RCGP Heritage

Ann Telesz discusses shift in care that more post surgery care at home and her experience in home births as a GP:
Interviewer
Yes so can, could you say something about the shift um work or services from hospital to primary care. Can you say anything about that?
Telesz
Yes, I mean,  a major shift is, is with uh postoperative are of patients with acute conditions in their homes. Using outreach teams but with a general practitioner being responsible. Yeah, I mean I think, I think that's been a very important shift. Um even say in maternity people going home two days after a caesarean section into the community not, that the GPs necessarily that much involved with them, but they would be the backup if there were concerns.
Interviewer
So when, can you say if you were involved with maternity care then?
Telesz 
Oh in maternity care yes  it was a lovely part of our work when so when we were first doing maternity care we would go and visit patients routinely for their postnatal care. Obviously because we were paid for it as well, but we would go as soon as possible after they'd had their baby and then make another two visits as well as then inviting them in for their six week check. And that gave an opportunity to really get to know the family.  I was also involved with intrapartum care. We had responsibility for beds at the local hospital [interviewee confirms this was Whipps Cross Hospital], the maternity unit for  the lower risk part of it and so if one of our patients had their baby we'd go in and see them and, you know, just check everything was alright. Check the baby over and then do the discharge check as well, but all then went.
Interviewer
Can, can you say way?
Telesz
Uh finance
Interviewer
 Hmm
Telesz
Uh we were no longer paid. We could still claim for maternity care even if we hadn't visited the patients at home and so it was not thought it was an appropriate use of our time as a practice to be doing that rather than other things.
Interviewer
Can you say whether or not you were involved in home deliveries?
Telesz
Phew, uh the only ones I did, I mean, yes is the answer to that, so yes in terms of supervising uh the midwives who did them, but also I did end up being called out of surgery, just at the end of surgery one morning and arriving and doing the delivery, you know, finding the car outside the house with uh the doors open, front door of the house open, the women lying on the bed and the only thing that I would say, cause I don't like drama, but I did manage to make sure they, that we got a towel to put under her and told the husband to go and put the kettle on and then delivered the baby and then the ambulance people turned up a bit later. Midwife turned up a bit later by which time the husband was, held his car torch over my shoulder and I put a stitch or two in and there we were. But that was it you know, that was my, I didn't do hands on home deliveries as a matter of course.
Interviewer
Yeah, I think planned deliveries weren't being done at home.
Telesz
Well planned deliveries were.
Interviewer
So, so, who was doing those?
Telesz
The midwives, independent, with our supervision yeah, yeah

Travel has possessed its own challenges from staying in communication to the weather itself, as Dennis Cox recounts:
I wasn't quite sure what it did apart from being able pick those people at 35 + who needed a smear And, you know, we were proud of it [laughs] and we were also proud of putting our notes in alphabetical order and we were also proud, and then treasury tagging them and putting a little hole in each corner treasury tagging because, you know, in some practices it was just like shuffling cards, but in these old, old Lloyd George envelopes.


 So those were the, you know,  actually summary, you know, if you have ever, if I think about those, things we went through over those years which was just, you know, ordering your notes. Getting the write order. Getting some of the paperwork to, to thinning it out a little bit. Then the big thing was summarizing them and going through the notes. These were all extra tasks you did on top of a busy, you know, it was often doctors. So, at the early days it was doctors who did it. You know, later we trained people to do the summarizing, but you know, but it was a real task then.


 You know, I think for future generations will find it hard to imagine how doctors knew who needed vaccination, who didn't, whose test results were through things like that. So the future generations will find it hard to imagine the work involved with filing. You know, actually getting results on paper, creating actions, getting those actions through on paper actually the  paper based visit systems to make sure that everybody, all the visits had been ticked off, what was the method, you know, accepting the visits. I remember, you know, a really bad day of visits would be when an extra sheet was sellotaped on the bottom of the [laughs] visit book. Um cause of course, you know, future generations won't realise that doctors used to do these things called home visits then, you know, a lot.


We did a lot of home visits. We never refused a home visit. So, you know, so in the typical day then was quite it was, it was quite, it was, it was ok I, I think it got more intense as things, time went on. And it had a pace to it, you know, we, when I started, I think we were, we would combine with other practices in a rota so there'd be the St Ives rota so that would be about four, four practices joining together. I can't remember how, how often we'd be on call. Maybe one night in ten something like that. Not, [clears throat] not terribly onerous, but hard when you did it.


And remember when we went out.Well there was two things. When you went out your wife or your partner, be often the wife then it was the wife who was trapped at home because she couldn't, we'd there was no mobile phones so she couldn't leave the phone unmanned. So I'd be only the one on a weekend, when I was on call, would be the only one who could go and get groceries or something like that, she'd be, and then we were, you know, my poor wife would be trying to bath the children and the phone would be ringing and then she's completely untrained, but having to actually do some assessment or and then somehow get hold of me. And she'd get hold of me by bleeping me and then I would find a telephone usually in the patient's house to phone back and get the details of the next, of the next call.

And also, I really, it was so difficult, and I remember like on a snowy windy night when I'd lived, I lived in Bluntisham, you know, I'd got out to see, to see a child with earache, for example, with a, you know, with a shovel in the back of the [car] and wellington boots and going down these country roads thinking actually if I go off into the ditch or something like that I've no way of telephoning anybody to tell them what had happened., Jill doesn't know where I've gone. No, no there's record of where I'm going to. Where I'm going, you know. It was quite, it was quite different, you know.


It was quite quite different.

Dr Lloyd describes how digital technology has significantly impacted how GPs and patients interact:
Lloyd
I think that's I think that's what I would like to do. First get it out of the way in the instance is tell you about things that I saw changing. Within my practise, and I say I, joined as a fifth partner. But by the time I left I. Think there were eight partners altogether? We had no practise nurse. We had four people at reception by the time I left, there were two or three practise nurses and dietician. Goodness, there's what and it changed. The cause of taking on additional… some initiatives, you know, we broadened what we did from just doing. Morning and evening surgery and visits. To a much wider range of things. And that is very enjoyable in some ways, but of course it meant you were using up time and resources. Doing things which perhaps you had initially intended to do. 

When it started, we had five minutes consultation times Mad, it seems mad. But then people came in just to have their blood pressure checked, or to have their injection. And they're being allowed in 2 minutes, so wasn't ideal. Of course, consultation times, lengths and. When I started, it was not unusual to do 10-15 visits. By the time I finished, we weren't doing anything like that. When I started, you had on call for 24 hours every week. And I remember. One of my registrars set a record of getting 10 night visits after the time of 10 o'clock. That's a lot, isn't it? You wouldn’t do 10 visits during the day now. And I mean, I say it was glad when we didn't have to do them. Anymore, but on. The other hand, I think in a sense that change made a massive impact on general practice. Because we had this move, well, we I'm not responsible for you all the time anymore. 

There's, I think the sense of continuity they had when you were on call. You weren't personally on call, but the team was there all the time. Yeah. You know, look at what my daughter does now and she does some traditional general practice, but she also works for 111 and out of hours and things like that and. Its uh more a sort of portfolio then a single job to do.

So anyway come guess what other things changed. I mean also the thing about being on call you Know you, you used uh your telephone number, you’d ring up and say yes  I come and visit you now. And then that phone number would be rung by my wife. Say, could you tell Doctor Lloyd he's got another visit because you know when he had a bleep. And wow, that was amazing, they could actually contact you. It doesn't always work. And then you got this old mobile phone, right? This massive thing that didn't, terrible reception in some areas. But then, because once you finally got phones that work that made a huge difference. It made it easier in some ways, but also of course you were that much more available. So you couldn't sort of say, well, I can't speak to you just now because you can, you're there, get on with it. 

So I think that they like many innovations, they have their Advantages and disadvantages. We had a people switching system, it wasn't a system, it was just people have sent in little scraps of paper and the senior receptionist would write out, hand write prescriptions. And then we would sign them after we finished morning surgery. Wow. We actually introduced the card system where people have all their medication listed on a card. And when it was next due and things like. And then. I met up with a guy who is his brother to one of my fellow trainees in Taunton and he was from Ireland, he said. oh, Huw, I don't whether be interested in trying out this computerised repeat prescription system I've got for you and he came with this old I don’t think it's a laptop. It was not an eormous computer, but We started to computerise our peer prescriptions.

Interviewer 
Can you remember by when that was?

Lloyd
Let me think. I was supposed to probably be in. Certainly after I came back from Australia but never early 90s, I think probably.

Interviewer
Yes, that's when we started out. That's works for me. Just wondered to give people an idea. interesting, yeah.

Lloyd
Yeah. About then. And that was the first step towards computerization and of course. Computerization started to evolve. General Medical records. And before that, we had the old Lloyd George. And we thought about going to af, but actually isation overtook that thank goodness because it was a massive change. The fact that you had things on call, you could pick notes up from your desk was excellent. But then of course, it did mean that everybody had to be very careful about making entries and I'm not sure every time all the entries were made that should have been. 

And I none of the part of my, I'm digressing a bit. Let's stick with computers and what they do. Again, It was, it was good because you could bring up results so very easily. But it was only partial. It's not like the computer systems that I see in operation now. So there's always various limitations to them, always worried what would go wrong and how might it work if it crashed, which it did the times. Probably still does, I don't know, but one thing happens. [cough] excuse me

Interviewer
That's alright.

Lloyd
Yes. And then other things was things like the fact that people could take their own blood pressure. You know that made a big difference because they could monitor themselves. People start to test their blood sugars at home and and would monitor that more regularly. So there's more devolved the patient. I mean, when when I started, you know, people would look to me and say what should I do, doctor? And I had great difficulty with some patients to make them realise that perhaps they would be part of that decision making process.

Kate Cabot, GP partner at a six partner practice in Acton, West London, discusses how her practice introduced new tools for treating patients:

The European not to take note. So we've got back. We're all talking about it, but it was only really when Trish Greenhalgh did a really good article in the BMJ on the 3rd of April about. What's happening here? Let's start wearing masks, because you need to be, you know, take precautions. What's wrong with the precautionary principle? And we started then wearing masks for or if, if we could find some to, to see patients. And we also that coincided with beginning to realise that people were getting ill and some of them were not telling the truth unfortunately because they wanted to get seen. I'd had one or two scary ones where we hadn't got to the stage of wearing masks with all consultations, and someone would sit down and say, take their temperature. They got a temperature, they got a cough and you suddenly jumping back, saying, hang on a minute. You didn't say you had a temperature to the staff.

And then, you know, then we realised we had to completely reconfigure. We're gonna have to full telephone triage. The staff because at first they were just asking all those questions about have you been to those hill towns in Italy? It was all pretty rubbishy because we were already realising that it wasn't just people from hill towns in Italy, who are all these funny little bits and pieces  round them up. You had to actually start suspecting anyone coming in, with the temperature and a cough that they might have covid. So we then had to put up our. You know, full telephone triage for all patients who wanted to be seen and trying to start getting hold of a bit, few more masks and then, you know, going and buying screw fix eye visors from the DIY shop. Getting some old plastic nurses aprons out of their store cupboards and just trying to cobble together our own and get some rubber gloves and things we just still had so that we will then begin to protect ourselves. And that's, that's the sort.

 And there’s this thing about actually just realising that if you wanna, we've gotta take precautions. So we're gonna have to start really wearing masks all the time to see all the patients. And I remember doing a visit when we were beginning to. Well, when you go and see someone who's got a cough, get them to wear a mask, get them to wear a mask as well. And that was. I can remember this very memorable visit, unfortunately this woman eventually, after many months, seemed to die of COVID in, though that time I don't know if she had Covid or not. She had a terrible chest and the chance COPD and I had to go visit her at home. But you know, I very much remember standing on her front door step feeling very self-conscious in a plastic apron, mask. And I said to the daughter, she'll need to put a mask on if I'm going to examine her chest. And that was kind of way before it became normal practice and then we just started getting into this sort of rhythm of being much more protective about everything. 

And that's when I actually did write to Martin Marshall because I heard him on the on the radio or something saying, well, at this moment, we don't think that mask is going to be needed. So my logic was well if we were wearing masks, asking patients to wear masks. What? Why are we not saying everyone to start wearing masks? Because what's the point? You know, we do. There must be some kind of reason for wearing masks and why are we not now saying everyone should be wearing masks? Certainly in general practice, in hospitals and why, why not wear masks on public transport ? 

And at that stage there was this enormous establishments of denial that there was any point in wearing masks or people wouldn't wear masks or really use up all the masks? And it was interesting. I checked we didn't start. I think it didn't become mandatory to wear masks and public transport , TfL until the end of July. And all that time, you'd have people. Cooped up together.

Dr Mackintosh asks what role will digital technologies play in the future:
Mackintosh
So I think the challenges of the workload have been there and we're still coping with that. But I think sometimes there's also this challenge of managing the future. Trying to set things up for the future in a way that's going to be the best for patients and GPS. And I don't think some of the things that being suggested as a great hope are really the way too go. So that's what concerns me actually more than, more than even the workload actually, but I think I'm in the minority there. I think most of my colleagues are just a bit, not a bit very ground down. 

But if you look at the history of general practise there, as far as my take on history, general practise is that these key moments throughout the last 100 years where you know, think particularly about the early 2000s when the new contract was negotiated is that, there's key moments where all of a sudden everybody realises that GP's are doing a load of work. Which no one knows anything about. And I think we're at that point again. Or that there's some work going on which has value. Which didn't have a light shined on it, and so I think maybe, hopefully we're just at that point where there's going to be another sea change. But I would like to play my part in making sure that that goes in the best direction.

Interviewer
Yeah, that, that's. I can hear a lot of hope there.

Mackintosh
Oh, yeah, yeah, I'm not. I mean, we recently had a salary doctor come and join our team which is doing some days with us, and I'd met her sort of socially. But then when she came to the practise, I said look I'm a GP geek being GP is my job, but it's also my hobby and so I'm interested and passionate about loads of different aspects of general practise and I still feel that way. And that's just me.

Interviewer
That's all really interesting stuff. Thank you for sharing all that.

Kate Cabot, GP partner at a six partner practice in Acton, West London, discusses how her practice introduced new tools for treating patients:

Interviewer
And we mentioned in passing earlier home visits from your childhood, was that a part of your practise?

Cabot
Yes. And I always used to say I liked home visits because I found it really fascinating going into people's houses and seeing all their wedding photographs, this old lady or, you know. I like the idea of homes. It's when we had a bit more time to do it, I mean. When I first started with Helen Sapper, she used to do chronic visits, which is literally had a list of people, and she would go and see them once a month, even if they weren't calling for her. 

So it went from that model to really sorry we can't do because we had to reconfigure the practice once there were two of us. We had to start cutting this thing out that Helen had offered them. And we had to sort of explain that, you know, I'm sorry, that was very nice. But I'm really sorry, you know, but keep the practise going. You know, if you need anything, call us. But we can't just come and see you for a cup of tea. 

So it really went from there where you had enough time to wander around to see people to really having to say, look, I'll only come if I think I'm going to gain and you're going to need me to come. You're going to do something useful out of that. And of course, what we found out in the pandemic is we didn't really have to do a lot of those visits, particularly with video links. If someone did actually have a smartphone. In the house. Actually, very few visits are really neede. But it's probably one of those more sort of qualitative sort of holistic things that. Probably help makes the patient feel good in some ways, and actually I always used to think added a lot to my experience, but unfortunately was another thing where time was not allowing us to sort of enjoy visits anymore. 

And you got a lot of people who didn't like doing them, they’re time consuming. But, you know, I think it's a shame to lose that because there is something you learned, something about that elderly person. You saw them as a real person. Not just as a very old person with nothing much else, I always used to just still remembering some of the interiors you go into. And you'd never get that really, even if you had the video thing on, you wouldn't quite get that feeling or the. But I think it's unfortunate. It's probably a luxury that the NHS can't afford most of the time.