The Back Pages viewpoint A day in the life... NOTHER Monday morning in a 21st century Lanarkshire general practice, revived by a Aweek s holiday. A cubic metre of mail to inspect. First, the National Service Framework for Older People: documentation so bulky that it comes with its own built-in plastic box. Thank goodness for the handy 32-page Executive Summary. Onwards to the North Lanarkshire Council, Department of Community Services, Sport and Recreation Section, Get Active ‘Whereas an Programme, Information Notes, where referral procedures are outlined... doctors et al epidemiologist today complete registration form and hand to patient . So far, so good. But things turn serious ... to emergency referral of patients, where the Emergency Admissions Project Team ease the burden would save his feet of transferring patients from darkened bedrooms to CCU with a sample SIGN-recommended by using applied admissions letter , to improve communication (grammar corrected) between primary and statistical techniques secondary care . The sample letter contains 18 separate information fields for completion, on representative though to achieve a balance between data capture and user-friendliness the EAPT triumph in condensing all 18 into a single A4 sheet. subgroups, Chekhov had 10 000 index cards Would access to CPN services be managed with similar brevity? No such luck. The old system of referral featuring random messy phonecalls: I m a bit worried about this chap, do you printed in the local think he could be seen soonish is clearly failing. So the CPN service, now split beteween a police sweat-shop. He Focused Intervention Team (FIT) and an Assertive Outreach Team, is to be accessed with yet had come like the another form. Also A4, but over two sides. The number of separate fields to complete: 37. At least 19 separate boxes must be completed before there is any mention of the clinical problem. biblical census-taker ...’ And meanwhile, to allay anxiety that our new PFI-funded hospital lacks sufficient beds, we are Chekhov in Sakhalin delighted to welcome the Early Supported Discharge Service... Consultant sessions (Eldely Iain Bamforth, page 510 Medicine) have been identified for this service not to mention a coordinator, physiotherapist, occupational therapists, rehabilitation support workers, assessment and care managers, and E- Friends in low places grade nurses , but no GPs for some reason. We won t be needed, thankfully. (is) an excellent catalyst Now, in the odd world of Jacobean Tragedie, cranking up the emotional ante for all it s worth, I would be deploying dramatic licence here, condensing a month s worth of irritation into a day. for revolutionary But, for once, I m not. The above all arrived on the same morning. And I haven t reached the thought. If it inspires a punchline yet. For on that very same morning another missive arrived, from the Lanarkshire generation of doctors to Primary Care NHS Trust, Palliative Care Project. A covering letter, plus forms to complete for organise against top- all Lanarkshire patients unfortunate enough to require palliative care. Forms does not do justice to this particular piece of paperwork. We re talking card, not paper, A4 with an extra down stupidities, it will half, and in lavish Technicolour. Previous auditing has revealed that some patients with terminal have earned its author illness are not supplied with adequate dosage of pain relief and laxatives, and this patient-held another sabbatical... card is the solution. Guideline prompts for the analgesic step-ladder, rescue medication, morphine/diamorphine conversion notes, opioid side-effects, and adjuvant prompts, plus Neighbour reviewing Willis, page 514 helpful notes on the STASS Score (Support Team Assessment Schedule, in case you were wondering) all the details are there. Many months ago our primary care team had considered this scheme, then an anodyne contents proposal. We worried that it was intrusive, excessively bureaucratic, and did not offer particular 506 news benefits for our patients we were already trying hard, though maybe not demonstrably so, in psychoanalysis, all these areas. But now we have no choice. We have signed up for clinical governance, and dermatology, pedantry participating in this scheme is now mandatory. If we don t use this form we are penalised 508 miscellany financially. child protection, inequality on-line I don t wish to sound too nihilistic here. These are all initiatives of honourable intent some 510 essay of my best friends have produced standardised referral letters of Booker-winning elegance, and Chekhov in Sakhalin audit effectively. But taken together there is a failure to realise that for every form, someone Iain Bamforth has to fill it in, and that final common target is, generally speaking, our good selves. 514 digest Friends in Low Places, We deal here with managerialism out of control. No friend of good patient care. Walsall, Headlong, It’s time to fry the chops Time for another break. plus Salinsky’s books Alec Logan 516 reflection Deputy Editor Berlioz, neurology, Reference and heart failure, 1. SIGN Guideline 31. Report on a recommended referral document. SIGN Secretariat, Royal College plus Newfoundland of Physicians, 9 Queen Street, Edinburgh EH2 1JQ. Tel: 0131 225 7324, Fax: 0131 225 1769, E-mail: 518 matters arising [email protected], www.sign.ac.uk tunes, Kosova, Diary 2. Eccles M, et al. Effect of audit and feedback, and reminder messages on primary care radiology plus Goodman referrals. Lancet 2001; 357: 1406-1409. 520 Contributors plus Munro The British Journal of General Practice, June 2001 505 Psychoanalysis and general Dermatology Working Party practice: what did the Romans Report do for us? HE 14th Michael Balint Memorial HE first ever review of current best Lecture was delivered at Princes Gate practice models, Assessment of Best Tin April by Dr John Salinsky, a TPractice for Dermatology Services in general practitioner and editor of the Primary Care, was published in April and Journal of the Balint Society. The lecture, presented to the Government s Action on entitled Balint groups and psychoanalysis: Dermatology Taskforce, one of three what have the Romans done for us? is given programmes in the National Patients Access under the auspices of the Balint Society Team (NPAT). It will also be submitted to every second year, and was introduced by the current Associate Parliamentary Group the President of the RCGP, Dame Lesley on Skin (APGS) enquiry into dermatology Southgate. services in primary care. John Salinsky began by recalling the origins The Dermatological Care Working Group is of the Balint movement in the 1950s and an autonomous group of health professionals noted that Michael Balint and his and patients comprising representatives for psychoanalyst colleagues wanted to offer The Associate Parliamentary Group on Skin some much needed help to family doctors (APGS), British Medical Association who were struggling with bewildering (BMA), British Dermatological Nursing psychosomatic problems. The GPs who took Group (BDNG), National Association of part benefited enormously from Balint s Primary Care (NAPC), NHS Alliance, case discussion groups, which have since Primary Care Dermatology Society (PCDS), spread all over the world. Nowadays, Royal Pharmaceutical Society (RPS), Royal however, very few analysts in Britain are College of Nursing (RCN), Royal College of involved and most groups, especially those General Practitioners (RCGP), and the Skin in vocational training schemes, are led by Care Campaign (SCC). GPs. Where have the analysts gone? Skin disease affects around 33% of the Perhaps the Balint Society itself has put population and accounts for around 15% of them off by modernising Balint in a way a GP s workload. It can have a significant that deliberately played down its and detrimental impact on patient quality of psychoanalytic origins. Did the loss of the life, increasing susceptibility to a range of analysts really matter? complex psychological difficulties. Yet because skin conditions are rarely life- As an illustration, the audience were treated threatening, decision-makers and policy to a video clip from the film Monty Python’s planners ignore the hidden costs to patients Life of Brian, in which John Cleese asks his and the NHS. Similarly, inadequate revolutionary Judean followers: what did undergraduate training leaves many non- the Romans ever do for us? . The followers specialist health professionals ill-prepared to produce lots of examples ( the aqueduct, give optimum treatment to patients with skin roads, wine, law and order, sanitation , etc) disease. to the dismay of their leader. Britain had Romans too, but they left Britain in the fifth Nearly 80% of dermatology consultations in century, leaving little trace of their culture primary care arise from a small number of behind. Were the psychoanalysts the Balint conditions: acne, eczema/dermatitis, movement s Romans ? psoriasis, skin infections, and leg ulcers. Many of these can be well controlled by Strangely enough, the Balint movement in effective patient self-management, yet non- continental Europe is still predominantly led compliance and incorrect use seems to be a by analysts. In Britain, GP leaders do very problem, particularly with topical well as leaders of vocational training preparations, because patients are groups, as they are not tempted to make too inadequately informed about their skin many interpretations . They stick to more disease and its treatments. simple interventions designed to encourage the group members to do the work and to The report identifies how care pathways can focus on the doctor patient relationship. But be developed to meet NHS modernisation even these apparently simple ideas are targets and improve outcomes for patients informed by Seven Principles which our with skin conditions and recommends that psychoanalyst Romans handed down to us. guidelines should be set up by the They are underpinned by the idea that some Department of Health to direct the mental processes are unconscious and that development of specialist dermatology patients and doctors have strong (often clinics with proper resources and targets for unconscious) feelings about each other.