Dr Gregory . Retired GP Partner.
I am not hopeful of meaningful change being possible for individual GP partners under the current partnership & independent contractor to the NHS model,where GPs are held hostage to the mandatory contract workload by insufficient investment & resources.
Unless all GPs become salaried employees with the associated legally enshrined protection over their working hours,duties and time off,in the face of an historically grossly underfunded and oppressive 'John Wayne' like contract (where the practice is seemingly found to be responsible for everything & everyone for less than this would actually cost),how can principals in partnership 'cap' their workload exactly?
At the end of the day they are deemed legally responsible for meeting the terms of the GP contract and,sadly,our representatives seem perpetually unable to negotiate realistic financing for this.
The fact that the financial and manpower resources available to practices are increasingly inadequate to meet the unending demands of our contracts will be unchanged despite these 'talks' with NHS England about the effect of this toxic pincer grip on individual GPs trying in vain to bridge the gap on a personal level.
I suspect little will change with either the range of responsibilities expected nor the level of funding provided until & unless it is NHS England & HM Government who are legally expected to provide the financial and staffing resources required to safely meet the terms of the negotiated contracts.
Even then,the history of failure to fully meet the actual costing of the genuine demands on secondary care services adequately and the numbers of hospitals running in crippling financial deficit doesnt bode well.
Wasn't the money supposed to follow the patient??
So,another disgraceful abuse of power against powerless NHS personnel, and GPs in particular, is planned.
However,this strikes one as being such an vindictive and egregious suggestion that I doubt it would survive a legal challenge.
Such a move would surely be considered a breach of the GPs fundamental human rights & that of their dependents.
I also doubt that the Secretary of State for Health has such power over NHS staff or contractors to the NHS, especially since the govt famously amputated themselves from the legal responsibility of running the NHS under Lansleys disastrous reforms and are therefore no longer our employers or contractors.
What legal structure could empower such confiscation of a GPs pension by the Secretary of State for Health? These monies are not ill gotten gains and cannot be seized in the same way as criminal assets. There can be no public interest in going after the GPs pension and any punitive action or sentence as a result of prosecution should be ordered by solely the courts ( & by the GMC with regards to ongoing registration).
If you follow the logic used in this proposal then will confiscation of the accused GP's personal property and private home be the next step as these too was paid for by their NHS income?
Innocent until proven guilty should remain the guiding principle...though the Dr B-G case being a prime example of why even then a case can be ,rightly, overruled on appeal.
The NHS pension is surely a private asset of the individual & not the property of the state to withhold and it is certainly not public money. It may have been earned in the service of the NHS but ( even if that employee subsequently commits a crime)it was earned legitimately and belongs to the employee who will have paid their contributions over many years whilst being overworked and ill supported in an often overwhelmed and underfunded system...a fact whose implications should be studied in depth when considering any prosecution if NHS staff.
Further to my previous comments above ..
Chris South, 'The Times'.. today...
"Pressure on GPs to cut down on antibiotics may be leading to fatal infections in older people, a study suggests. Those over 65 who did not immediately receive antibiotics for a common illness were up to eight times as likely to develop sepsis and up to twice as likely to die, researchers found."
Of course reducing inappropriate antibiotics use & countering antibiotic resistance is a laudable aim we all aspire to,but these prescribing comparison statistics really tell us only part of the story.
We were all taught that Medicine is not clear cut and patients don't always follow the textbook & present as expected. GPs & Nurse Practitioners may be exposed to layers of such advice, as P Cundy has noted above, and this increasing pressure not to treat with antibiotics risks the suppression of clinical judgement. I recall about 12 years ago there was a phase where reduced antibiotic use was associated with increased numbers of significant complications, in particular a worrying increased morbidity & mortality in young adults due to pneumonia.(I can't imagine how devastating for all concerned such a case would be).
To my mind, whilst this sort of prescribing information is very useful,it would be more useful if it was also matched with the outcomes associated with those prescribing trends (for both those patients treated with antibiotics and those where treatment was withheld) & preferably in similar populations.
Until we all have prompt, & accurate in house bacterial infection confirming tests,(eg the recently developed rapid sepsis test will be a welcome addition when & if it eventually reaches primary care),then unimpeded clinical judgement is key.
What we need is not so much to know who prescribed less antibiotics but when it is safe not to, which is where clear guidelines are valuable. But these remain guidelines and no GP should feel pressured to ignore that clinical instinct that says treatment with antibiotics on this occasion is wise.
It seems logical that there will be a point whereupon low antibiotic prescribing levels may lead to an increased risk of poorer outcomes occurring due to progression of untreated or belatedly treated bacterial infection. This is a particular concern in this unfortunate era of increasingly understaffed & underfunded services where lack of resources may impact the ability of the patient or their GP to keep that individual's clinical situation under regular & prompt review.
Lastly, until and unless the liberal use of antibiotics in other countries worldwide and their use in animals and farming is addressed our contribution may be too little too late.
Alas, and oh so very predictably, it’s more like Rob Peter to pay Peter!
I feel for the local practices and the staff in the one haemorrhaging patients...sadly there will be more of these unless the toxic working conditions leading to GP recruitment, and retention problems are addressed effectively.. I won't hold my breath!.
Like others, my reaction was surely it must be illegal to prevent people from registering elsewhere but,rather conveniently, it seems there is wriggle room contained in the small print surrounding having ' good reason' to do so.
The NHS Constitution concerning choice and GP services says:
"You have the right to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons.
With regards to how this particular CCG bar on registration movements might have been arrived at I see that, whilst it is a legal duty and they must " have regard" of & consider the NHS Constitution when exercising functions, in fact this is a procedural duty only. Apparently it is not unlawful for an NHS body to act in a way that contravenes the NHS Constitution provided they can show they 'have considered the relevant provisions very carefully' and have only departed from it for 'very good reasons'.
Regardless of the long ingrained habit that we doctors work on and on until 'the decks are cleared',it is very unwise to enact such an expectation these days without both the employing practices and their staff/locums seeking advice as to whether their medical indemnity would include extra unexpected hours of work.
In fact, it is unlikely that the locum will be indemnified for uncontacted hours of clinical work & in doing so they may well open themselves to a significant risk of being without cover for the work done at the end of an over long shift,(even if that's 'just lab results and prescription requests') as this is when fatigue may well increase the risk of errors and omissions occurring.
Any practice requiring their staff to work beyond their contracted hours should be open about this and ensure these are duly indemnified first..and of course that any overtime is remunerated correctly.
please note David Banners assessment of the situation...this is the article that should have been written.
Remove the date and it is no longer a 'target' but a mere aspiration.
If we wait long enough no doubt 5,000 GP trainees will eventually have qualified in the interim (& whom the then Health Secretary will claim as his/her having achieved the 'target').
Sadly it is likely that there will continue to be a flight for the exit by both recently qualified and experienced GPs given the underfunding, understaffing & continued unrealistic demands & poor working conditions that they are often exposed to in the primary care setting.
No doubt the net gain of 5,000 extra GPs, over and above the number working when Mr Hunt made his famous pledge,will remain a mere aspiration.
And what action will be taken to ensure that all those who have already retired over the last decade or so did have their pensions calculated accurately??
Now,these ARE what one might call 'TOP' GPs!
No discharge summary being sent or available in a timely manner while it is still relevant has been a longstanding issue for GPs across the country. Picking up the pieces and making sense of whatever appropriate ongoing management is needed ( if any) has sadly become a regular feature of post secondary care GP review. In this case where a large cohort is identified simultaneously it is appropriate that the hospital staff are to undertake the necessary screening of cases concerned. GPs are not community SHO's at the beck and call of hospitals and the adage that investigations are the responsibility of the requesting clinician should stand.
I am very surprised that it's only 1 in 5 GPs reporting such long working hours...( Sadly that always seemed the norm to me & my colleagues!).
I suspect the other 4 in 5 are not including the hours of laboratory results analysis,letters to read and respond to,meetings and practice admin done which are done after the surgery doors shut.
Add the work done whilst at home,and when supposedly 'on leave', in the form of written reports,dictation and referral letters,telephone calls and on-line practice work done via remote computer link and you'll find most GPs too busy to respond to a survey!!
I agree with Sue..£100m set aside to achieve 'ethical' recruitment of,so far, pitifully insufficient numbers of new GP colleagues from outside the UK.
What a boon that money could have been to practices to maintain existing manpower & staffing levels in the currently overburdened & underfunded world that is UK primary care.
It has always seemed to me that the powers that be are happy to waft obscene amounts of money to all and sundry, no matter how hare brained the scheme,rather than hand the money directly to General Practice or to GPs themselves.
Whilst the recent £20k incentives to retain GPs in practice and relocate them to the increasing numbers of areas most in need of GPs seem to have been effective (and with £100m there's your 5000 GPs right there!), of course recruitment from outside the UK is one approach in addressing the increasing lack of GPs. However,simultaneously allowing the current manpower resources to be suffocated and wither away whilst you address overseas recruitment is like trying to fill a holed bucket with gold dust.
Once these GPs are in post it is not unreasonable that practices will be responsible for the them as normal employees. But,after the initial language development support and UK NHS orientation training has been given, it remains to be seen what support these GPs and their host practices will need (and whether they receive this) after they 'go live'.
It seems likely that some of that £100m will be needed to cover, not only recruitment & relocation costs, but to also provide ongoing mentoring, & possibly social support,for a protracted period after placement in order to maximise the chance of the successful immigration and integration of our new and very welcome colleagues.
However,if the noxious working conditions that are afflicting existing GPs are not addressed, and the recent reports that Brexit has brought with it an increase in reports of racism and intolerance then they may not stay for long.
Absolutely on the nail Copperfield. I struggle with this vacillation myself so forgive my taking the time for the essay to follow( I’m retired!).
I am deeply proud to have been a GP and of the ‘old style’ form of practice to which we devoted our lives but knowing that that same system demanded everything of us unreasonably. This eventually stole my health & nearly killed me in my surgery chair -quite literally.
We should want GPs following behind us to expect a better deal where they will work to equally high standards and be dedicated & committed whilst ‘on duty’but where workload,pay and conditions are vastly more reasonable ,leaving them with sufficient time and energy for themselves and their families.
We dinosaurs are of an era where it was expected by others ,and therefore ourselves , that we give our total commitment to the job, and never say No. We’d strive for excellence & continuity no matter what and leave the premises only when every last task was achieved , ( to then log on to the remote computer link from home after a quickly snatched supper for yet more hours of test results, hospital letters , reports & admin).
I believe this willingness to subsume ourselves hails from the 2 in 1 hospital rotas we survived and the conspiracy of silence surrounding the effective running of the hospitals by JHOs & SHOs . We worked through often very poorly supported 9am-5pm hrs to then face far too frequent out of hours sessions with the Reg ,SrReg and Consultants all absent from the frey & on call from home -barring the 10pm & 8am ward round ( & God forbid you didn’t have an extremely good reason to disturb them).
That we had almost no sleep for days on end and rarely any decent food available added to that toxic mix. We never dared to complain because that was just how it was..put up and shut up and wear your exhaustion with pride.
All these years later things remain far from perfect however. Hospital rotas may have moved away from of the dark ages of 1:2 towards shift patterns ,despite laments that this is at the cost of continuity and experience ( we oldies might say the type of experience you can do without though). But that Dr Bawa Gaba, & 2 of her nurse colleagues suffered much of the same systemic failures, were left exposed & then shamelessly offered up as the responsibile scapegoats suggest there is still a very long way to go.
However the expectations of younger doctors have changed and they are no longer willing to put up & shut up and tolerate unreasonable work practices..nor are their defence societies...good on them and long overdue !.
For us moving into General Practice way back then it seemed an improvement, for a while, because of the illusion of control as a GP, especially once a principal.
But the reality eventually dawned on most that we dinosaurs have no control, there is no stopping the torrent of work & expectations & that resources and support will continue to be withdrawn or eroded & , for many, our income falling way below our consultant colleagues.
Hence modern day GP has become a ‘not-so -golden -handcuffs’ scenario with many of us trapped & risking ‘last man standing’ personal financial devastation if we follow the other exhausted GPs stepping off the treadmill. (No such risk if juniors choose a hospital based career or non principal GP career...no wonder we can’t recruit !),
The exponential increase in workload and responsibilities over the decades since we started out and the ever shrinking levels of investment and support eventually took its inevitable toll on many of us with burn out and low morale rife and early and ill health retirements now souring. We were all behaving as King Canute ,deluded that we could stop the incoming tide.
The later cohorts of GPs amongst us have witnessed our earnest committment, hard work & dedication being repaid with an endless ratcheting up of workload pressures , worsening resources and falling income whilst simultaneously being regularly denigrated by the government ( amongst others) for our efforts and cheated of much of what should be our private time.
Who can blame them if they do not wish to join us on the ever faster and unreasonable treadmill that is current General Practice and certainly not as Principals .
Thank goodness for those of us who ,despite all the negatives, still love the job, have a fascination for medicine and for people and who continue to cope against the odds with huge responsibility and a high pressure workload.
I fervently hope the BMA ,LMCs GMC and the various royal colleges will act so that no doctor is overburdened and under resourced or unsupported . Nor should we allow any back sliding to the ‘stiff upper lip approach’ to what have essentially been abusive working practices nor tolerate the ( ludicrous) complaints that the doctors are not ‘resilient’ enough if they point out the unreasonable demands or conditions they face (& after Dr Bawa Gaba’s experience more will rightly do so).Rather, let’s see that our representatives work to ensure Doctors have the time, tools and conditions to do the job they love to the high standards they espouse & with commensurate remuneration.
End of rant!
Methinks he assumes too much!
Management speak gobbledegook borne of misinformation and wishful thinking.
Here's a novel cost cutting measure for Maidstone & Tunbridge Wells NHS Trust....
Don't engage expensive, working for profit, external management consultant agencies to advise you when your in-house & 'at the coal face' staff can tell you where the money is needed if you would only listen.
There you are.. simples.. kerching!!
An extra £6,051,199 to spend on the currently underfunded clinical workload!!!
I'm sorry but the advice given is at odds with my clinical experience over a long career striving at the coal face of general practice..but what to I know!
No doubt,once the fallout of following this advice becomes clear and both a significant number of patients (and doctor's careers) come to harm & ENT clinics are busier with chronic sinusitis and it's sometimes serious complications as a result, there will be a further announcement of "as you were". I am completely behind the advice about appropriate prescribing but when bacterial infections complicate (what albeit may have been an original viral infection) antibiotics are an effective treatment in my humble experience.
Sorry Nigel, I disagree with your conclusions on this occasion. As an experienced GP and as a sufferer of neuropathic pain myself (quite appropriately and very successfully treated with pregabalin via initial pain clinic assessments &recommendation) ,I and most GPS know these drugs are a godsend for people whose lives would otherwise be severely blighted. I am sure however that all GOs will be anxious to ensure these are not used inappropriately.
The problem is not that these drugs do not work, though it may be an inconvenient cost that so many people may benefit from these expensive medications, rather it is that these drugs are falling into the wrong hands and are being misused. The problem is not principally one of incorrect prescribing but of a failure of medication monitoring and issue , and also illicit purchase from other sources quite apart from GP surgeries.
The answer is not to make the correct use of these medications fall under suspicion and risk failure to prescribe where clinically appropriate what is an extremely effective treatment for neuropathic pain.
As with all drugs we need to ensure that such medication is issued to patients whose clinical needs meet the criterion for their use, as here with gabapentinoids and Neuropathic pain.This is most often a chronic pain problem where treatment of necessity becomes long term and I am concerned by suggestions I have read elsewhere on this topic that issues should be short term only. I cannot agree that long term ongoing treatment of chronic ongoing pain should be considered in any way a prescribing 'failure' but rather as meeting a clinical need.
What is required is for the issued amounts and frequency of the medication ,which will usually be predictable and stable, to be agreed with the patient and monitored subsequently such that any misuse should become apparent. If it takes the drug being reclassified as a scheduled drug in order to do this reliably then I am not against this so long as deserving patients are not excluded...we should not throw the baby out with the bath water.
Obviously, any GP role changes here will have a limited effect where these medications are obtained illicitly for the sole purpose of misuse from other sources.