his practice establishing an appointment system rather earlier than other
practices in the town.
In '53 we
started [an] appointment system … and the receptionists were completely
looked after… One or two occasions you got a nasty person in and were
told to leave the list. But our receptionists were first class… They are
the first people to see the patient, they’ve got to welcome them to the
place, treasure them. If the
matter seems urgent they’ll push them through. If they look a bit sad
and weary give them a cup of tea... (5)
practices the Family Doctor Charter marked a change in the duties and
status of reception staff.
E.: Prior to 1966 we had
a kind of housekeeper-receptionist. We had a flat attached to the old
surgery and we had a family who lived in it.
The wife of the family kept the close clean for us and she answered
the phone for us during the day. …
When we formed the group practice and moved to the premises in Neilson
Road we no longer needed a receptionist-housekeeper of that kind.
She got a council house … and we continued to employ her as a
receptionist. … She was full-time and we had two part-time ones … then
one of the part-timers became full time … that was sufficient for many
years … I don’t know how they get on with things nowadays, but they
seem to have a staff of about a dozen in the place now. (6)
doctors took a variety of approaches to appointments and reception staff.
R: I always had three
receptionists and we were open six days a week and we always ran open
surgeries. Because one of
things that pissed me off most about the previous practice was the way in
which they just came down on the patients every time… I thought it was a
dreadful appointments system and it utterly discriminated against the
poor. …You know, they
[patients] didn’t have the same options, because they had to think about
the bus connections all the time because they were in the peripheral
schemes. And secondly, they
didn’t tend to have the phone so all the receptionist had to do was keep
them on the phone till their money ran out (laughs). (7)
practice administration has not only grown, but has also included new
groups of staff.
F: So it’s five
receptionists and practice manager… It’s been a gradual thing over the
years. I think the first
increase was 1990.… There’s more forms to be filled in, there’s more
things that need to be discussed, there’s more bits and pieces to be
planning ... (8)
D: When I came here [in
1988] … the practice had absolutely no management structure … we had a
bookkeeper but the principal seemed to do everything in terms of actually
dealing with the genuine business side of things… We did have a manager,
probably quite late in the game in relative terms compared to other
practices… and then we went through a number of managers with a series
of disasters, because we were totally unrealistic about our expectations
of the manager. … These
people came in and they would all have significant strengths in one area
or another but be completely disastrous in one area or another….
Eventually we got so disillusioned with the idea of having practice
managers that we decided to abandon that completely. …We now have a
reception manager and a practice administrator... (9)
employment of new staff has added considerably to the pressure on space
within practice premises.
D: So when we want to
bum we add on two extra rooms. We
talk about “the office”, the practice manager’s “office” and …
we talk about “the computer room”.
I mean there’s no door to it or anything.
I mean it’s …a corner in the corridor. (10)
Establishing the primary care team has been slow and there have
been difficulties, including communication between GPs and nursing
services that reflect a wider tension arising from sharing responsibility
the role of the district nurse changed in your time in practice?
W: You mean did district
nurses seem to me in 1964 to be the enemy?
Were health visitors the enemy?
By that I mean that your district nurse would go out and see
somebody in the morning and she’d put in a call in the afternoon, and
the same with the health visitor. …So you then found yourself picking up
these things, which had been probably known for a while but have now come
in as a so-called 'emergency visit'. And that didn’t go down well…
Well this was work that they were introducing at a time when
you’d already done about fourteen calls that day, and a long surgery,
and you knew there was another long surgery coming up, and you were in the
process of trying to digest a meal, and they’re on the phone.
So, yeah they were looked upon as the enemy (laughs) in that sense.
nurses are very much part of the team [now] and if there are problems you
have a chat with them and when there are long-term problems with people
they’re more in charge of the situation really than you are.
I mean the health visitor and district nurses I see every day and
have a chat with and if there are problems we decide how to approach them
and how we should go about it.
H recalls in the early 1980s discussing caring for patients with
Parkinson’s Disease with his trainer.
Now I had
swatted up on Parkinson’s disease and seen lots of folk in hospital and
I thought I knew everything about it.
… And it was very obvious that I didn’t know about dealing with
people at home with Parkinson’s disease.
“How do you manage this?' And I said, 'You give this drug, that
drug and the next drug”. And
he said, 'Well no, that’s not what we really mean by managing it.
You involve your district nurses, you get the OT out… and you
organize care'. … And you learn more about teamwork in general practice
and they had regular meetings with the whole practice team; the social
worker was involved as well. There
was a much better relationship between the social work input there. (12)
recruit and retain staff in a variety of ways.
T: The two girls who are currently practice
nurses are the only practice nurses we’ve ever had.
And they both came from our district nursing staff.
We pinch them. Ehem,
our health visiting staff, has evolved over the years … but we haven’t
had a great deal of turnover of nursing staff.
… So I hope that reflects that they, feel as if their a valuable
part of the team. (13)
Some of the
GPs spoke of having to acquire understanding with individual non-GP
D: I think partly it’s
initiative and partly it’s fulfilling a role that compliments what
we’re doing and obviously you’ve got to compliment what they’re
doing as well… There’s one of my health visitors that I know when to
involve her and she knows when to involve me… it’s a negotiated order,
it’s a negotiated position over time. (14)
is a sense amongst some of the younger GPs of continuing tensions in the
primary health care team.
Nurses are very good at working to protocol…but nursing as a
whole is under-utilized. I
think there’s a danger that if we over utilize them there’ll be less
of a job for ourselves being that there is a lot of things that they can
do and do very well. (15)
that the nurses are doing too much was reiterated by another GP with
reference to the concerns of dermatologists.
R: The dermatology system is being
redesigned and the dermatologists are very nervous about the nurses
looking after leg ulcers and having access, if the nurse isn’t happy, to
refer directly to the clinic. They would rather that the nurse asked the
GP for an opinion and the GP referred to the clinic.
…The GPs job is changing all the time. What we’ve got to do is,
or I’ve got to do as a GP is, I’ve got to make sure that I’m doing
something which is something I can do. For instance, only I can do. (16)