Dr Helen Salisbury

Brief Outline: .

Background: Is a GP in Oxford.

A GP explains what primary and secondary care is.

Before we begin can you tell us a bit about what’s the difference between primary care and secondary care and where GP’s fall under this?

Okay. So primary care is basically the people you go to first, so that’s GPs, pharmacists, nurses, also actually includes opticians and dentists, they all come under ‘primary care’. ‘Secondary care’ is care offered by specialists usually up in hospitals and usually you’d be referred to secondary care from someone in primary care.

Okay, so I’m guessing a patient would have to go through primary care first before they can be seen in secondary care?

That’s usually the case, yes. So your GP, if you needed specialist treatment or some service that’s not available in primary care, would refer you to secondary care.

And where does A&E land in these categories?

Yes A&E is kind of in the border really because it’s at the hospital but it does count as a hospital service so, it counts as secondary care.

A GP explains what out of hours care is and what it covers.

What is out of hours care and what does this cover?

So out of hours care is GP care, so it’s in the community but when your GP surgery is closed. So most GPs cover from 8:00 in the morning till 6:30 in the evening and some do clinics in the evenings and the weekends as well. But outside those times, other GPs will be offering the same sort of service but to a bigger range of patients.

So are these, is this out of hours service somewhere that patients go to or is it over the phone, cos I know there’s some phone services as well?

Yes, usually what will happen is that you will ring up, you may get some advice over the phone, you may be invited to come to the out of hours centre to be seen by a doctor. Or sometimes the doctor may come to you if that’s necessary.

A GP explains what a walk-in centre is and the kind of problems dealt with there.

What is a walk-in centre and what kind of problems are dealt with there?

Yes. Walk-in centres are mostly in big cities and they’re for dealing with urgent problems, usually minor illnesses, things like minor infections or minor cuts and sprains, things like hay fever. They’re run by nurses. You can walk in you don’t have to have an appointment.

Okay.

So they’re very useful for urgent care for small things, but they don’t have your records there and usually there isn’t a doctor there. It’s just a nurse lead service.

And so I’m guessing it’s similar to A&E, well within GP practices.

It’s a little bit like a minor A&E absolutely, but it’s not somewhere you’d go if you had a broken bone.

So if someone went into a walk-in centre and they actually needed medication or something, can someone prescribe them with medication or?

There’d be some limited things that they can prescribe. So they might be able to give them things like antibiotics for a bladder infection or cream for athletes foot or something like that. But they wouldn’t be able to give more serious or long-term medication.

If that was the case and they couldn’t be provided with medication, what happens after a walk-in centre appointment?

So two possibilities: one, if it’s urgent, that patient would be likely to be sent onto A&E.

Okay.

Or if it’s not something that has to be dealt with absolutely immediately, then the patient would be asked to go and see their own GP back at home.

A GP talks about when it’s best to see a nurse instead of the GP.

Can you tell us the difference between a practice nurse and a GP and when it’s the best time to see a practice nurse rather than a GP?

Okay, so practice nurses usually have quite specific jobs within the practice. At our practice, our nurses sort out all the immunisations, they do most of the cervical smears. They will do dressings for wounds and things like taking out stitches. And they’ll also see some minor illness but nurses can’t on the whole make diagnosis. And they can’t usually prescribe, so actually that’s deciding whether something needs an antibiotic and giving prescription for that.

Would a patient have to see a GP first before they can see the, a practice nurse or can they see a practice nurse straight away?

No, usually they can see a practice nurse straight away and often receptionists will help someone decide who the best person to see for a particular problem is. So, you know, if actually what you need is travel advice or smoking cessation advice, then the nurse is the person to see. But that’s often why the receptionist will ask what the problem is so that they can direct you to the right person.

A GP talks about the range of health problems they deal with.

Can you tell us about the different health problems that a patient might come to see a GP about?

Yes, there’s a huge range of things. So GPs look after people from pregnant women and new born babies right to people at the end of their lives. And some of the things they look after are long-term conditions like asthma and diabetes and sometimes there are things that just arise new, like chest infections and that need treatment or diagnosis.

A GP explains that doctors also help patients worried about their mental or emotional health.

Can you talk a bit about mental health and when a patient should come and see a GP about it.

Yes. I mean lots of people come to the GP when they’re struggling, when they’re struggling with anxiety, with low mood, with stress. And then they will work with the GP to find out actually what can be done to help. Sometimes that will be in the form of counselling or some other sort of talking therapy, sometimes it might be to help with medication.

Okay because usually, from my understanding, is a GP would refer the patient to an IAPT service or someone else that can actually help them for a longer period because a GP can’t do that, is that true?

Often a patient will be referred on because, as you say, doctors only have usually fairly short appointments and patients may need a longer time, and also some different skills to help them through whatever that psychological problem is.

A GP talks about the various minor health problems that patients can see them about that can’t be dealt with by pharmacists or nurses.

Pharmacists are really good as a first port of call for minor illnesses. They can sort out things like sore throats and hay fever and colds. However, if its’s not clear what the diagnosis is, you may well have to see the GP. And also if you might need antibiotics, only a GP can prescribe those. In terms of minor cuts or sprains, again the pharmacist may be able to help you with painkillers and dressings. But if its’s a question of very strong painkillers or there may be broken bones, again you’ll need to see the GP.

A GP explains what a long-term condition is.

Can you explain what a long term condition is?

Okay, long term conditions are things that we can treat and look after but we can’t make them go away. So that will be things like asthma, diabetes, high blood pressure and some conditions that happen like a stroke, so people get a little bit better but they don’t get better completely. In that situation they need care for a longer period of time and also monitoring to make sure the condition is as good as it can be.

A GP talks about mental health and when it’s a good time to see the doctor.

Can you talk a bit about mental health and when a patient should come and see a GP about it.

Yes. I mean lots of people come to the GP when they’re struggling, when they’re struggling with anxiety, with low mood, with stress. And then they will work with the GP to find out actually what can be done to help. Sometimes that will be in the form of counselling or some other sort of talking therapy, sometimes it might be to help with medication.

Okay because usually, from my understanding, is a GP would refer the patient to an IAPT service or someone else that can actually help them for a longer period because a GP can’t do that, is that true?

Often a patient will be referred on because, as you say, doctors only have usually fairly short appointments and patients may need a longer time, and also some different skills to help them through whatever that psychological problem is.

Lots of people come and see GPs when  they’re struggling, struggling with low moods, struggling with worries. And I guess the time to come is when that’s really having an impact on your life, when it’s difficult to cope getting on with your daily life. Many people will come, sometimes what they need is counselling rather than psychological therapies and usually a GP will refer on to somebody else to do that. Sometimes they may need medication. Sometimes they may need just a break from work because of the situation they’re in makes it difficult for them to continue.

How do GP’s deal with the issue if a patient came in with mental health issues but it actually lead onto physical health problems where a GP would actually have to deal with it.

Yes, it’s sometimes difficult to know how much is a mental health problem, how much is a physical health problem. Some mental health problems lead to very definite physical problems. Things like eating disorders when people can become very ill because of their mental health condition. Sometimes people will have many symptoms, a lot of pain, a lot of headache, and actually the underlying problem may be to do with their mood, and some of those things are often a symptom of depression. So it often takes a lot of working out and many times GPs are having to pay attention both to the mental health and the physical health of their patients.

A GP talks about the sexual health services that they usually provide.

What sexual health services does the GP provide and from what age is it provided from?

Okay, so GP’s provide nearly all the contraceptive services, so helping people not get pregnant if they don’t want to get pregnant and really that’s from as early as they need that.

Okay.

They will also provide some testing for things like Chlamydia, which is a very widespread infection that can affect fertility, so that’s useful to screen for that and to treat it if you find it. GPs will also do testing if people have symptoms, take some swabs, try and find out what, if anything, is causing the symptoms, whether that’s ulcers or discharge or something that they think might be sexually transmitted.

Okay, and seeing as you brought that up and you said that anyone can come in for sexual health, to use the sexual health service, imagine it was a teenager and I know teenagers can only come in with an adult and they don’t want an adult with them, how would you go about that?

Yeah, that can be, can be difficult. So teenagers can come on their own if they want to. There’s rules that mean that GPs shouldn’t treat a child unless they know that that person understands exactly what’s going on.

Okay.

Okay, and there are various questions we have to ask ourselves about who needs to know. There are occasions when GPs will prescribe and treat for people, particularly over 14, if they understand what’s going on. It’s often better if parents do know but that’s not always possible.

A GP talks about what’s important when choosing a doctors’ surgery.

Another quick question, I always assumed that when a patient comes to deciding which GP to use, I always assumed that it would be the one closest to their house because that’s where their family doctor would be based. Is there any other decisions that they should take into consideration when choosing a GP?

Yes. I mean convenience is a big thing, can you actually get there and also can the GP get to you if you need visiting at home because most GPs still do home visiting and would visit you at home of you couldn’t get to the surgery. But, having said that, in most cities there’s a number of different surgeries you could go to who would cover where you live and then you need to think about how convenient it is for you, what their opening hours are like, what recommendations you might have from others about the doctors at that surgery.

Okay, and can patients choose who their GP is or are they required to stick to their family doctor?

Patients

If they have preferences.

Patients can certainly ask to be seen by a particular GP and can ask to register with that GP. Some GPs will be very, very popular and their list will be full so they haven’t got room for anyone else, so there are limits to that choice, but basically people can choose.

A GP explains what a health check involves.

Can you tell us about the different health checks that a patient needs to go through with a GP?

Yes. The routine health checks that happen, there are a few that happen when a baby’s very small. Then from the age of about 26 onwards, women are invited to have cervical smears and these are, that’s another thing the nurses do by the way, cervical smears which are to look at the health of the neck of the womb. And that’s a way of detecting changes before cancer develops, so it’s quite important to have those. 

Other than that, there are no routine checks scheduled really until about the age of 40 when the NHS health check comes in, which basically involves blood tests for cholesterol and some measurements of blood pressure, weight and height and advice about how to keep your heart healthy.

A GP talks about a young person’s right to be seen alone and confidentiality.

What rights do young patients have in terms of seeing the doctor or a GP on their own? Because I know there’s an age restriction.

Yes. Different GPs do different things. There’s no hard and fast rule about when a patient can be seen on their own. Parents have parental responsibility until 16.

Okay.

But a lot of teenagers may want to talk to the doctor about private things even before that. So my practice is, if I see a teenager with their parent, I’ll deal with whatever they’ve come with and then I’ll always ask to see the teenager on their own just for a few minutes after the rest of the consultation so that they have a chance to discuss things they can’t say in front of their parents.

Okay so you guys have the option of the parent leaving the room?

Yes.

If they want to discuss anything personal?

Absolutely. And I try to do it as a routine, so it happens every time I see that teenager so they know they could come with one thing and have a chance to talk about something else that’s bothering them on their own.

So what would you do in a case where a parent left the room because you decided to talk to the teenager, and then the parent came back in and said oh I’m worried about what my child discussed, what was spoken about?

Yes. I think it’s difficult. If it was something that the teenager told me in confidence and I wasn’t worried about the child’s safety as a result of that, then I would ask them to discuss it between themselves.

Okay.

But I wouldn’t break that child’s confidence.

Okay, and I’m guessing after 16 a child, a teenager, can come in by themselves to the doctors?

Absolutely, absolutely. I mean they can before the age of 16 if they want to.

Yeah.

And children choose different times. So some children are very happy coming when they’re still 14/15; some people like to come with mum or dad even when they’re 17, 18, 19.

A GP explains when a patient might be referred for counselling.

Sometimes a GP refers a patient to counselling services, in what situations does that occur?

So if a patient comes with an emotional problem, a psychological problem, it may be that what that patient needs is a time and space to explore those problems with a sympathetic listener, a counsellor, and often those counsellors will work in the same place as the GP, so the patients will prefer to come back to the same place just to spend some more time talking to someone about what’s going on. And helping, it will help them come to their own decisions about what needs to happen next.

Okay and how long would the patient have to wait for these counselling sessions or is it done straight away after the GP’s appointment?

It varies hugely in different areas. Often there’s quite a long wait for counsellors. It may be a couple of weeks, it may be as much as two or three months.

And having said that, would you, if the problem was ongoing, would you advise the patient to come back and see you each week for a GP appointment or just wait around for the time to see a counsellor?

Again it depends a little bit with what’s going on. I would usually want to see the patient in the meantime just to make sure they’re okay.

A GP talks about confidentiality at doctors’ surgeries and sexual health clinics.

Confidentiality plays a big role within the GP service. So how do you go about confidentiality and when is it an important issue?

Yeah, I mean it’s important all the time. The basic rule is that: whatever the patient tells the doctor stays with the doctor. It gets complicated when you have people under 16 because their parents have responsibility for them. But doctors must act in the best interests of the child. And if the 14 year old understands exactly what’s going on and is adamant that they don’t want their parents to know, then there may be cases when things like contraception might be prescribed without necessarily alerting the parents.

Okay, is there a situation when you have to inform the parent about their child?

There are situations where you may want to let other people know that’s going on particularly if you’re worried about the welfare of that child. So if, for example, a 14 year old was having a relationship with a much older person, then you may think that that child needs some help. It raises something called safeguarding issues about whether that child might be being exploited. So in that situation you would talk to the child about it but you would probably need to break that confidence.