should be a Covenant and not a Contract.

From that beginning, it suddenly became easy – and I am converted: writing down your values is worthwhile after all; it really did help to be able to look at them together as a practice and say ‘yes, this is what gets us up in the morning’; it’s helpful to remember them on a bad day when you’re tired and you’ve lost sight of what you believe in; it’s good to know that they are there as a yardstick for us to measure ourselves by – and one that we have put there on our own account rather than something that has been imposed upon us.

It feels scary to do so, but we would like our patients to know our values, and would like to know what they think of them. They are ideals – some would say idealistic – and we know we won’t always live up to them. What will happen when we fail? How will we feel if a patient throws them back in our face and tells us how badly we have let them down and how hypocritical we must be? It’s a risk we will have to take, but it feels a risk worth taking. More likely is that our patients will help us to shape these values further and improve them.

So, we have published them on our website, and we’d be interested in your thoughts.

A Message To Our Patients

Last week the Care Quality Commission (CQC) published data on every GP practice, placing each practice in one of 6 bands in order to prioritise them for inspection. The CQC has been very keen to point out that the way it has banded practices is not a judgement on them, as this can only come when the full inspection is completed. Despite this, the newspaper headlines described large numbers of ‘failing practices’ which will have inevitably worried patients; the fact that the CQC used the word ‘risk’ in its reports is a shame, as it has made it more likely that patients will be concerned.

At Binscombe we have been given a band 2 out of 6, which has been hard to take, not because we are worried about an early inspection – we are happy to be inspected at any time – but because the banding does feel like a judgement, and we believe that we give far better care than that. The banding may also have caused anxiety for our patients, and this too is a concern for us.

The CQC reports look at 38 individual pieces of data, from how often the patients at a practice attend A&E, to how our patients rate the practice in the annual GP survey, to how many patients with high blood pressure achieve a certain blood pressure target. There are many other pieces of data they could have chosen, and we had no idea until last week which they would choose, but these are the ones they have picked. Each indicator has an expected value the practice is meant to have achieved, and if the practice is significantly below that value then this will indicate a ‘risk’, with the number of ‘risks’ determining which band the practice ends up in.

There are several indicators that come from the GP annual survey on patient care where we have scored exceptionally well. For instance, when it comes to the percentage of patients who said that the GP they saw was ‘good or very good at treating them with care and concern’ we were expected to achieve 85%, when in fact 97% of our patients felt able to say this. We are incredibly proud of this. We don’t get it right every time, but we always try hard to listen to our patients, to share their concerns and involve them in all decisions about their care.

Where the practice has been criticised in the report mostly relates to indicators that are more about monitoring than listening. These are:

  • The number of patients with diabetes whose blood pressure has achieved a target of 140/80
  • The number of patients with diabetes who have had a routine foot examination in the previous 12 months
  • The number of patients with diabetes who have had their urine tested for protein in the previous 12 months
  • The number of patients with serious mental health problems who have a record in their notes of alcohol consumption in the previous 12 months

And one area to do with the layout of our practice waiting area:

  • The number of respondents in the GP survey who said they could not be overheard in the waiting area.

These are not unimportant, but there is always a tension in a GP consultation between addressing the concerns a patient wants to talk about and the requirements to monitor and treat things like blood pressure. In an ideal world we would always do both, but too much attention to the latter can make the patient feel like they are not being listened to and that the doctor’s agenda is more important than their own.

Last April, Jeremy Hunt said he wanted to end the ‘tick-box’ culture in medicine that too often distracted GPs from spending quality time with their patients, and this is something we have welcomed. While we will address the concerns of the CQC, we will never want the patient to take second stage.

The issue of being overheard in the waiting area is a difficult one. We would certainly like to have an area where patients could talk in the confidence that they cannot be overheard, and we take confidentiality very seriously, but we are constrained by the practical reality of our building and the waiting area. It is not easy to see how we could put up a screen between reception and the waiting area, but we will certainly be looking at any possible solutions to this problem.

We take the CQC report very seriously, and we will be working to address the issues raised within it. We know we are not perfect and we are always looking to improve the care we provide for our patients. When Chris Jagger was at the practice he always used to say that our patients are our greatest asset; this is as true now as it ever was, and we are very grateful for the support we receive from Binscombe patients.

The Wrong Kind of Virus on the Line – the Demise of the Binscombe Express

I’m delighted to say that this post needs to be amended. As you will be able to see from the helpful comment from the CQC below, they do not have a problem with wooden toys. The advice we received from the Surrey PCT infection control lead that we had to remove wooden toys in order to be CQC compliant was misguided, and the Binscombe Express can stay! I will be blogging again soon on how this came about, and have left the blog in its original form below, but am very grateful for the swift clarification and common sense approach of the CQC.

Here is the original post:

This week saw the Binscombe Express roll out from the station for the final time, pushed reluctantly into an early and unwanted retirement. It might never have rivaled the glamour of the Great Western, or the notoriety of the Orient Express, but in certain circles among the toddlers of Godalming it has ranked right up there in importance with Thomas the Tank Engine. I’m talking, of course, about the Brio train set in my consulting room. Lovingly home-made in a simple figure of 8, it has been the undisputed domain of my younger patients f or the last ten years. A room otherwise associated with illness, strange metal implements and painful injections has been given a friendly, familiar face by its presence, and I am desperately sad to see it go.

And the cause of its demise? Not, for once, austerity and the bankers, or even Michael Gove declaring it to be too educationally liberal – it is the edict of the Care Quality Commission (CQC) that has banished my train set, declaring it to be too hygienically hazardous to be allowed to stay.

The Binscombe Express
The Binscombe Express – condemned by the CQC

The CQC has turned its attention on GP practices this year, with the intention to improve health and safety, and in particular, infection control. This is not a bad thing – to have rigorous procedures for the sterilisation of invasive medical instruments, for instance, is clearly a very good thing indeed; nor should GP practices aim for anything other than a high standard of cleanliness, but is a wooden train set really that hazardous?

The CQC website states that the guidance it applies is based on the Health and Social Care Act 2008, which has a great deal to say about infection control, but does not actually mention toys in GP surgeries. Despite this, it has become de rigeur for infection control teams to target these hazardous objects in our rooms, and in particular to condemn wooden toys. I have not been told what evidence this is based upon although I suspect it is on the basis of swab results growing numerous bacteria on their surfaces, which is odd as the vast majority of infections that children might pass to one another via my Brio would be viruses. Plastic toys are deemed acceptable as long as they are swabbed with an alcowipe at the end of the day – which is also odd since viruses won’t survive the night outside of their host.

I have no doubt that some parents will be glad to see the train go, and I am sorry for any concern it might have caused, but it is important to remember that this is not a long-stay hospital ward where people with poor immune systems and open wounds run the gauntlet of super-bug infection, but a GP surgery where children bring the same germs that they merrily carry with them to schools, playgroups and nurseries. And without the child-friendly toys in my room, it would be naive to think that children won’t try to play with something – the options they are likely to head towards now will be the clinical waste bin, the hydraulic mechanism of my examination couch, or the old favourite of opening and closing various finger-trapping drawers. Is this an improvement?

What concerns me most about this dictat from the CQC is the way it focuses on the potential health risks associated with toys, but is entirely blind to any health benefits. What value should we place on a child being at ease when they visit the doctor? Many adults are fearful of seeing their GP, and I suspect that much of this stems from negative childhood experiences which set a lifelong pattern of health-seeking behaviour. Can a train set make the difference? Well, I can’t answer that, but I have seen the eyes of many anxious children light up when they come into my room. And for more immediate benefits you would just have to compare the quality of the conversation between adults when a child is happily and safely occupied than when they are bored, fearful or frustrated – it is hard enough to remember what the doctor has said at the best of times.

There is a worrying underlying trend here which pervades so many Government directives these days – which is where that which is easily measurable and defined trumps that which is less easy to describe, regardless of any relative merit. We see this in education, where SATS scores dominate how both teachers and schools are judged, and no value is placed on a teachers’ ability to inspire and develop their pupils outside the narrow viewfinder of the test. The obvious example in health is the Quality and Outcomes Framework of the GP contract, which is based entirely on what can be measured – like targets for blood pressure, cholesterol and diabetes control. These are not unimportant, but the end result is that the humanity of General Practice, like deep listening, counselling skills and patient-centred care (which cannot be measured so easily) is in danger of being squeezed out of the consultation entirely.

There seem to be no grounds for appeal to reprieve my train set, but I will continue to resist any pressure that threatens to reduce the relationship between doctor and patient to mere figures and targets, and every so often I will continue to stand up and say: “Now, hold on a moment!”