Stop, look, and listen

bayley susie

I have been criticised for being fairly vocal and negative about the current state of general practice. There is one reason for this: I am incredibly passionate about the importance of good quality primary care.

I worry that increasing fragmentation combined with decreasing funding is a threat to patient safety, and our sanity. We are regulated from all angles, and yet no regulator can rate or quantify the subtle changes we make to patients’ lives on a daily basis.

This week I had one of those consultations that make you feel proud to be a GP.

Sometimes our vast skill-set doesn’t involve diagnosing a rare condition. It doesn’t require us to complete a tricky coil fit, or remove a particularly stubborn sebaceous cyst. It simply involves us listening and guiding.

This isn’t a skill that will be picked up by QOF, or that follows NICE guidance, nor any other metric that the powers that be like. But it is one that can make a phenomenal difference to our patients.

The patient in question was Mrs X. I hadn’t seen her for a while, but I had seen her hospital communications and had fielded advice. I had invited her in for review but she was ‘too busy’ with hospital appointments. It was blatantly obvious she was having a rough time.

The oncology team had tried a number of modalities for her metastatic cancer, but it was spreading and her chemo had to be ‘temporarily’ stopped until her renal function picked up. The renal team was unable to do too much for the rapidly diminishing renal function because the cardiologists were worried about how her heart would cope with the necessary interventions. Her heart failure impacted her cancer treatment options, and so the cycle continued. Her drugs went up and down as her biochemistry changed and she bounced in and out of hospital. She was fading. But despite this, all of the specialties were still ‘treating’ her.

She came with one simple request: pain relief. She had been regularly seeing some of the cleverest doctors in the hospital. People brilliant in their own right, clinicians who I would be delighted to look after me. Each of them managing their respective condition faultlessly, but no one had actually treated her.

I was fortunate she was the last patient of my surgery, so I had that rare luxury in general practice: time.

We chatted through what was going on, the treatments promised, the tests pending. She sighed; she was in pain every day, struggling with sleep, she could see no end to the medical interventions. She knew that no amount of investigations could change the outcome and no amount of treatments would stop the inevitable.

In that consultation, those 10 minutes that turned into 30, she just wanted someone to tell her that it was OK to say ‘enough is enough’. She wanted to permit any one of the three life-limiting diagnoses to take their natural course. She wanted to be supported to make the decision to stop and gain back some control.

So she left the room with some good analgesia, a planned early review, an advocate, and hopefully some peace of mind.

As the door closed I felt overwhelmed. It was one of the most career-affirming consultations I had had in years. I also felt cross, because although the level of care, time and attention I gave her was totally necessary and appropriate, it was equally completely unsustainable for our modern general practice. Our modern general practice that promises so much, but funds so little; that suggests we can address all patients’ wants, rather than accepting we can only treat needs.

So when I am angry and negative about this career through my campaigning with GP Survival, it is for Mrs X and patients like her. It is because we hold such a unique and important role in the NHS. The more you starve general practice, the more patients are treated as numbers and diagnoses, and not as individuals. General practice will continue to hold a pivotal role in patient care—it just needs to be given the respect and appreciation it deserves.

Dr Susie Bayley, GP and blogger.