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A faulty production line

Gerard Bulger

  • GP clinical judgement leads to 20% fewer referrals than NEWS score, finds study

    Gerard Bulger's comment 28 Jan 2020 5:33pm

    These scores are designed for ill patients, say post-op, who are going off. Not for patients getting ill in the first place. It is COMPLETELY wrong for Primary Care as we are supposed to find patients before vital signs change. In fit patients signs change late, very late. My last 7 inch leaking aortic aneurysm had a Mews score of 0, which is what is required to get him in and under gas, which they did in four minutes on arrival. What I detest about these scores is the false reassurance they give. Recently I had a patient, albeit in a prison setting, with a rigid abdomen and I arranged him to be sent in; 1-2 hours was Ok, as he had been ill for three days and stable. Little did I know that this was countermanded later and he was not sent in as an emergency because MEWS was 0. MEWS 0-1 mean not ill according to ambulance and nurses. I discovered this four days later. He still rigid abdomen, now with a mass. I have a moderate tantrum, so at last he goes in. He dies four days later. Don't get me started o the risks of Pulse Oximeters in primary care.

  • Do you want to be stranded at the top of your licence?

    Gerard Bulger's comment 06 Nov 2019 9:31pm

    Microspecialisation and part time working is crushing general practice causing mutiple appointments and thus overloading the system, exhausting doctors, who respond by limiting their roles (eg the diabetic lead) making matters worse. We need to get back to being general practitioners.

  • Can the Government fail to act on GP waiting times?

    Gerard Bulger's comment 20 Aug 2019 11:43am

    Long waiting times is the professions' fault. We have all gone part time, reducing flexibility with surges in demand, and now most GPs micro-specialise, creating multiple appointments when one would have done before. Over last 20 years we moved from treating patients with problems to screening and prevention which seemed a good idea but is not working out. We created a nation of the worried well and the approach caused harm with over-diagnosis which we then have to manage with more appointments. I had 2,700 on my list with 1.25 doctors yet patients never had to wait more than three days in 2007 and emergencies on the day.

  • GPs should not prescribe antibiotics for impetigo, says NICE

    Gerard Bulger's comment 20 Aug 2019 11:30am

    I wonder if they are right.. I often wondered is antibiotics were OTT. I have never used hydrogen peroxide cream. Did not know it was a thing.

  • Stricter rules will deter GPs from working in Australia, say recruitment agencies

    Gerard Bulger's comment 30 Jul 2019 4:15pm

    MRCGP (UK) does not have all the remote stuff that RACGP and ACRRM has, the latter even more challenging and good. GPs in Australia do mote stuff, especially when remote, and all doctor training assumes you will be on your own, remote and flying doctors will not get to you because of weather for 48 hours. GPs do skin cancers, minor surgery, setting bones and more. General Practice in OZ is still General Practice, which a much wider remit. Most UK GPs seem terrified to do anything, not even suture a laceration, or joint injection. Do not panic. you can work and get there while working towards the exam. Supervision is pretty hands off, its not like being a trainee again. I suggest ACRRM exam, as a more remote orientated course. So at the start while working you cannot claim the higher "VR" fees until you have one of those exams. There are still plenty of interesting places to go. My inbox is full of pleading Oz agencies asking me back and claiming they can fix the visa.

  • If, when and how to use FeNO

    Gerard Bulger's comment 24 Jul 2019 7:58pm

    Asthma is reversible disease. It comes in attacks or is seasonal. Does FeNo still work when patient comes in seeking a repeat and their peak flow is on target. This test will only work if we catch them wheezing?

  • GP’s indemnity fees doubled to over £1k after state-backed scheme launch

    Gerard Bulger's comment 13 Jul 2019 6:51pm

    GP in English write NHS prescriptions on System 1. They are NHS funded and is in similar manner to hospital scripting as issuing medications to the patient is recorded on the system. They are not FP10s. For a decade + there have been plans to make clinics in prison standard GP practices, but so far has proved too complex (as many extra services) to set up

  • GP’s indemnity fees doubled to over £1k after state-backed scheme launch

    Gerard Bulger's comment 12 Jul 2019 11:55am

    I asked NHS Resolutions what would happen if I made a claim working at any prison, or needed help, next week. The first thing NHS Resolutions will do is look at the trail of contracts to see if Schedule 2L of the NHS Standard Contract is there (in effect APMS). If not mentioned I would not be covered, so back to MPS, having paid the double premium for “private” work cover.

    GPs do not know the wording of contracts up the chain, so we remain at risk.

    The main contract will not necessary APMS/PMS at all. But depends if somewhere in the documentation there is a Schedule 2L of the NHS Standard Contract (each a “Primary Care Contract” in effect APMS) added on to the contract. That is all that is needed.

    NHS Trusts pay a premium each year for their CNST scheme, and the premium depends on their risk and claims rate. NHS Trusts could, if they wanted, include GPs, but you can see why they would rather not. The CNSGP scheme has NHS England pay a global premium. There is no group membership or risk premiums to pay. So it may be all that is needed if for all prison providers to look at their contracts, and add if not there, Schedule 2L of the NHS Standard Contract and we are covered after all!

  • GP’s indemnity fees doubled to over £1k after state-backed scheme launch

    Gerard Bulger's comment 12 Jul 2019 11:51am

    Are there any out of hours services that do not have "Schedule L" in effect APMS contracts? They too would not be covered

  • GP’s indemnity fees doubled to over £1k after state-backed scheme launch

    Gerard Bulger's comment 12 Jul 2019 11:50am

    My MPS fees may no make sense to full time GPs. I am part-time in London prisons, and my other NHS GP work is in Scotland as two week locums, where MPS fees are cheap anyway and now comes with a separate certificate and premium.

  • This fearmongering over missed cancers will end up costing us GPs

    Gerard Bulger's comment 10 Jul 2019 9:20pm

    The must-read that explains the mess we are in
    "Over Diagnosed making people sick in the pursuit of health" by Gilbert Welch. These arguments are the real crisis in healthcare, not privatization or models of funding. The debate should be about benefit, and what is causing harm. Creating a nation of worried well is harm.

  • Welsh GP practices face six-month delay to IT switch due to safety checks

    Gerard Bulger's comment 10 Jul 2019 9:05pm

    Well Ivery liked using Microtest systems as ergonomic. Back in the Fundholding era I saved £20,000 staff costs at the Fundholder's Support Agency as it was so much faster and slicker than three other system it replaced. The clinical Evolution product lets you get instant picture of the patient on first screen which I so miss on other systems. One "flaw" is that set to allow so much local preferences and customisation which great in the end but I suspect tedious to set up.

  • Incidentaloma on the rise: how GPs are left to manage unexpected findings

    Gerard Bulger's comment 06 Jul 2019 10:18pm

    The best book that describes how this came about is
    "Overdiagnosed: Making People Sick in the pursuit of Health" by Gilbert Welch. It should be a compulsory read for all journalists spouting their human interest stories, NHS executives, health administrators and CCGs.

  • NHS to consider taking on GP premises liabilities

    Gerard Bulger's comment 27 Jun 2019 1:36pm

    GPs are giving up any vestiges of being self employed professionals. They have to be salaried and PAYE under tax rules as business expenses fall too low. GPs no longer have to contract for out of hours, no longer responsible for their computers, some given up looking after their staff. Young GPs want part-time big team working, so never have the burden of personal responsibility for anything, even patients. Conclusion: as I wrote in RSMJ all primary care should move into hospitals and GPs be salaried there. Patients want to go to where the scanner is anyway. We cannot fight this trend that arises from within the profession, er trade.

  • Fear and loathing in the appraisal process

    Gerard Bulger's comment 26 Jun 2019 10:23am

    I think it is OK. But FAR TOO OFTEN. But we should do it every three years, with a phone call with appraisers at 18 months. Now that everyone has been revalidated, it can slow down now. I think LMCs,GPC,Pulse should lobby for that change. RCGP even, but doubtful as part the medical education industry who have a vested interest

  • Tomorrow’s IT for today’s GPs – building a future-ready system

    Gerard Bulger's comment 19 Jun 2019 10:36am

    The problem is Government planning in any IT area. Stop it. Have they not learnt anything from the CfH debacle which set our IT systems into aspic? At one time GPs could chose, and their main driver would have been ergonomics and patient safety. We lost 15 years of innovation and lost innovative IT companies because of Connecting for Health.

  • I'm being denied an appraisal - for being a British GP working abroad

    Gerard Bulger's comment 08 Jun 2019 2:25pm

    He could always have a private appraisal and pay for it.

    I have a long and updated blog about this issue.

    I was based in Australia for 7 years and kept up my appraisals every year, working one or more days in the UK when on my travels. After this I walked back into UK practice. I am not sure why GMC, which used to be so pragmatic has recently followed the RCGGP and medical Educational industry line that working abroad is a sabbatical...when we are short of doctors discouraging anyone to come back.

  • Out-of-hours service had no GP on shift 125 times in a year

    Gerard Bulger's comment 07 May 2019 7:56pm

    I worked in Australia. Home visits rare, and if you want (say terminal patient) and there is no out of hours visiting...Services that tried to set it up were made insolvent by medicare changes in fees, as there was no evidence they improved health. If anything increase Casualty use. For seven years in UK I did my own on call for 2,400 patients and seldom woken up.

  • GPs required to take pictures of lesions before skin cancer referrals

    Gerard Bulger's comment 09 Apr 2019 4:35pm

    Such a shame GP have to refer and not deal with these lesions as GPs do in Australia where I have worked. There was a study eons ago from Liverpool that suggested GPs were better at it anyway (better margins). But it is the description and history that counts. If photo needed use dermascope, if you have that kit might as well do all in house.

  • GMC advises doctors to seek legal advice if reflections ordered by court

    Gerard Bulger's comment 12 Sep 2018 1:46pm

    They should have sought legislation to prevent such requests. Worse thing now is Trusts now demanding Appraisal Outputs, printouts from Clairty as a reference and part of thier contracts. I refused as should all GPs. I think NHSE will put a stop to this nasty habit