GPAQ Questionnaire Results

The GPAQ Patient Satisfaction Survey has been an annual part of our Quality and Outcomes Framework (QoF) work for several years now.

Each year patients fill in a questionnaire after seeing the nurse or doctor in the practice. The results are then analyzed to see if there are any areas which can be improved.

This year we are very pleased to report that our patients continued to rate the practice very highly. Most of the scores were equal to or above the benchmark, some significantly so. Also, most of the comments were favourable. The majority of negative comments were about OOH or concerns with ambulance availability which we have no control over (these comments were passed on to Viv Smith, the Health Board localities manager).


2009 was the last year that this survey will be carried out within GP surgeries themselves - in future the questionnaire will be sent out and collected by the Health Board. (One such questionnaire was already sent out at the end of 2008).

We discuss the results of the questionnaire at a practice meeting and set goals for the year to come to continually try to improve our service. The following information comes from our most recent GPAQ discussion:


Last year’s GPAQ - 2008

A patient survey was carried out in the Practice during January and February 2008.

Completed questionnaires were received as follows:

Dr Robbie Coull 43
Dr Rosemary Wright 32
Kate Paton, Practice Nurse 33


Dr Wright analysed the responses for all three. Both GP’s scored above the benchmark for the majority of questions. Kate Paton’s scores were equal to or above the benchmark for all questions.

The main area of patient dissatisfaction revealed by the data analysis concerns waiting times (between the time of their appointment and the time they are actually called into the consulting room) and continuity of care by the same GP. Some patients also expressed a wish for easier telephone access to clinical staff.

Regarding patients’ comments at question 18, most were positive. However, several patients expressed concern over out-of-hours provision.


Last Year’s Priorities - 2008 to 2010

As a result of the GPAQ carried out in January/February 2008 the following

Priorities were agreed:

* to reduce the time patients wait once they arrive in the practice;
* to dedicate time for patients to contact clinical staff by ‘phone;
* to allow patients to see the same doctor more easily.

Changes Implemented in 2008

* Dr Wright’s morning surgeries now start at 9.20am instead of 9.00am to allow time for her to check emails, etc before seeing patients;
* Dr Coull has a short break half way through his surgeries to allow some ‘catching up’ time;
* Five minute telephone advice slots have now been included at the end of morning surgery for patients wishing to speak to clinical staff over the telephone.
* Since July 2008 Dr Jurgen Tittmar has been a salaried GP at the practice and has surgeries from Wednesday to Friday each week. Dr Wright is at the surgery on Mondays and Tuesdays. This allows patients who wish to see the same doctor to do so more quickly.



GPAQ 2009

A patient survey was carried out in the Practice during January and February 2009.

Completed questionnaires were received as follows:

Dr Rosemary Wright 19
Dr Jurgen Tittmar 23
Kate Paton, Practice Nurse 26

Response rates were not as good as last year; many patients were unwilling to complete a questionnaire at the surgery after seeing the doctor, preferring to take it away with a stamped addressed envelope for completion at home. However, many of these were not subsequently received in time for inclusion in the analysis. Several patients who attend surgery frequently to see the doctor and the practice nurse may have grown weary of filling in more than one questionnaire. Similarly, some patients have already taken part in the Access Survey carried out by Highland Health Board in November 2008.

Dr Wright analysed the responses for all three. Dr Tittmar scored above the benchmark for the majority of questions. Dr Wright and Kate Paton’s scores were equal to or above the benchmark for all questions. The score indicating satisfaction with the receptionists was also well above the benchmark.

Regarding the priorities set last year for 2008 to 2010:


* Waiting times – satisfaction with waiting times has improved this year with both GPs and Kate scoring above the benchmark. This was the main area of dissatisfaction last year.
* Telephone Contact – patients expressed a high degree of satisfaction in this area with all scoring significantly above the benchmark.
* Continuity of care – this is not relevant for Kate and has not improved significantly for the GPs since last year in spite of the new arrangements whereby both doctors are available every week (apart from annual leave, etc).

Although Dr Wright scored well in the area of patient autonomy, Dr Tittmar and Kate Paton’s scores were not as high as would have been expected. This may have more to do with the layout of the questionnaire than anything else; for the patient autonomy questions the tick boxes indicating the best scores are aligned to the left whereas for all other questions they are on the right. Not all patients may have realised this.

Patients appear to be satisfied with the practice’s opening hours. However several expressed a wish for evening or weekend opening hours. This may be connected to the unfavourable comments made by some patients about NHS24 and the ambulance service. There seems to be little doubt that patients would prefer to have an out-of-hours service run by the practice.

One comment criticised the music played in the waiting room.

Apart from criticism of NHS24, the comments at question 18 were very positive and show that patients value the service provided by the practice and appreciate the caring way in which they are treated by all the staff.

Priorities for 2009 to 2011

As a result of the patient survey carried out in January and February 2009 the following priorities have been agreed:


* to emphasise to Highland Health Board the widespread dissatisfaction with the current arrangements for out-of-hours care;
* to maintain the high standards of care currently provided;
* to change the music played in the waiting room.

In order to achieve these priorities Sue will carry out the following:


* contact Viv Smith, Locality Manager, regarding out-of-hours provision quoting comments made in the survey and other verbal feedback received at the surgery;
* ensure that all staff remain motivated to provide high standards of care;
* load a new selection of music onto the ipod in the dispensary. If this is not well received the Practice will consider asking patients for their suggestions.


Reporting Findings to Patients

The outcome of the survey will be reported to patients as follows:


* [This document will be posted on the practice] blog at strachurmedical.com;
* Members of the community council will be invited to a meeting to discuss the results of the survey.


Additional Information

It was not felt appropriate to widen the survey to collect additional material. The Practice provides medical care for about 900 patients. A survey designed to target a specific group, eg relating to a particular condition, would be unlikely to produce meaningful results as the numbers in each group would be too small, and in a small, close-knit community, such as Strachur these discussions are a constant feature of practice life.


The Practice may consider asking patients to suggest music they would like to hear in the waiting room.

Quality and Outcomes Framework (QoF) points 2008/9

We're delighted to announce that Strachur Medical Practice scored 998.5 out of 1,000 in this year's QoF.

QoF is the Quality and Outcomes Framework that every NHS General Medical Services GP Practice has to complete each year. It measures quality care over a wide range of areas such as blood pressure, cholesterol, diabetes care and so on.

You can view Strachur Medical Practice's QoF points score and disease prevalence rates online and compare it to other practices in the area, and to the Health Board and national averages. (This year's figures are not available online yet, but previous years are.)

We only missed two points of the 1,000 - one was because we decided not to collect ethnicity data on our patients because we had an ethical objection, and a half point because one of the staff vaccination certificates went missing.

I'd like to thank all of the staff at the practice for their hard work at acheiving this excellent score.`

Repeat prescriptions by email

Some patients have been asking about emailing us their repeat prescription requests.

Unfortunately we don't currently support this for lots of reasons (it is more likely to go astray, it is less secure, and there are more chances of a mistake with the prescription).

There is software that allows patients to make appointments and order repeat prescriptions online, but our current clinical computer system (GPASS) is not really up to the job.

We are in the process of requesting a new clinical computer system from the Health Board. As always, this will take a long time (and probably lots of meetings with people in suits) to arrange. Once we have this new system, we will be able to set up a secure online ordering system.

In the meantime, I apologise to anyone who is disappointed that we don't yet have email/internet ordering.

Carers

Carers work very hard looking after relatives, friends, or neighbours who require help. It is very rewarding to help people in need, but it can also be hard work. It's important that we support carers as much as possible: helping them to help others.

Strachur is a small community, and we know many carers through our contacts with them in the surgery and in the village. However, we are keen to hear from anyone who is providing regular unpaid help or care for anyone in the community.

If you, or anyone you know, is helping or looking after someone in the community then please let someone at the practice know. We can advice on help and support that is available.


Update!

The BBC reports that the Connecting For Care website has been launched, which aims to help carers through online forums, advice, and links.

Influenza is circulating!

Influenza is now circulating in Scotland.

If you have had symptoms of flu for less than 48 hours, of have been in contact with someone who has flu in the last 48 hours, and you are over 65 years old or you have any of the following problems:

• Asthma


• Chronic Bronchitis


• Heart Disease


• Chronic Kidney Disease


• Diabetes

then contact the surgery to see if we can provide you with antiviral treatment (Tamiflu tablets).

Health Board appoints Out of Hours contract to Tighnabruaich

At the public meeting at the end of November the representatives of Higland Health Board announced that the Out of Hours contract had been awarded to Tighnabruaich surgery.

Without in any way criticising the Tighnabruaich GPs, I find this a very strange decision. I felt that the bid I put in to continue to provide Out of Hours cover was a good one. We would have had a local service, provided mostly by GPs who know the patients, and able to provide a rapid response to medical emergencies.

I have now received some of the information I requested using the Freedom of Information (Scotland) Act which includes the minutes from the Health Board meeting at which the decision was made. This shows the scores awarded to the three viable options.

Strachur (cost per patient £116)
Cost Effectiveness = 2/5
Response Time = 3/5
Sustainability = 2/5
Public Acceptability = 3/5
Ambulance Cover/Response = 3/5
Total = 13/25

External provider (cost per patient £382)
Cost Effectiveness = 1/5
Response Time = 3/5
Sustainability = 2/5
Public Acceptability = 1/5
Ambulance Cover/Response = 3/5
Total = 10/25

Tighnabruaich (cost per patient £33)
Cost Effectiveness = 5/5
Response Time = 2/5
Sustainability = 3/5
Public Acceptability = 3/5
Ambulance Cover/Response = 3/5
Total = 16/25


I feel the Strachur bid has been marked down unfairly in several areas:

Response Time = 3/5
Being based in the middle of the practice area, our response times could not be faster. In fact, our response times to category red calls (999 level emergencies) are comparable to 999 ambulance response time targets of 20 minutes, which far exceed the contractual requirement to respond to emergencies within one hour. This is particularly important in view of the problems with ambulance response times in the Strachur area.
Expected score 5/5

Sustainability = 2/5
Again, it is difficult to understand why we scored so low for sustainability and why Tighnabruaich should score higher (it is no secret that Dr Carle in Tighnabruaich is a lot closer to retirement age than I am!).

However, the minutes of the meeting show that Tighnabruaich had been asked to guarantee a three year contract (the minutes state: "Letter received confirming 3 year contract support if approved". I was not approached to see if I would be willing to support a three year contract. This gave an unfair advantage to the Tighnabruaich bid.

Expected score 3/3

Public Acceptability =3/5
There is no justification for such a low score. It basically says that our patients would be just as happy to be covered from Tighnabruaich as from Strachur. I can't imagine how anyone could imagine this to be the case.

Expected score 5/5


Ambulance Cover/Response = 3/5
This score was the same for all of the options. However, the Strachur bid included an offer to respond to 999 calls in the area (as at present). This significantly improves the ambulance 999 response times, as a GP based in the practice area can respond to 999 emergencies faster than ambulances based in outside the practice area.

Expected score 4/5.

So, I would have expected the Strachur bid to have scored:
Cost Effectiveness = 2/5
Response Time = 5/5
Sustainability = 3/5
Public Acceptability = 4/5 or 5/5
Ambulance Cover/Response = 4/5
Total = 18/25 or 19/25

I'm going to write to the Health Board to ask for clarification of why we scored so poorly and why the Tighnabruaich bid appeared to have an unfair advantage by being given an opportunity to improve their score.

Health Board takes over Out of Hours

The Health Board will be taking over the responsibility for Out of Hours GP calls from 6pm on Wednesday the 14th of November 2007.

I'm sorry about the short notice of this, but I only had confirmation of this myself a few hours ago. This was due to a legal dispute over our contract with the Health Board.

The Health Board initially will provide locums to cover the practice in the evenings and weekends and says it will have a more permanent solution in place by February next year. I don't know what that solution will be as the Health Board have not told me what the options are that they are looking at (the last time I heard from them they had three remaining options they were looking at, down from an original list of 8 options).

In the mean time, patients should continue to call the surgery if they require urgent assistance day or night. Between 6pm and 8am the phones will either divert directly to NHS 24, or an answering machine message will tell you what number to call to speak to NHS 24 and/or the doctor on call.

Sadly, one option that the Health Board has already rejected was our offer to continue to provide 24/7 cover from Strachur with a mixture of the current doctors and locums. You can download a copy of the business plan that I submitted here to read more about the plan.

There is a community council meeting on the 28th of November at which the Health Board and I will make presentations regarding the Out of Hours and I hope as many people as possible will attend.

Out of Hours cover

Currently the Strachur Medical Practice is opted in to providing 24 hour medical cover 365 days a year. It is only one of two practices in the area that still carries this responsibility.

As I've mentioned before on the practice blog, this 24 hour responsibility is a huge burden. This is not in any way the fault of the patients in Strachur, who rarely call except in a genuine emergency. I think patients living in rural areas understand that the GP cannot always be immediately available. If a patient had a medical emergency, and called the surgery only to discover that I had gone to Glasgow shopping with my family, then I think they would understand. In the past, the doctor would leave word and would either see the patient on his/her return, or the patient would go to the hospital in Dunoon.

However, my contractual and professional obligation is to be immediately available within the practice area at all times for emergencies. We only have three calls per week in Strachur on average, yet I cannot take my children to Benmore gardens for a walk. A meal in the Loch Fyne Oyster bar is fraught with danger because of the poor mobile phone signal. What if someone dies because I was not able to be contacted?

If a patient were to complain, I would not face a sympathetic hearing. I would be judged by peers who have never worked in remote general practice or as singled handed GPs. Judged by their standards, a trip to the shops in Dunoon could easily lead to me losing my practice, having registration as a doctor taken away by the GMC, or being sued in court.

The Health Board currently pays the practice around £20,000 per year towards the costs of the on call. However, to get a locum doctor to cover the practice costs between £1000 and £1600 per weekend and £100-£200 per night. Were I to be incapacitated for a period of time, the cost of out of hours locum cover alone would be around £110,000 per year. Recently, a friend of mine (a single handed GP on one of the small islands) became very unwell and had to be admitted to hospital. Her Health Board helpfully told her that she was in breach of contract leaving the island and should not have allowed herself to be admitted to hospital until she had organised a locum doctor and waited for them to arrive on the island to take over from her.

Also, it is increasingly difficult to get locums who have any experience of this kind of out of hours. Recently, I have had locums who were worried because they have always worked in Out of Hours centers which had receptionists to answer the phones, nurses to help with patients, and a driver to drive them to visits at night and weekends.

So, reluctantly, I've decided to ask the Health Board to allow me to opt out of the responsibility for providing 24 hours medical cover.

I have submitted a bid from our limited company to continue to provide out of hours cover from Strachur with more locum doctors at the market rate of pay, and they are considering this option. It is expensive, and works out at around £400 to £600 per call.

I have also said that I will always be happy to respond to medical emergencies in the area when I am here even though it will no longer be part of my contract and I will not be receiving any payment for it. Dr Wright has said the same, as has Dr Tittmar. That is part of living in a rural community. If we are unavailable (or the call is not an emergency) then the Health Board will have an alternative system in place for patients to use.

Actually, I think this is the system that most people think we have at the present anyway.

Download leaflet (pdf)

Vacancies: Practice Manager and Practice Receptionist

We are currently looking for a Practice Manager to work 15 hours per week in the practice and a Practice Receptionist to work 19 hours per week.

The posts can be combined should someone want to work full time, or can be split if we have applicants that wish to work part-time in one or other of the posts.

Anyone who is interested should ask at reception for an application pack, call 01369 860 224, fax 01369 860 225, or email pm@strachurmedical.com.


The closing date for expressions of interest is Wednesday the 12th of September, with a planned start date of Monday 8th of October, 2007.


Practice Manager Job Description

Receptionist Job Description

Application Form

Marion Jamieson leaving

We are sorry to announce that one of our receptionists, Marion Jamieson, is leaving the practice at the end of September.

Marion has been with the practice for several years. Although she no longer has a house in Tighnabruaich, she has been traveling in some distance to work in Strachur twice a week. She and her husband have recently moved to a new house in Ayrshire and the traveling distance is now too great for her to continue working at the practice.

We wish Marion and her husband all the best in their new house, and I'm sure all the patients will want to join in our thanks for all her work in the practice over the last few years.

Anyone who would like to contribute to her leaving gift should speak to Liz Fraser at the dispensary hatch any weekday morning.

Breast Screening Service

The Breast Screening van will be in Strachur from the 25th-27th of July.

Women between the ages of 50 and 70 should have received an appointment by now through the post.

If you have not received an appointment, or are outside the normal age range but would like to arrange an appointment, all 0141 572 5800.

New lights

The electrician should be coming on Monday (18th June, 2007) to fit the new lighting for the practice.

I've always hated fluorescent overhead lights, and the ones in the practice are the old-style ones which are particularly ugly and prone to headache-inducing glare.

To replace them, we'll be using ceiling mounted spot lights. We can't mount them into the actual ceiling because we would have to remove too much of the roof insulation for fire safety reasons.

However, Ikea do nice spot lights mounted on a ceiling track that should produce a pleasant, warm light in the practice with minimum glare.

Book writing

I'm busy writing a new book just now, and my publisher has given me a deadline of the end of July, so Rosemary Wright and Jurgen Tittmar will kindly be carrying out all of the surgeries until the end of July. I'll still be on call at times, and I'll be about at the surgery doing paperwork and generally trying to avoid actually writing the book!

Robbie Coull

Practice manager leaves

As many of you know already, Gill McCormick the practice manager is no longer working with us. Sadly Gill had to be dismissed last month, which means more work for the rest of the team at the practice.

We'll be looking for a new practice manager later in the year.

Change in consulting times

We've been experimenting this month with a slight change to our consulting times. We have been having an afternoon surgery from 3pm to 5pm on Tuesdays and Thursdays. Previously we had an evening surgery from 4pm to 6pm on those days.

This seems to work very well. Patients who work, or who have children, can now get a routine appointment at a range of times to suit them. Also, Kate our practice nurse works from 3pm to 5pm on those days now as well. This allows us to work joint appointments more easily. This makes things easier for patients who need to see the doctor and nurse together. It also makes things faster and easier for patients that the nurse wants the doctor's advice on. Or for patients that the doctor needs the nurse's assistance with. For example, intimate examinations or wound dressings.

So the new consulting times for the doctors are:

Monday 9am-11am and 4pm-6pm
Tuesday 9am-11am and 3pm-5pm
Wednesday 9am-11am
Thursday 9am-11am and 3pm-5pm
Friday 9am-11am and 4pm-6pm

This makes a huge difference from the old consulting times that Dr Basu used which were just from 9am-10am and 5pm-6pm each day.

(Please note that for now Dr Wright still uses the old consulting times on the days that she is working.)

A warm welcome to Dr Jurgen Tittmar

We have a new GP working at the surgery with Dr Coull and Dr Wright.

Dr Jurgen Tittmar is from Northern Ireland, but has been living and working in Lewis and Harris for the last 10 years. I trained with him in The Western Isles Hospital and at the Group Practice, Stornoway, from 1996-1998. He has since been working as a GP partner in Tarbert, Harris.

He and his family (wife and three young children) are studying for a B.A. in Theology in Glasgow for two years.

Dr Titmarr will be working in the practice on Monday all day and Tuesday morning most weeks, and will be on call for emergencies overnight most Mondays.

We're delighted to have Dr Tittmar's help, and I'm sure the patients will make him very welcome.

Robbie Coull

NHS Prescription Tax rise

The NHS has decided to increase the prescription tax to £6.85 from the 1st of April.

Easter Holiday

The surgery will be closed on Easter Monday, the 9th of April.

Dr Coull will be on call for emergencies over the Easter weekend, so in an emergency call 01369 860 224 to contact the doctor.

Parents - get free Calpol and Nurofen on prescription from the dispensary

Coughs and colds are in full swing just now, so remember that children are entitled to free Calpol and Nurofen for Children, on prescription, from the dispensary.

Simply place your order at the dispensary. Usually it will take two working days for us to dispense and check you medication, but if your child needs to see the doctor, we can dispense it during your consultation.

We're now 20% bigger!

The practice list size has grown from around 700-750 permanent patients in April 2006 to just under 900 patients now.

To cope with the extra workload, we have extended the doctor's consulting times to allow up to 100 patients to see the doctor each week without having to 'double up'* any appointments.

We are also hoping to employ a technician to take bloods and do blood pressures. This will free up more time for patients to see the doctor and practice nurse.

Thank you to all the patients who have made the effort to come to the surgery instead of having a home visit. This helps us to be one of the few practices in the country that sees all patients the same day, while still allowing patients to book appointments in advance if they prefer.




* 'Doubling up' is when we squeeze two (or more) patients into an appointment slot. We do this to make sure that everyone can still be seen the same day without having to wait. However, this means less time for each patient, and often results in the clinic running late.

Free WiFi Wireless Internet Spot

The practice waiting room now has a free wireless internet access point.

If you have a wireless laptop, or a WiFi enabled PDA (such as the Palm TX), then you can use it to surf the internet or send/receive emails from the practice waiting room.

Simply select 'Strachur Medical - Public WiFi' from your wireless device to use the free service.

Like the internet, the WiFi spot is an open network. So don't send anything confidential (such as passwords or bank details) unless you are connected to a secure web page. Secure pages are indicated by https:// at the start of the address and a lock icon in your browser.

See here for more information on using WiFi.

Medication Reviews

We now have the automated medication review system up and running. It took a bit of time (there were several hundred patients with nearly two thousand medications that all had to be updated on the computer by hand).

This system will allow us to monitor patients on repeat medications more safely. The system will automatically remind you when you are due for a medication review. Medication reviews are usually done every six to twelve months, and they allow the doctor to check that you have had all the right monitoring done. This greatly improves the safety of repeat prescribing.

You should also notice that your repeat ordering form has been tidied up, making it easier to order your repeat medications.

The safest way to order your medication is to tick the boxes on your repeat order form, and to hand this in to reception. You can also post it to us at the address at the top of this webpage. Or you can fax it to us on 01369 860 225. Please try and avoid phoning in repeat requests if at all possible, as this is more likely to lead to mistakes and ties up the phone line and staff time.


Your medication will be ordered and checked, and will be ready to collect from the dispensary in 2 working days.

If you see a note on your repeat ordering form saying your medication review is due, then simply make an appointment to see the doctor for review before ordering any more medication.

Merry Christmas and Happy New Year

The staff at the Strachur Medical Practice would like to wish all of our patients a very Merry Christmas and Happy New Year.

The surgery will be closed on Monday and Tuesday 26th and 27th of December 2006 and Monday and Tuesday 1st and 2nd of January 2007.

Dr Coull will be on call over Christmas and Dr Wright over New Year. In an emergency, you can contact us on 01369 860 224 as usual.

Hot drinks now available in the waiting room

The waiting room now has it's Flavia coffee/tea maker up and running. It's already popular, and patients can now make themselves freshly brewed coffee, tea, or hot chocolate from the dispenser.

Personally, I can't stand machines that make instant coffee/tea from freeze dried stuff. I think it tastes terrible. So, I've invested in a Flavia SB100, which I've seen used in some NHS hospitals, churches, and so on.

It is an excellent machine which makes fresh coffee/tea from individual brewing bags. It's a little more complicated to use at first, but I think the effort is worth it. There is an instruction leaflet explaining how to use the machine, but don't hesitate to ask for a demonstration.

We've also got real mugs, fresh milk, and napkins (as well as take away cups). And we're buying new leather chairs for the waiting room (a leather sofa is awaited as well for those who prefer to lounge while they wait).

A daily newspaper, and new copies of Top Gear, Gardeners' World, Empire, and Marie Claire are available on the coffee tables to read.

To help cover the running costs of the coffee machine, we do ask if you could put £1 in the honesty box when you make yourself a drink (the water cooler is, of course, still free).

If you have any comments or suggestions, please don't hesitate to let us know.

New coat of paint

As recent visitors will have noticed over the last week the painters have been in.

It's the first new coat of paint since the practice was built as far as I am aware (which is what? 15 years?).

Finally the waiting room no longer looks as if it has been the victim of a grenade attack, and the practice in general looks and smells clean and fresh.

There are still two rooms to paint - the dispensary and the reception area. These will be being painted this Wednesday and Thursday (the 4th and 5th of October 2006), and they will cause the most disruption, as we will have to remove all the shelving units from the dispensary (so if at all possible, try and avoid asking for or collecting repeat prescriptions on those days).

New dispensing hatch

We've got our new dispensing hatch in now. It looks great, and means that patients can deal direct with the dispensary when ordering/collecting prescriptions.

I'm hoping that Liz with say a few words about the new hatch, and if so I'll post them here.

Problems with the phone system

I think we finally have the phone system working properly.

It's been a bit of a nightmare getting the phones to work, and although most people will not have noticed, I know some patients had occasional problems getting through to us. This is something that we take very seriously, because of course we want patients to be able to contact us quickly and easily in case of an emergency.

The problem with the phone system that we inherited from Dr Basu was that it was an old system that our engineer could not service. The way the system was set up, all of the extensions rang when there was an incoming call, including an extension bell in the back garden. Apart from the fact that this must have been driving our neighbours crazy, it is disruptive to have the telephone ringing all the time in the consulting room when you have a patient with you. Also, as we had decided to close over lunch, we needed a bypass number so that the GP on duty could call still into the practice when the answering machine was on. We were unable to reprogram the old system, as it was too old for our engineer to service, and even something as simple as connecting an answering machine to the old system was a major problem.

The new phone system arrived and was installed by the engineers the week before I left for my paternity leave, and seemed to be working ok. However, one patient quickly pointed out that the bypass system we were using (which meant patients had to key in a number to get through to reception) did not work if you had an old pulse phone. This was quickly sorted by splitting the phone lines, but once BT had done this for us, we started to notice occasional problems with patients not being able to get through to us, or staff not being able to get an outside line.

We have had the engineers back out to reprogram the system, and it appears to be working well now.

Do please let us know straight away if you notice any problems with the phone system, and apologies for any inconvenience that the teething problems may have caused.

As always, should there be a medical emergency and you are unable to contact us for any reason, then don't delay - please dial 999 and ask for an ambulance. If possible send someone to try and find the doctor at the surgery in hours, or at Strachur House or Manse Gardens out of hours.

New addition to the family

I am delighted to announce that the Coull family have been blessed by the arrival of their second daughter, Annalise Rose Earnshaw Coull, who was born at 10.59pm on the 15th of July 2006 weighing 7lb and 6oz.

Out of Hours Cover

Strachur is over an hour from the nearest Accident and Emergency Department (Inverclyde or Paisley RAH(1)) and around 25 minutes from the nearest ambulances (Dunoon and Inveraray) and Minor Injuries Unit (Dunoon).

Currently we provide 24/7 emergency cover 365 days a year for anyone in the Strachur practice area (from the Rest and Be Thankful to half way down Loch Eck). The new GP contract allows GPs to 'opt out' of 24 hour cover, and currently the Strachur Medical Practice is one of the few GP practices in the UK that has not opted out.

The opt out has been popular with the vast majority of GPs because of the costs of providing 24hr cover. The cost of getting a locum doctor to cover the Strachur practice is between £1000 and £1750 for a weekend and between £100 and £400 for a night on call (£78,000 to £195,000 per year). But the Health Board only pays the practicE around £20,000 to provide the service, so a few bills for locums to provide weekends off and we end up making a loss!

The main problem with providing 24hr cover is not the number of calls that we receive. Unlike town or city practices we receive only a small number of out of hours calls and the vast majority of those calls are genuine emergencies. The problem is the nature of the on-call itself. Unlike an on call district nurse (we don't have one in Strachur), or most other on call jobs, the doctor is on call for life-threatening emergencies. In some cases, seconds can literally mean the difference between life and death for a seriously ill patient. I respond to such Category Red calls with a green light fitted to the car, and have special emergency training to deal with all types of medical emergency. This means that the car boot is full of emergency equipment (no room for shopping!), and I have to be careful when I have my wife and/or child in the car - emergency driving can mean sudden stops, which are not ideal for pregnant women and children, I can't just pitch up at a serious road accident and leave them in the car!(2).

The other main problem is communications. Pagers don't work in Strchur or the surrounding area(3), and mobile phone coverage is variable (I was really annoyed we missed the recent Bluegrass concert because there is no mobile reception in the Village Hall). To complicate matters, when I took over the practice I discovered that the phone system installed in the practice is so old that you can't use an answering machine with the practice phone line(4). So there is all the stress of worrying that people will actually be able to contact you when someone has a massive heart attack, or crashes their car into a tree. In my experience, the worst calls always happen when the mobile phones have gone down, or a power cut has knocked out your answering machine. The idea of one of my patients dying because I they could not contact me literally keeps me awake at night. And of course, there are no banks, cash machines or large shops in the practice area, A trip to Dunoon means constant worry about 'is the mobile working', 'how quickly can I get back to the car if I have to run', 'what will Ellie and Mirrie do if I have to abandon them?', and a trip to Ikea could lead to being struck off by the GMC for leaving my patients without adequate medical cover.

In some ways the stress is actually worse because genuine emergency calls are infrequent - emergency equipment is more likely to die unnoticed in the back of the car when it is only used once every couple of months than when it is in daily use. The same is true of emergency drugs going out of date, or batteries failing.

Having written all of the above, I'm asking myself why I would be stupid enough to continue to provide 24 hour cover! We have thought about dropping it, but of course we feel a duty to provide a safe service for the community and our patients. I don't think NHS 24 is a safe service that I can recommend to patients (more of that in a later blog), and I think Dunoon is a long way away to have the nearest doctor/ambulance if you are having a heart attack in Strachur. Besides, the Dunoon doctors are not very keen to cover Strachur, as they think it's a long way too. Plus, I've spent the last eight years doing this kind of on call, and I enjoy emergency work.

So, in an emergency call the practice number and a message will tell you which number to contact the doctor on (either myself, Dr Wright, or one of our locums). In case of dire emergency, if the phones fail, call an ambulance first, then send someone to look for us - either at Strachur House or Manse Gardens.



Notes:
(1) The Vale of Leven is about 45 minutes from Strachur by road, but has had its Accident and Emergency Department downgraded, and the ambulance crews now bypass the Vale to go to Paisley RAH.

(2) At a road accident, the first emergency vehicle on the scene parks in the 'fend off' position so that if any other car should crash into the scene, they hit the fend off car and not the rescuers working on the injured - not a safe place to leave a 2 year old or a pregnant woman.

(3) The old BT pagers used to work here I think, but BT has since shut down its pager network. The remaining networks (such as Vodafone paging) don't work in Strachur.

(4) The new PBX phone system is sitting in the practice and waiting for an engineer to come and instal it.


Photo: providing emergency cover with emergency BASICS vehicle in Kinlochbervie, October 2000

Appointment times

Up until now the Strachur Practice has had open surgeries. That is, the surgery times were 9 till 10.30 and 5 till 6, and anyone turning up between these hours could wait be seen in the order that they arrived.

Open surgeries are the traditional form of General Practice, and have the advantages of simplicity and ease of access. Basically, you turn up and you'll get seen...eventually. That's the disadvantage - you may need to wait a long time to be seen. Waits of over two (or even three) hours is not uncommon on busy days.

But, after eight years working in small remote practices, I'm acutely aware that the great fear of patients is that an appointment system will mean having to wait days or even weeks to see the doctor - a great problem for larger surgeries in cities and towns*.

Thankfully, there is another way to run small surgery appointment systems which combines the best of both worlds. I've set up four such systems in the past for Highland Health Board in remote practices similar to Strachur and they all worked very well.

The idea is that you phone the practice first to be told our best guess as to when you will be seen. This avoids the long waits and uncertainty, lets people plan their day better, and is great for people who have to get friends or family to bring them to the surgery.


Photo: The kind of queue we want to avoid

Of course, the appointment times are only estimates - medicine is complex, and sometimes we need to spend longer than average with patients, or there may be an emergency that can't wait, but the important thing is that you won't be turned away. If you need to be seen that day, then you will.

So, from now on call us before you leave to come down and we'll tell you what time to come down. If you want to arrange a time for later on (up to several weeks in advance) then let us know and we will give you one of several 'available in advance' appointment slots. If you prefer, come to the surgery as before, and we can tell you roughly when you will be seen, so you can go and do your shopping, or whatever else takes your fancy, in the meantime.

Of course, if you prefer the old system, you can still turn up and wait in the waiting room and catch up on the local gossip.




*In fact the larger city and town practices are getting much better at seeing patients sooner (not least because they now get paid a bonus for doing so in the new contract).

New Centrifuge arrives

Our new centrifuge arrived this week.

We had to pay for it ourselves (the Health Board does not fund them) and it cost us around £800, but it means that for the first time the practice will be able to do kidney function blood tests.

Kidney function blood tests (U+Es) are essential. They let you check on the salts in the blood that can be affected by medications such as water tablets (diuretics such as furosemide or bendrofluazide), blood pressure tablets (such as lisinopril). In extreme cases, if not monitored properly over months or years, changes to the potassium salt in the blood from some medications can lead to heart problems. This can include, rarely, sudden death.

Without a centrifuge to prepare the blood sample before it is sent to the lab, the sample spoils and the result is useless.

Now with the new centrifuge, we can get accurate blood test results no matter when the sample is taken. This will avoid the risks of salt imbalances in patients taking such medications.

If you are on blood pressure tablets and would like to check if you need a U+E blood test, please call the surgery to discuss your medication.

I take it all back

The manager from the Health Board Estates department came up to see us and could not have been more helpful this time.

The Health Board have authorised us to get in John Brown of Strone to do most of the work, and the Health Board will organise the rest.

So over the next few weeks we will be getting:

• the treatment room door (rotten) replaced


• dispensary shelving to store drugs


• new shelving for our notes (which were scattered all over the place)


• broken door locks replaced


• the sinks that didn't work fixed


• the toilet fixed


• the rusty railings repainted


• the rusty/damaged gates repaired and repainted


• the gate posts repainted


• the grounds repaired


• the parking spaces repainted, including adding a second disabled/parent and baby space at the front


• the rooms repainted

Of course, this will mean some disruption as we get around 16 years worth of maintenance work done in the space of a few weeks, but it will be well worth it in the end.

Health Board estates department not meeting its responsibilities?

One of the things that struck me most when I looked at the Strachur Practice before coming here was the poor state of repair of the health center building and grounds. The Health Center, Doctor's House, and grounds are all owned by the Health Board and the practice rents the building from them.

As has been mentioned in a previous post, the layout and design of the practice is poor. But much more worrying was the fact that there was no running water in the treatment room, and that the treatment room's external door was rotten the whole way through. Not only can you see daylight through the holes, with water pooling on the treatment room floor whenever it rains, but clearly it is not possible to maintain a clean clinical environment. It turns out that this was an internal door which was fitted externally, and that this problem had been ongoing for at least two years.

This breaks so many laws it's hard to know where to start - Health and Safety, Infection Control, and of course the legal responsibility on landlords to provide an watertight building.

Anyway, when we did our walk-round with the Health Board on the 14th of April, I pointed these out to the Estates Manager responsible for the Health Center. I was assured that these issues would be dealt with by the 23rd of April. However, the Health Board's contractors failed to turn up on the 23rd as promised. Nor did they turn up on the 26th as was then promised. Phone calls to these contractors produced a series of 'no-one at home' type calls and unanswered messages. So, we have told the Health Board that we are engaging our own contractors to put these serious issues right, and that we will then bill the Health Board for the work.


Of course, these are just the most serious problems. We also have:

• outside 'security' lighting that doesn't work - I nearly fell and broke my neck leaving the practice after dark one night


• walls that are pockmarked and dirty - for a new tenant, the Health Board really should have repainted the premises, and I think that the current state of the practice is depressing and unprofessional


• gates, fences, walls and grounds that are unkempt, rusty and dilapidated - not only is this ugly, depressing and unprofessional, there are rusty sharp pieces of wire sticking out which could cause injury.

So, we are insisting that the Health Board tackle these issues rapidly too and will be giving them a deadline of two weeks after which we will commission our own contractors.

Argyll and Clyde Health Board had a very poor reputation, and in my experience and opinion (and, it would seem, that of the Scottish Executive), management incompetence was rife in the Health Board. Thankfully, Highland Health Board has now taken over responsibility for the area. Highland Health Board, as with any public body, has its problems, but is in my opinion one of the more competent Health Boards in Scotland. Certainly, the standard of the Health Center buildings in Highland area is very high.

So, hopefully, as Highland Health Board reforms the health services in the Argyll area, the standard of our buildings should improve to a more acceptable level.

Changes to the practice building

One of the first things patients will notice is the change to the practice premises.

As with any 'small business', GPs tend to run their practices differently depending on their own styles, and a new doctor taking over the practice is a bit like a new shop opening. Of course, we can't shut the 'shop' for a couple of weeks to allow refitting to take place, so the changes will take place between now and the beginning of May 2006.

Firstly we cleaned the practice premises, and disposed of any old or out of date equipment and stock. This took me around five days, with help from my wife, Ellie, and our new practice manager, Gill McCormick.

The practice construction and layout is far from ideal, having been first built in 1967, and then extended around 10 years ago. The treatment room was unused (the district nurse had been using it as an oversized office and store room), and was reached via stairs which is a problem for any patients with mobility problems. The dispensary was in the reception area, and was too far from the doctor's consulting room to allow easy supervision of dispensing.

Sadly, as the premises are rented from the Health Board, we will need to wait for a new coat of paint (which is badly needed). Amazingly, when I arrived I found that the water supply did not work in the staff toilets or the old treatment room. Even more concerning, an internal door had been fitted as the external door in the old treatment room and had completely rotted away at the bottom. You could see daylight, and water was pooling on the treatment room floor! We have met with the Health Board (now NHS Highland) and they have assured us that these problems will be fixed within the week.

So, having sat down with Dr Rosemary Wright, Gill McCormick, and the rest of the staff, to work out how best to use the space, we decided to move the rooms around. The treatment room has become an office for the practice manager, a store room, and a coffee room for staff which can be used for meetings and training. The nurse's room, which will double as a treatment room, and the doctor's consulting room have been swapped round.

The dispensary will be moved to the small room between the receptionists room and the new doctor's consulting room. This will allow the doctor to supervise the dispensing, improving safety and reducing the chance of errors in dispensing. The reception office will be used to house a new filing area for patient records, which are currently spread out over two rooms. A new access hatch has been ordered specially for the dispensary, which will allow patients to order and collect their prescriptions from a separate window in the main corridor.

The waiting room has been cleaned, and old magazines and posters removed. New posters will appear on the notice board shortly, favoring local notices. Other notices will be transfered to leather-bound files which patients will be able to read in the waiting room. The old 'advertising' TV in the waiting room will be coming down, and a new play table for children with a fixed wooden train set has been ordered.

These changes are all designed not only to improve the look and feel of the practice, and make using the practice easier, but also to improve safety and make the practice more efficient.

We hope that you like the changes, and we appreciate your patience while the renovations are carried out. If you have any suggestions or comments, don't hesitate to let us know - or post a reply below.

Welcome to the Strachur Medical Practice weblog

Well, here I am with my family arrived at Strachur from Inverness to take over the practice from Dr Basu.

I thought it would be a good idea to keep a blog of my time in Strachur*, which will hopefully be of some interest to patients (or anyone else!).

This way patients will be able to get an idea of the background to the changes that we are going to make, and any plans that we have for improving the service in the future.

It also allows patients to discuss the way their surgery functions with their GP in an informal way.

I hope you find it useful.



*obviously this blog will be non-confidential matters, such as personal experiences in the area, but mainly the running of the practice.