Survey points way forward for Lerwick Health Centre
Rosalind GriffithsThe problems with appointments at Lerwick Health Centre could be tackled by making better use of nurses and nurse practitioners and having a lead GP to run the practice.
These are some of the recommendations that emerged from a survey carried out last year by the Public Health Partnership Forum, which will be discussed by a meeting of the board of NHS Shetland next month.
Other suggestions from the survey include improvements to the waiting area, more flexibility of appointment times and the need for customer care, as patients’ desire for continuity of care with the same doctor came across strongly.
The survey was answered by 908 people, about a tenth of the practice’s patients. It found that 78 per cent of respondents were unhappy with the appointment system, and whereas 70 per cent wanted appointments with a doctor and eight per cent wanted to see a nurse, only two per cent asked to see a nurse practitioner. One of the key findings of the survey was that greater use should be made of nurse practitioners, who are qualified to diagnose ailments and prescribe medication.
The system of pre-booked appointments was deemed unsatisfactory by patients, as 53 per cent waited more than two weeks.
An attempt to tackle this was the introduction of the walk-in clinic, where patients could wait for an appointment. But 78 per cent of the 682 respondents who had used the clinic were dissatisfied with it due to the long waits involved – generally more than an hour. Forty one per cent had waited between two and three hours, and four per cent had left without being seen.
The survey, led by SPPF chairman Harold Massie, helped by his team, found improvements are needed to the organisation of the service in Lerwick Health Centre.
Mr Massie said: “We believe there could be more dedicated practice management and we have recommended that there is a lead GP . . .We would like to see a customer care strategy for the health centre which puts continuity of care at the heart of the service.”
Initial discussions at a previous health board meeting raised the possibility of patients being looked after by a “small team”, rather than seeing different health professionals on every visit.
It was also suggested that the boundaries of some country practices could be extended to take the pressure off Lerwick. The situation could further improve with the appointment of a consultant obstetrician, meaning that GPs would not be called away to hospital maternity unit.
DR A McPherson
Help ma bob ! How often are you going to kick an organisation before you realise it needs some care and attention/love/support ? The “survivors ” ,(Drs ,nurses and ancillary staff) of the tragic events that befell Drs at Lerwick health centre through the late 1990s (Air ambulance crash , broken neck , MS , heart attack, mass departures due to stress and harassment ) have done amazingly well . They deserve better . Give them a cuddle , bake them a cake , find them some new colleagues . Get on the campaign trail Shetland times and Lerwick folk . Support Lerwick health centre !
John Tulloch
It isn’t my impression that the criticism is aimed at the medical staff, rather it’s the organisation of the delivery which is thought to be lacking.
We are fortunate in Arrochar to enjoy a first class service and having had some recent experience of dealing with Lerwick Health Centre, I recognise some of the complaints reported, however, I suspect the patient to doctor ratio at Arrochar is lower than at Lerwick.
The Lerwick difficulties aren’t a recent development and if people are departing in droves due to stress, there must be something fundamental amiss. It may well be that there are simply too many patients for Lerwick Health Centre staff to cope, especially, if we consider demand from the several residential care establishments, albeit, maternity ward cover should now be considerably reduced.
It’s said, “You can’t get a gallon from a pint pot.”
ian Tinkler
I have many friends whom work for Shetland Health Board as medical professionals; they are forced to sign documents muzzling them from any criticism of “The Administration” which affectively silences them from the press. Sadly in private not a single one of them has ever, to my knowledge had a single good word to say about the way they are managed. Certainly, in my sphere of dentistry, many surgeons found the management and treatment dictates intolerable and simply left for pastures new. Perhaps the same is happening here.
Rachel Buchan
I’ve always thought that the only answer to this is a bigger health centre, and more medical staff. I can’t see any other way around it. Less stress for the patients, and for the staff too!
John Tulloch
It’s quite clear from the article in this week’s paper that, other than a comfier seat while they’re waiting, that Lerwick Health Centre patients needn’t look forward to any significant improvement under the present leadership.
The comments from NHS Shetland’s leaders say it all:
Chairman Ian Kinniburgh: “People should be realistic about what they expect.”
Board Member Malcolm Bell: “The ‘Dr Finlay’ model is not appropriate here.”
These comments are as abominable as they are patronising and complacent.
Robert Sim
So what do you suggest as an alternative, John, given that most models have been tried? And how would you suggest the NHS go about achieving it
John Tulloch
Thanks for your question, Robert. As I’ve said before in the context of education, I’d be happy to come along and assist NHS Shetland for £800 a day.
However, recalling my earlier comments, if patients are having to wait for two weeks for an appointment and medical staff are departing in droves due to stress, wouldn’t that be a good place to start?
1. Establish whether the medical staff resource is adequate to deal with the demand for their services. This will not be difficult for someone familiar with Queueing Theory to work out.
2. If the staff resource is clearly inadequate – and all the indications are that it is, or at least, has been, prior to the new appointments at the hospital materialising – then establish what a sensible level of staffing would be.
3. Once you know what is needed you may then consider whether to re-allocate the areas covered by the GP practices and/or whether more staff are required. There is no point in compounding the problem by shifting it to another practice!
4. If you don’t have the money, make the case and get it.
One final point. Ralph Roberts talked about people wanting, ‘Oliver Twist-like’ to see their “own” doctors and while that is unlikely to be possible all the time, it is highly desirable that it be the case for consistency of diagnosis, continuity of treatment and fewer misunderstandings and/or administrative errors.
The current arrangement seemed to begin following a series of complaints against medical staff and of course, seeing a different dictor every time means it’s very difficult to apportion accountability for complaints, thus camouflaging weaknesses in the system,
Given the reported stress situation, such things need to be treated sensibly and knowing what the ‘correct’ level of staffing should be would provide a datum from which performance issues may be judged fairly, in the context of workload.
An improvement in this area would, doubtless, reduce demand for services.
The Lerwick people are not being ‘unrealistic’ to expect a significantly better service than they are getting. It’s much better, elsewhere, and nobody is asking for the ‘Dr Finlay’ model, rather it is comments of that sort from people who should know better which are ‘inappropriate’.
Robert Sim
Thanks for your reply, John. I take your point regarding the general approach (that would certainly qualify you to be a consultant) but I had wondered if you had some system in mind which could be applied in Lerwick. Personally, I preferred the telephone triage system that was in place for a while.
John Tulloch
Thanks, Robert.
First, may I say that Malcolm Bell has kindly contacted me, pointing out that the ‘Dr Finlay’ quote was attributed to him in isolation, as opposed to the full context of his comments at the meeting, and he also provided me with full details.
I understand, of course, it isn’t easy to precis what’s said at a meeting for a news report and doubtless, the full intent of Malcolm’s comment has slipped through the net on this occasion.
So I withdraw Malcolm’s name from my above criticism, the rest of which, in the absence of further information, I stand by.
Back to the main point, LHC difficulties. I’m a long way away from this and the only information I have on the local situation is what I read in the media so this effort must be taken in that light and I’ll try and keep the comments general.
First, what does ‘triage’ mean?
Briefly, it’s a system for allocating scarce resources based on priority (first aiders at a road accident attend first to casualties who are most likely to die) and it’s designed for emergency situations like disaster response in hospitals and battlefields.
I don’t doubt ‘telephone triage’ is ‘an efficient system for allocating scarce resources’, such technical (‘hard’) systems can be ingenius and extremely effective.
The bare fact that a ‘triage’ system is in use, however, surely betrays the reality that LHC is under-resourced.
Fire-fighting is a useful analogy. If you spend all your time fighting fires, as opposed to preventing them, you may be working hard and become very good at fighting fires, however, no fire-fighting system will prevent you from having to continue ‘fighting fires’, in perpetuity.
This is known as an ‘urgency’ mindset, as opposed to fire prevention, which would be considered ‘important’, the former resulting in becoming, permanently, under siege.
And it’s ‘ditto’ for many fields, not least, health.
It follows that the ‘telephone triage’ system may have a role but is an “unsustainable” way to run a local health service, at least, in the context of daily appointments.
‘Hard’ systems are mechanistic and tend to fail when they impact or depend on significant human involvement and when they are imposed on people it’s assumed users will always behave predictably and of course, they often don’t.
I’m also unaware of any system sufficiently ingenius to eke a ‘gallon from a pint pot’, hence the need for a supply and demand analysis. Moving on:
The principal actors in the LHC situation are patients and medical staff, supported by administration staff. Considerable numbers of people with widely differing aims, priorities, cultures and problems are involved and their needs should be part of any solution. Otherwise they may be poorly-treated/trained, overwhelmed or, even, ‘throw a spanner in the works’.
What is needed is an honest, thorough review which takes account of human factors, a so-called ‘soft’ systems analysis and a start has been made, we already have the patients’ views.
However (it may have been done?) we have not heard about any formal consultation of the medical and admin staff at the centre, by which I mean an honest, organised inquiry aimed at establishing their views, gathering ideas about obstacles and improvements, and gaining their trust and co-operation.
If a Lead GP is appointed that individual should be well-positioned to understand the concerns of medical staff and ensure they are taken into account.
While that’s ongoing an investigation of supply and demand issues with help from someone competent in queueing theory would provide clarity about staff resource levels and serve as a relatively low cost gesture of good faith towards staff, patients and the public.
LHC is a relatively small operation and queueing theory isn’t ‘rocket science’. I’m sure Aberdeen University would be pleased to assist, if contacted.
Once all these investigations have been done, it should be possible to determine the next steps towards the eventual aim which should be determined and clearly stated at the start (it may have been done?) which, ultimately, is to provide a service of, at least, similar, quality to those provided in comparable locations.