Appointments.

I recently read a blog post by Dr Jon Griffiths that gave his insider tips about general practice – so I thought it would be useful for me to do my own top ten helpful nuggets to make navigating booking and having an appointment an easier process for all involved.

Generalist

I am a generalist and proud. I chose to specialise in general practice and I have a breadth of knowledge and skills because of this. After a busy week, if I’m feeling in a moody disposition, I can feel a bit like a vessel in which referrals or tests are requested. This can be both from patients and secondary care colleagues I can be left feeling far from an experienced, autonomous clinician.

Often, I can make a diagnosis by simply asking you a few questions; I do not always need bloods or an X-Ray to confirm my opinion. You do not always need to be referred to a hospital clinic and now that we have much stricter referral pathways for a lot of conditions this is even less likely to happen.

Headache is a good example here as it is a common symptom that, in general, has a benign (i.e. not sinister) cause, however, a lot of patients worry that a headache is a sign of a brain tumour. In general, chronic headache does not require tests such as an MRI scan. Your GP should take a detailed history, taking in to account any ‘red flags’, such as pain waking you from sleep or associated with vomiting or visual symptoms. This history will help them decide if it is chronic tension type headache, episodic migraine or something to be more concerned about, such as a tumour.

Quite often I do not prescribe a drug during a consultation but instead will suggest a visit to see your local pharmacist to discuss a specific off-the-shelf or over-the-counter medicine. A lot of medication is cheaper at the pharmacy vs using my prescription pad: hydrocortisone cream, antihistamines, antibiotic eye drops or decongestants to name a few. I have an idea for a future blog post about self care and must-haves for your medicine cupboard.

Some health problems will take a lot of time to get better, for example, with a chest infection, antibiotics may take away some of the symptoms but you may cough for a further 2-3 weeks beyond this and that just requires rest and patience. Some conditions require you to make lifestyle changes, engage in exercise or make a change to your diet. I cannot wave a magic wand and fix your back pain which has been ongoing for two years if you yourself are not willing to make changes at home or work to facilitate this.

History

When describing your symptoms try to be as specific as you can, think about when it started, saying ‘a while’ or ‘a few months’ is not that helpful. If you’re dizzy, can you clarify what it feels like, is the room spinning, do you feel lightheaded or unsteady? If you have ‘passed out’ did you actually lose consciousness or did you just need to sit down for a minute until the feeling had passed? A GP will try and let you give a narrative of your symptoms to start with and then we will ask specific questions relating to timing, onset and other symptoms that you may also have felt.

Another tip I would give to both GPs and patients is to acknowledge that the patient is sometimes the expert in their own disease. This is especially true when the patient (or family member) has a rare disease that we don’t have a lot of contact with in primary care. I think it is so valuable in these cases to admit the limits of my knowledge and take an honest approach. However, going forward I would look in to their condition in more detail and take their lead when it comes to change in symptoms.

Tell us early in the consultation if you have researched your symptoms and are worried about something in particular. It is easy to *insert popular search engine here* your symptoms and come up with a worrying diagnosis. If your GP knows what you’re worried about it’s easier to allay your concerns and understand your expectations.

Examination

If you have a sore knee or a rash on your thigh expect that we might want to look directly at it. If you have a cough, do not be surprised when I want to listen to your chest and your back. Try to wear appropriate clothing so that we can access the part of the body we need to in a timely fashion, skinny jeans can be tricky to remove when anxious and in a rush! If you need an intimate examination you are always entitled to have a chaperone present if you choose to.

Tests

If you do need tests try to find out how long the results will take to come back and how the practice might communicate that with you. Patients are able to now sign up to see all of their notes online and you can see all processed results on there. We do not routinely inform patients of normal results but will be in touch with patients if any abnormalities either by text, phone or letter.

Blood tests are variable, a full blood count for example can be back the same day, thyroid function test take 2-3 days and more specialised bloods like a coeliac or autoimmune screen can take beyond 7 days. X-rays and scans take much longer to come back, an X-ray or ultrasound locally can take 1-3 weeks to be reported and a CT or MRI anywhere between 3-4 weeks unless something requires immediate action, in which case the radiology department will fax us urgently with the result.

Timing

At my practice our standard GP appointment is 10 minutes long, but you have the option of making this a ‘double’ if you ask when booking. This is especially useful if you have more the one problem to discuss. Some clinicians do an internal sigh when a patient brings out a list, but I actually think it helps when a patient has thought about why they are going to the surgery and committed it to paper. I may not be able to cover all the things on said list but it is useful to know what the patient is hoping for at the get-go, then I can work on expectations. It may well be that a few symptoms on your list are actually linked but you are unaware, for example, tiredness, constipation and dry skin can all be caused by hypothyroidism so being aware of your list early can save us both time!

I often get patients that say ‘I’ve done you a favour doc, saved everything up for today, I haven’t seen anyone for a couple of years’… its actually easier if you see us more regularly so we can manage each problem as bite size pieces rather than trying to ‘fix’ two years worth of medical issues at once. I will say to my patients that I cannot deal with everything they want covered in their 10 minute slot but I am always more than happy to get them booked in for another routine slot to cover other aspects of their list if needed.

Punctuality is vital. Yes your GP may be running late (and as mentioned in previous blogs this is not because we are slow/lazy, it is because we have been dealing with medical complexity prior to your slot) but it is your responsibility to be on time for your appointment. It is generally considered that if you are beyond 10 minutes late the appointment has gone and you should rebook, however, there is obviously flexibility here if you are acutely unwell or dealing with children/elderly. I will often tell the receptionists that I will happily see the late patient when I have a gap or at the end of my list if they are happy to wait.

Urgent vs Routine

We split our clinics up in the urgent care and routine care. This is because the flow of the session is very different depending on the type of patient we are expecting to see. If you attend urgent care with a very chronic problem with a complex history it can slow the clinic down and you can be left feeling like you haven’t been properly sorted. A routine appointment allows more time and consideration for both the patient and clinician. If you have had a quick change in your chronic symptoms then please do book a same day urgent appointment.

I thought it would be useful to give a few examples of some cases that could have been better managed in a different type of appointment slot:

  • A patient in my urgent care clinic with a mole present for over three years, no change. (should have made a routine appointment with a GP)
  • A patient on my urgent phone call list who had forgotten to order their repeat prescription for a week needed it within the next hour as they were about to head to the airport. (patient should have avoided this scenario and requested their prescription earlier, query should have gone to our prescription admin team)
  • A patient on my urgent phone calls that wanted to know the exact results of their bloods. They had already been filed as normal and a message sent for the patient to be reassured and advised to book a routine follow up with their original clinician if needed. (should have booked a routine phone or face to face appointment with a GP, ideally who they initially saw)
  • A patient in my routine clinic that had booked their appointment two weeks prior who was suffering acute onset shortness of breath and coughing up blood (should have been see the same day in the urgent care clinic)

I have been a patient as well as a doctor. I find it tricky booking appointments for myself and my family. I have two week days off and am available over the weekend but this can make for a narrow window. The easiest way to make an appointment these days is to use the online booking; it allows you to see all the available appointments across the next week or two.

Continuation vs Access

In the current GP set up, it is very difficult to provide both continuation of care, i.e. seeing the same GP each time and a same-day service. Most practices will be able to offer you an appointment with your chosen GP in 2-3 weeks time or a same day appointment with the on call GP but not an urgent appointment with your chosen GP. If you have chronic or complex conditions it is easier for both the patient and clinician if you continue to see them for follow up. Unfortunately this is not always possible given part-time working and annual leave, so it is useful practice for GPs to have a ‘buddy’ system so complex patients have a back-up GP when their preferred GP is away.

Other professionals

As I have mentioned in previous posts, we are increasingly diversifying the workforce in primary care. This may mean a GP is not the best person to see you for a particular problem. When a receptionist asks what the nature of your problem is, it is not because they are nosy; it is because they want to book you in the right slot with the right clinician. I have a great working relationship with our receptionists and they do such a great job in sometimes challenging circumstances. They may suggest that you would be better seeing a musculoskeletal (MSK) practioner if you want a cortisone injection of your knee, a practice nurse if you need a cervical smear or an urgent care practitioner (UCP) if you have an acute sore throat.

A lot of urgent care clinics are run by a mixed team of professionals so you may not see a GP during your visit. We try to allocate the appropriate clinician to each patient on the list; this may be a UCP to a cough, a practice nurse to an infected leg ulcer and a GP to newborn baby with a rash. If a practice nurse or UCP is unsure after seeing you, they will always escalate to a GP for further discussion.

Social Problems

I think a lot of people are surprised when I say a lot of the problems I see in general practice are not medical symptoms. I deal with depression or anxiety that is triggered by poor housing or tense relationships. I see children with worsening asthma due to damp housing or patients with dementia wondering the streets causing disturbance to the neighbourhood. The medical and social elements of wellbeing are closely interwoven.

Stress at work, for example, is a common problem and I can help patients with how to manage their stress and sign them off work for a specific period: what I cannot do is solve any issues with the employer. I try to help where I can in these situations but GPs can be limited in their role. If I sign post a patient to their occupational health department, social services or the citizen’s advice bureau, it is not because I am fobbing them off, it is because another organisation can better deal with the issue at hand.

Over the last couple of years we have worked with a ‘social prescribing’ team, Jasmine and her colleagues offer a fantastic service providing support for a number of social problems, which includes organising volunteering roles for people struggling to get in to paid work, arranging a befriender for a lonely elderly gentleman or assisting a patient with depression to fill in her benefits form who is struggling to concentrate and focus.

Private work

If something is out of the remit of the NHS contract, i.e. the GP contract then a practice can offer that service privately. This includes occupational medicals, travel vaccines, ‘To whom it may concern’ letters for employers, holiday travel insurance claims to give some examples. ‘Fit to do a *insert adventurous sport here*’ letters are a contentious issue; you may find some surgeries refuse to do them as GPs are not generally indemnified to do them. It is advisable to see a specialist sports physician for these. ‘Fit to Fly’ letters are similar and most GPs will now write; ‘Mrs Y is 22 weeks pregnant and so far had an uncomplicated pregnancy’ rather than ‘Miss X is 18 weeks pregnant and fit to fly’.

And there we have it, ten suggestions that might help just one person get more out of their appointment. I hope it’s been helpful!

As usual, if you are unwell, do contact your own surgery or 111 for advice.

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