Managing Uncertainty

It’s often said that GPs are the jazz musicians of doctors: improvisation and managing uncertainty are part of daily professional life in primary care, and this is what makes the job so rewarding. But this year things got significant more uncertain: national politics have created a such a dense metaphorical fog around the future that makes that makes it hard to plan for the future of the NHS and primary care on both macro and micro level. The BMA poll last year showed half of the UK’s 12,000 EU doctors are considering to leave, while one in three of my colleagues in primary care are considering hanging up their stethoscope within the next five years, independent of their nationality. Then there are the concerns around the sustainability of provision of medicines (at present there don’t seem to be any naproxen and 40mg furosemide tablets available), isotopes for imaging machines, the severe shortage of nurses and paramedics. The list is endless. My beloved NHS -and particularly primary care – is getting severely battered, and it feels like it is only kept (barely) working by the good will of its workforce. Which seems to be wearing thin. I find it unlikely that the ban on fax machines is going to change this.

After so much moaning let’s just remind ourselves how important the GP model of the NHS is for the communities they serve: Barbara Starfield, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore consistently showed that having a primary care practice in your community, even after correction for socioeconomic factors, results in lower all cause mortality; lower mortality from cancer, heart disease, and stroke; increased life expectancy and better self reported health; lower rates of admission to hospital; lower infant mortality; reduced health inequalities; and reduced costs (Caley, M. (2013) BMJ). I find it unlikely that you can deliver these benefits if you shift consultations to online providers.

/rant over. If you’re lucky and you have a few days off over the primary gifting season, enjoy them. If you -like me – have to work between Christmas and New Year, I wish you luck, nerves of steel and understanding patients.

Eels and Maldon

If you walk down the lovely high street that traverses the centre of Maldon in Mid Essex, you come across something that has become pretty rare in England: a pie and mash shop (and a good one to boot). Being the purveyors of traditional East London food stuffs that they are, they also do stewed and jellied eels, but a) not particularly liking fish and b) never understanding the local connection, I so far stayed clear of this local delicacy.

pie and mash
Image used with permission by GRFX_GURU from Flickr.

Well, ‘local’ in this case is probably -in the true sense of the word – far fetched. Until a few days ago I wouldn’t have had a clue about the provenance of the eels sold in mid – Essex, but then I wasn’t aware of a charming little book called ‘Maldon and the Tidal Blackwater, Volume 1’ that I acquired for a mere two quid from a misleading titled second hand book store called ‘Simply The Best Frames’ (conveniently located just a few yards away from the pie shop). I was under the impression that I bought a quick recap of the local history, but after opening it I realised that I actually bought the ‘History of the Heybridge Basin Eel Industry 1928’. Maybe the picture of four sturdy men with a large net full of eels – instead of one of the East – Saxons that founded the place – should have made me suspicious. As it is a rather slim volume that somehow made it into my holiday reading pile, I took it for an afternoon on the beach and read it in one go. It beautifully details the history of Maldon as the capital of eel distribution in the South-East over the last seventy years.

I have been there plenty of times, happily munching away at my pie with mash and baked beans, but last week a friend of mine ventured in there and brought some eels home. I didn’t particularly wanted to come close to them, but I have been reassured that they are amazing.

So, before you venture to Maldon, read up on its Eel related history and if you’re so inclined, have some. Just another reason to visit this little jewel.

Uncomfortable was just the beginning.


4 Months after the decision of the majority of Welsh and English voters outside London to leave the EU, life in the UK has become unsurprisingly uncertain for the average EU citizen. It’s not what I was made for: I am German, and as such political and existential uncertainty is genetic anathema for me. Never in my life I woke up and had to find out by a Radio 4 radio presenter that the majority of my fellow inhabitants of this sceptered isle had not only decided to turn their back on the most successful economic bloc but also to make life for people like me mighty uncomfortable. Which something I don’t really understand, because:

I am not taking anybody’s job. Just like my fellow 27,000 EU doctors in the UK, we were hired in to work in posts that did not attract British graduates. According to that postillon of Brexit, the Daily Mail, the vacancy rate for posts for doctors in the NHS is 7%. Filling these posts will now even be trickier, as recruitment from the EU has just become virtually impossible, with European colleagues now rethinking their decision to work in a country that might ask them to leave in two years.

I came to the UK not for need, but for want. It will soon be 20 years since I started my first job as a Junior House Officer in Dudley’s Russels Hall Hospital. Not the most glamorous or attractive post, you will agree. But that’s the point: I didn’t come to the UK because I was unemployed in Germany, au contraire. I just wanted to work in the UK, full stop. Like so many other Germans of my generation, anglophilia is in my genes. We grew up with Freddie Frinton, Monty Python, Dave Allen (ok, so he was Irish), British pop, language excursions to England’s beachside towns (I was exiled to Brightlingsea for 6 weeks. Best language trip ever!), so moving to the UK was a dream that was harboured for many years. Graduation just made it finally possible.

I am not living in an ethnic ghetto. Ask any European academic working in the UK, and you’ll find a group of people who have assimilated completely into British life. Okay, so we can’t get rid of our accents (and boy, do you remind us), but apart from that you will find us being immersed in British culture, whether it’s on a local or national level. And why? Because we love it. That’s what why we came over here for. British culture is so much more vibrant and varied compared to other nations and sports the best public broadcasting service in the world (apart from Radio New Zealand National). The BBC alone makes it worth living here.

I am not leeching of the state : Like my fellow EU citizens me and my darling partner are net contributors to the British state: we are paying a considerable amount of taxes, rarely use the NHS or council services, buy local and/or British and don’t send our wages (which, by the way, would be considerably higher back in Deutschland) to our relatives. An UCL paper from the centre for research and analysis of migration reported that European migrants made a net contribution of £20bn to UK public finances between 2000 and 2011. Those from the 15 countries which made up the EU before 2004, including France, Germany, Italy and Spain, contributed 64% – £15bn more in taxes than they received in welfare – while east European migrants contributed 12%, equivalent to £5bn more.

So, why do Amber Rudd and Jeremy Hunt (and probably a few people more) want to get rid of me and my colleagues? For the last twenty years, the UK has been my home, so I wouldn’t have a clue where to move to. If someone would tell me to go home, I’d probably ask why he wants me in Essex this very minute.

It’s all rather baffling. Or, actually, it’s more than that.

It’s scary.

It has created existential uncertainty for a group of people propping up public services of the country they love. And it doesn’t look like it’s going to get better.



NHS Hack Day

It’s about 5 1/2 hours with an undermotorised miniature four wheel drive from Mid Essex to Newcastle. That’s about 330 minutes or 9 Matt Bianco albums. So no problems with the entertainment. One starts in Maldon after the afternoon surgery with ‘Whose side are you on’ and arrives in the North around 22:00, slightly hoarse with ‘Echoes’. I had never been before to Newcastle and had always been keen to attend a NHS Hack Day, so the rationale was obvious. Up North it was!

After a Matt Bianco and Radio 4 filled drive up North and navigating a surprisingly busy Newcastle city centre (London’s slow decline of night clubs has obviously not reached The North yet) full of, er, happy twentysomethings and a fortunately quiet night I enjoyed a lovely brisk forty minute morning walk through a now empty Newcastle to the venue that was chosen to be NHS Hack Day central for one day: a handsome, modern space in the middle of the city and the core of a new science park. Very impressive. Inside was a pretty impressive crowd of chapettes and chaps of all ages happily chatting away. So far so good.

NHS Hack Days have an easy organisational structure: you show up with a problem that you want to have solved or a feature that doesn’t exist yet and pitch to the assembled crowd of developers, project managers, clinicians and patients. After the pitching sessions you set up a mini stall and discuss issues and further ideas with interested attendants. The projects that gathered a following then spend the next day discussing audience, features and technical details before building it. The finished prototype will then be presented to the audience – and whap bang – a new helpful IT tool for the NHS has been created.

Pitching Session at 09:30 on a Saturday. Impressive.
Developers, developers, developers, developers, developers

The talent at the table I found myself at was impressive: a UI expert, trainers, clinicians, an entrepreneur, patients and patient advocates. There was a definite urgency to come up with a tool that would make it easier to monitor chronic conditions and find a technology enhanced solution to it. To keep us from drifting into navel gazing or feature overload, we were periodically yelled at by a friendly enforcer, helping us to keep the project on track. Project management enhanced by decibel. Very effective.  Unfortunately the flu that had been niggling at my brain for the previous 48 hours finally broke through the paracetamol barriers and I had to concede defeat and retreat to my hotel for a prolonged recuperation period, but the teams continued to work on their projects for the next 24 hours.



I’ll be back. This is too much fun not to attend again. Hopefully next time without flu.

It’s getting uncomfortable

A few months ago the BBC reported that “The poll of more than 900,000 patients found that, in the last two years, the proportion saying it was not easy to get through on the phone rose from 18% to 24%.”  The Telegraph, not a particularly pro public sector paper started an article under the headline “GP services are imploding as surgeries ‘at risk of closure'” with the paragraph

Two-week waits for GP appointments have become ‘common’, doctors have warned, while thousands could be left without a family doctor entirely due to financial cutbacks.

Then there is this interesting poll suggesting that one in ten GPs is planning to emigrate.

The Guardian rounds up our little press review with the news of falling GP numbers due to a recruitment crisis.

Since then there has been the confirmation via survey that overloaded GPs cannot cope any more and risk burnout.

I am not surprised that patients are getting upset with their GPs. For 8 years I saw a daily battle for appointments being fought  all over the East End, with long queues in front of practices at 07:30 in the morning (I recently saw a lady who brought a camping chair and her breakfast).

Over the last few years there has been a relentless onslaught on my profession from politicians and  – undoubtedly synchronised – from the usual corners of the press. The reason for this is beyond me. Primary care – as it is practiced in the UK – is the most cost effective way to deliver health care and so I naively presumed a government that has austerity as the main driver for its policy decisions would embrace and foster such a system. It’s widely recognised that ever pound invested in primary care saves 5 pounds in secondary and tertiary care, so investment into general practice is a financial no-brainer.  GPs were initially reassured that things would get better before the 2010 election after David Cameron promised  “With the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS“. What the nation got was the 2012 Health and Social Care Act, reducing general practice’s core funding and introducing a seven day GP service on a smaller budget.

It is getting uncomfortable in primary care, both for patients and providers. A+E is struggling like never before. If Brexit would really become a reality, then I would predict a considerable amount of EU doctors starting to think about their future in the country and the health system they love, risking another 20,000 doctors leaving (often serving areas that are struggling to attract graduates). There are about 3,000 GPs from the EU working in primary care, arriving every morning in their practice to do what they without doubt feel is the best job in the world, for patients they have been looking after for decades, in cities, towns and villages they have made their homes.

With another sudden, significant loss of doctors, the current crisis in the NHS would feel a gentle breeze, compared with the storm that’s coming, so better wrap up warm and batten down the hatches.


Primary Futures

I had a great morning: I spent two hours in a primary school telling kids about what it’s like to be a doctor. I’ve done these gigs a few times before, and every time I leave I understand why primary school teachers love what they are doing. Pretty much devoid of cynicism, these kids still love learning, are genuinely interested into pretty much everything and ask questions straight from the heart. First in assembly, then in a classroom full of year five kids, I haven’t had that much fun since since seeing ‘Guardians of the Galaxy’. The questions where thought- and insightful and to my surprised ranged from the gory (‘Have you ever seen a live brain’?) to the philosophical (‘What do you do when people have to die’) to the hard – hitting (‘Have you ever lost a patient’). I was asked whether I had a PhD (No. Bummer.) and was told GPs are the bestest doctors of all because they know EVERYTHING (which is of course almost true).

The whole shindig is organised by ‘Primary Futures‘ which aims “to widen the horizons and aspirations of primary school children by helping them make the connections between their learning and their futures”, and coordinated by the Education and Employment Taskforce, a charity that as far as I understand was launched by good old Gordon Brown in 2009. My main reason for registering as a volunteer was an article in the Guardian reporting on the incredible lack of medical students from poorer background in the UK which really disturbed me, as back at medical school in Germany we seemed to have pretty broad spectrum of students, straight through classes and ethnicity (probably due to the lack of significant student fees).

So, if you have an interesting job and you have a few hours, register and tell a bunch of ten year olds what you’re doing. They will appreciate it and might just quote you 20 years later.




GP Fatigue

Last month I attended another RCGP conference, and while I can’t help feeling overwhelmingly happy while being surrounded by 1500 of my peers, the mood was pretty sombre. This is unsurprising as the majority of GPs are in a pretty dark mood. On one hand there’s the government induced trinity of early retirements, exodus of GPs to a better work-life balance to NZ, AUS and CAN, and the lack of new GPs coming through, all made worse by the governments new junior contract and seven day work proposals. You can’t help but feel that our current government is out to bash the profession into submission, but to what intent?

I am struggling to understand what they actually want from us at present. 7 days opening? Not possible due to lack of practising GPs and actually not wanted by the public. We are experiencing an ever increasing demand for our services, with an increase of 19% of GP consultations over the last 5 years. With other words, an ever diminishing number of primary care doctors are desperately trying to cope with an ever increasing number of patients with more and more complex problems. No wonder the London LMC’s survey of GPs showed that more than 50% of their members are close to, or experiencing signs of burnout such as depersonalization and emotional exhaustion.

So, with the GP workforce in crisis and fatigue in doctors increasing the RCGP rightly started to focus on the effects of this on patient safety. Maureen Baker, current chair of council of the RCGP, has a long standing academic interest in safety in medicine and rightly focuses on GPs pretty much being the only professionals who don’t have a working time directive around patient contact. You wouldn’t want to have a tired pilot flying you around, so why are primary care physicians allowed to see 50+ patients over a 12 hour day (and then probably do a few visits on the way home)?

Those tired GPs will need their weekends. An extension of working hours will deliver nothing of value for patients, because seeing a tired, overworked GP on a Sunday morning will neither be safe nor a particularly nice experience.

New Light through old Windows (not the Chris Rea album)

“Connectivism: A Learning Theory for the Digital Age” by ‘theorist’ George Siemens (nice job title) is a paper that was published in 2005 in the ‘International Journal of Instructional Technology & Distance learning’ in which he imagines a new epoch in learning, devoid of the constraints of the ‘classic’ learning theories behaviourism, cognitivism and constructivism. Throwing in hip concepts from the middle of the last decade such as chaos, self-organisation, complexity and networking (the only thing that’s really missing to complete buzzword bingo would be ‘AI’ and ‘Fuzzy Logic’) he states that ‘Personal knowledge is comprised of a network, which feeds into organizations and institutions, which in turn feed back into the network, and then continue to provide learning to individual.’ which for me sounds like a constructivist ideal of learning.  For him the learning individual sits within a (social or electronic) network of nodes and hubs in which knowledge flows both ways, but with the ‘pipe being more important than the content within the pipe’. Don’t know whether I agree with this. Even in our networked world (I recently counted 15 wireless devices hooked up to our domestic wifi router. This is a 2 person household!) content is still king and learning is still done within a constructivist framework. Yes, our motivation for learning has shifted and our potential sources for knowledge have ballooned as much as the number of connected items we use for learning, but we can’t escape the necessity for quality educational content. Even the biggest pipe can’t deliver good knowledge is it’s full of sewage.

Great ideas, no followup

As suggested by the course facilitator, I had a look at some of the e-learning projects that the OU is associated within the OER movement. Unfortunately the majority seem to be dying a slow death by lack of funding and uptake, as the seem not to have been updated for a few years. xDelia, Cloudworks, Coherere and Compendium all must have felt like a good idea at the time, but it looks like their websites are now all gathering dust. This reflects the fickle world of open educational resources: it’s not enough to rent some domain space and plonk some content in there. You have to have both the funds, the manpower and the motivation to keep these up to date and relevant. So many excellent e-learning content, devised with good intentions and a lot of money, is now languishing in abandoned directories on web servers, but even making them available for free doesn’t make them more attractive (or easy to find). That’s why the RCGP invests in regular update cycles of their courses and their content management systems: there is no point in having a few gigabytes of learning lying around, gathering dust. It needs to be curated, edited and updated regularly, otherwise it will end like one of the previously mentioned projects.

Sad really.

A New Year, A New Challenge

Last year I thought I had finally finished my Open University studies. After more than a decade of on and off studying this and that module (from Linux to child development and onwards to innovative design) I had finally gathered enough credits to get the OU’s special BSc Open. That’s it I thought. No more weekends in front of the computer. But then I found out that they also offer a masters in e-learning. That was it, I was sold. So here I am, being forced to blog regularly for “H817 Openness and innovation in elearning” and use this blog as a diary to reflect on the learning that has been achieved the previous week. This does not come easy, as the actual physical process of sitting down in front of a computer and coming up with something noteworthy for me is a rather painful one (as you can see from the previous entries on the website), especially after a day in the surgery. But it can’t be helped. So, for today’s exercise I had to read this 6 year old paper from Educause Review by Seely Brown and Adler, the magazine of a nonprofit with the task to “to advance higher education through the use of information technology”. The authors state that ‘the most profound impact of the Internet is its ability to support and expand the various aspects of social learning’, which with my e-learning hat on is of course is a wise and accurate truism, although the captains of the adult industry and the peddlers of cute pictures of cats and possums would – on hearing this – likely have a prolonged attack of the giggly fits. For them (in 2008) the most visible impact of the internet on education was the Open Educational Resources movement, an initiative by the Institute for the Study of Knowledge Management in Education that attempts to make access to high quality learning material and course free and easy. To my shame I’d never heard of them and wasn’t aware that the principles of OER had now been taken up by national and multinational organisations. Live and learn. The authors go on and praise the benefits of social learning – something I am doing this very moment by blogging to a -admittedly small – audience as a step forward from the traditional Cartesian method of learning, in which one only engages with one’s peers after years of studying. This being an article from 2008, the authors get quite excited about the then severely hyped ‘second life’ virtual environment in which -if I remember correctly – one walked around and looked at blocky buildings built by corporate sponsors who fell for the model and tried to dance awkwardly to music from bands who thought that streaming audio to SecondLife was a hip thing to do. Another example used by Seely Brown and Adler is the ‘Decameron Web‘, a collection of resources around a seminal 14th century text, hosted by the Brown university. The site was to be used an example on how academics interact and how content is created. Interestingly, the initiative created its own trail of papers on the impact of social, web based learning with an impressive list of publications using the decameron web as a particularly noteworthy example of e-learning. Mach and Bhattacharya for instance pick up on both Seely Brown/Adler’s paper and the Decameron Web in their 2009 review ‘Social Learning Versus Individualized Learning‘.  It’s interesting to see how the Open University attempts a similar model with this course, which seems all around creating, sharing and comparing content around the course work. It will be interesting to see whether the impact is as different as promised.