As a GP, you're part of a system. So what happens when the system is failing?
You only have to pick up a newspaper to read about the widespread effects of funding cuts on the NHS. Long waits in A+E, delays in ambulance response times and frequent cancellations of operations. This leads, inevitably, to patient dissatisfaction and, on occasions, adverse outcomes. The effect on the doctor’s morale and stress levels can also be significant and locum GPs are no exception to this rule.
Below I outline two case scenarios to illustrate potential difficulties and provide advice on how to manage such situations.
An ambulance delay
You are doing a week’s locum and it is lunchtime. You have been asked to conduct a home visit on Mr A, an elderly gentleman who has been experiencing intermittent chest pain and increasing shortness of breath. After assessing him, you are concerned as he has a raised respiratory rate, appears very tired and has reduced oxygen saturations. You diagnose pneumonia and are suspicious that his chest pain could be cardiac, rather than respiratory in origin. You feel he needs urgent hospital admission.
You call ambulance control and request a “blue light” ambulance. They tell you they are extremely busy, but will get an ambulance out to you as soon as possible.
You write up the hospital referral letter, explain to the patient and his family what will happen and wait for the ambulance. After 45 minutes the ambulance hasn’t arrived, the family are getting anxious and your afternoon surgery is about to start.
You need to weigh up the risks of the family taking the patient to hospital in a very unstable condition against the risk of waiting for another half hour for the ambulance.
You call ambulance control and they say it will be at least another half hour. The patient’s son wants to drive his father to hospital, as he feels he has deteriorated over the last few minutes. You explain that it might be risky, so they ask you to drive the patient yourself.
The hospital is only ten minutes away.
What should you do?
This situation is difficult and you are facing pressure from the patient’s family to get him to hospital as soon as possible. Whilst you share their concern, do not be tempted to drive the patient to hospital yourself, as, if the patient deteriorated, you would be unable to assist as the driver of the car. Your car insurance is unlikely to permit the transfer of patients either.
You need to weigh up the risks of the family taking the patient to hospital in a very unstable condition against the risk of waiting for another half hour for the ambulance. This decision is a clinical one and you should document your decision carefully in the clinical records. If the patient were to suffer harm, you would need to be able to justify and explain your actions.
This is a stressful situation and the medical needs of the patient also have to be balanced with the needs of the patients waiting to see you in the afternoon surgery. However, this patient is extremely unwell, and as such, it may be potentially dangerous to leave him waiting for the ambulance and return to your afternoon surgery.
You should consider calling one of the other GPs in the practice to explain the situation. They are likely to be familiar with the patient and may have advice to offer. If you are the only GP working there, it would still be an idea to call one of the GP partners on the telephone. They will want to know about the situation and may, if they are local, agree to come in for an hour to assist you.
It would appear that you may not be able to safely leave your patient and you therefore need to consider whether to cancel the initial part of your afternoon surgery and reschedule appointments.
Perhaps there is a practice nurse that could come out to join you, bringing a portable oxygen cylinder and monitoring equipment. Since there is going to be a delay in the ambulance arrival, it is important to consider what treatment you can provide to the patient in the interim. If the nurse is sufficiently experienced, they may feel competent to stay with the patient until the ambulance arrives, allowing you to return to the surgery to start your afternoon list.
Cancelled cancer surgery
You are doing a one day locum in a practice and see Mrs B, who is awaiting a mastectomy for breast cancer. Her operation has already been rescheduled twice and Mrs B attends your surgery, in distress. She was due to be admitted tomorrow for the surgery, but again, her operation has been cancelled due to lack of beds.
She expresses concern that her cancer could be spreading. She is a single mother with two young children and her own mother has had to come over from Europe to look after the children on all three occasions, only to not be needed at the last minute.
Mrs B asks you to do whatever you can to help her.
What should you do?
It is important to offer support to Mrs B at this stressful time, since she is concerned about the risk of deterioration of her condition. You may wish to offer to re-examine her, to ensure that the lump hasn’t changed in nature since she was last examined.
There is national guidance1,2 on how quickly patients should receive surgical treatment for their cancer; if this target is not being met, and lack of resources are potentially impacting on patient care, you have a duty to raise concerns3.
You should speak to the consultant responsible for the patient’s care, outlining the fact that your patient's operation for cancer has been cancelled three times. They may not be aware of this fact and may be able to arrange for the surgery to take place promptly. It would be important to highlight the patient’s social situation, and the fact that her mother has come over from Europe to assist her.
You should document all conversations in the patient’s medical record. It would be important to let the patient’s regular GP know the action you have taken, so they can follow her up and ensure the patient receives the right treatment.