There are some interesting political as well as judicial implications from this :
(1) ‘Presumed innocent until proven guilt’ is the cornerstone principle of western democracy and particularly in British common law . It is most extraordinary that this government was quietly imposing these changes in NHS and prepared to treat doctors differently outside this principle. GMC has been acting religiously and faithfully along this ideology.
The difference between being charged and being convicted is fundamental in our legal system . Yet , this government and its prime minister(s) are merging executive and legislative power in one to implement its secret agendas repeatedly . Suddenly , these doctors being ‘charged’ found themselves teleported to courts in Turkey , Russia , China , North Korea etc .
(2) Remember the fiasco of prorogation of the Parliament a few months ago (October last year ) ? Our PM clearly slaked his thirst of exercising this ‘power’ in a high profile fashion , despite being ruled unlawful by Supreme Court eventually. Obviously, he was running a lame-duck government which , in a matter of two months , turned into a comfortable majority of 80 seats in the House of Commons . So , are we going to see more of this kind of political demeanour in the near future ?
(3) Supreme Court appears to be the obvious target for ‘reforms’ if our PM chose to be vengeful . Some said that one of the reasons for the prolonged and abhorrent delay of implementing Brexit characterised by the paralysis in parliament, was the lack of a fit-for-purpose constitution to prevent the kind of deadlock between the government and the parliament we had witnessed. Traditionally, the power of our judiciary remains independent. But the story of Brexit , so far , facilitated by pro-government media , has repeatedly jeopardised this social norm of western(or shall I say , liberal ) democracy
Where do we go from here ? I think we need even more overseeing of this government’s behaviour from bottom to the top . Yes , it has strong power but not necessarily the authority.
‘’Authority and power are two different things: power is the force by means of which you can oblige others to obey you. Authority is the right to direct and command, to be listened to or obeyed by others. Authority requests power. Power without authority is tyranny.‘’
JACQUES MARITAIN, "The Democratic Charter," Man and the State
To me , the three qualities to earn authority in western democracy are namely , transparency, honesty and humility in 21st century ........
Copperfield was asking the question whether NHSE was deceitful or simply delusional. I would say that one has to follow the track record to determine whether any more benefit of doubt should be granted to NHSE.
Incompetence is perhaps even worse than malevolence.
As a minimum, it is already unforgivable that an executive department of the government holding public funds is repeatedly showing incompetence in serving its purposes.. Overseeing the contracts with Carillion and Capita have failed ignominiously . The waiting times in virtually all sectors of NHS have been drifting far away from acceptable targets . This debacle of PCN service specifications is ,in fact, epitomising the complete lack of idea to salvage this downfall of NHS (and Social Care) , and only to exploit GPs as their last way to get them out of jail simply because GPs are traditionally the gatekeeper of NHS, hence , perfect scapegoats.
The scandal of Dr Madan was only the first exposure of this ‘crime’ of NHSE as I never regret for a single moment to equate NHSE to Ministry of Plenty created by the great George Orwell in 1984 .
If BMA(perhaps RCGP) is to look up to the sky searching its pride and dignity , this is the time to seek legal challenges , run petitions and call for dissolution against NHS England .
To strive ,to seek , to find and not to yield?
Once again , like what I wrote about RCGP addressing to the chair of RCGP , BMA must recognise their name was ‘used’ by NHS England in the draft document where they represent one of the organisations from which ‘evidence‘ was obtained to underpin the requirements for GPs in the draft .
Therefore , this is about pride and credibility of BMA . If NHSE is allowed to sail this through with little ‘scathe’ , any future negotiation will virtually become extortion by the government instead . As I labelled this unique circumstance(namely recruitment and retention crisis) in the GP-land history as ‘scorched earth’ , BMA has no choice other than threatening NHSE and hence , government a nuclear Apocalypse and Armageddon in GP-land where no one is to win .
Ha ha ha
Agent Hunt , you just can’t beat the Machiavellian temptation, can you ?
On a serious tone , do not underestimate the importance of this news as every headlines in here have been dominated by the PCN service specifications draft last few days .
Contrived , duplicitous but also with determination, his story of politics has not yet ended .
Perhaps , GP-land has really turned into Gotham City 😈😂🤣
Perhaps if Dr Madan was still in charge , the former was more likely? 🤨😈😂
‘’Never attribute to malevolence what is merely due to incompetence’’🤓
Arthur C. Clarke, 3001: The Final Odyssey (Space Odyssey, #4)
I hope you understand that a political problem needs a political solution . And this draft document had clearly stated that the ‘evidence’ used by NHS England came from consulting various organisations including RCGP , BMA, Public Health England etc .Hence , you and your college has arguably ‘facilitated’ this debacle created by NHSE (so was BMA) . Foes or friends , I am sure that you know which side you want to position yourself , Professor .
Just submitted my ‘feedback’ enclosing this long comment to NHSE (and PULSE link for this article )
Only hope that this could be the last straw on the camel’s back , by any slightest chance just the deadline (today)
Salute to you
‘This is the way’
I am in that 1 in 10. But who am I ? Only an ordinary grass-root GP?
"It's a shame she won't live - but then again, who does?"
Spent four hours two days ago to read through the whole draft and condense it into a power point presentation for discussion with my fellow colleagues in my PCN yesterday. We also had lengthy discussions in our PCN alliance in Liverpool today .
If we trace back this story from the beginning:
There is fundamentally a social-norm-broken demeanour of NHS England in how this document was released shortly before Christmas with a deadline set at only two weeks into the new year . This is reminiscent of how our almighty prime minister was trying to block the parliament to debate Brexit through prorogation shortly before the general election last year . Whether this is a conscious effort or not , the impression of an imperious NHS England has undoubtedly generated an extraordinary, omnipresent swathe of negative responses from GPs , PCNs , LMCs etc . In the heat of the moment ,many colleagues are angry fraught with sentiments of betrayal and incredulity.
Then it is about the substances in this document which in effect , created more questions than answers :
Before long , every section requires a ‘clinical lead’
(1) Structured Medicine Review and Medicine Optimisation:- It appeared to be quite logical to have these tasks to be implemented by pharmacists employed through the extended workforce deal in the PCN DES .However , the fact that practices have to pay 30% of their salaries ( in contrast to that in social prescribers) , could always pose additional financial risks on practices . 100% reimbursement , to me , is the only way out to ensure these SMR/MOs can potentially transform general practice in line of the vision of NHS England desired. Realistically, this category easily requires two clinical pharmacists for an average sized PCN with 30,000-50,000 in population.
(2) Enhanced Health in Care Homes :- this part is widely considered as flagrant violation to how GPs believe that these patients in nursing homes can be looked after , given the current resources available. The evidence of improving quality of care is clearly yet to become credible and plausible for putting this minimum two-weekly ‘home round’ requirement into a black-and-white contract . In fact , one would argue that the ‘evidence’ used by NHSE is estranged from what clinicians would normally adopt and is merely a dogmatic imposition.
Yes , there seemed to be a leeway of arranging community geriatricians to do these rounds alternatively but it begs the serious question of how realistic that would be .
Nevertheless, there is also the part where PCNs would bear the obligation to train , educate and even vaccinate staff in these care homes . I would cynically challenge that the owners of the homes would be more than euphoric as they could make some investment savings?
(3, 4)Anticipatory Care and Personalised Care :- Again , it seems sensible to target certain cohorts of the population and identify them into certain ‘dynamic lists’ . We are already using electronic calculator software in the system to record frailty index for all patients aged 64 and above , from which we identify and label moderate or severe frailty. Other cohorts like end of life , type 2 diabetes and MSK conditions are all mentioned and easily identified . The road has already been well paved .
But the approach advocated in this document had heavily skewed towards writing up personalised care and support plans (PCSPs) and recording shared care decision conversations , number and quality of which are both measured metrically . Evidence of merit is yet to be established. The obsession of collecting so much health data not only creates enormous amount of administrative workload but also raises the question of the intent of NHS England .
Furthermore , there is also a very steep and prescriptive timescale requiring so many patients to be referred to social prescribing services . The ultimate ambition was to refer 16-22:1000 weighted population cases to social prescribers . Hence , for a size of 30-50,000 PCN , there would be 480 to 1100 referrals . Patient Activation Measure (PAM: a 100-point, quantifiable scale determining patient engagement in healthcare. ) is another tool adopted to satisfy the gluttony of data collection centrally .
Of course , last but not the least , we have to measure the number of the most contentious Personal Health Budgets annually .
(5) Supporting early cancer diagnosis :- very much politically correct as we all have been working our socks off , referring more and more patients by two week wait rule everyday . Thanks to NICE significantly lowering the positive predictive value for cancer screening parameters .
As I reiterated on this platform time to time , the bottom line issue is about improving cancer survival ( as compared to our OECD counterpart countries ) by shortening the referral to treatment time (RTT) . The recommended target of 62 days is currently well out of reach . The fact that we , GPs , are referring so many 2WR cases everyday , has already well consumed the capacity of imaging , endoscopists, surgeons and oncologists etc .The number of false positive cases to be excluded is burning the system out . Hence , the emphasis of NHSE to push GPs to refer more in order to ‘detect’ earlier is running under the caveat of the law of diminishing returns. No wonder the target of 62 days of RTT is becoming more distant reality. I can only hope the cancer academics and NHSE can come down from the top floor of the ivory tower to face the reality on the battlegrounds.
Yes , extreme conditions demand extreme measures . It is most disappointing but also ignominious that NHSE is barking up the completely wrong tree as the extreme condition GP currently is namely, recruitment and retention crisis .
The PCN service specification draft is simply killing the chicken before any more egg can be laid .
No doubt the ice ball is gaining momentum and getting bigger . I have yet to meet any colleague saying ‘great ’ about this draft .
Watched 1917 in the weekend , absolutely brilliant Oscar-potential-winner . Well , if this draft goes through , GP-land will become the ‘no man’s land’ between the infamous trench lines in World War One . 😈👿
First wave of nail bombs dropped . More will come ?
In a way , refusal to sign is a form of industrial action .
And for those colleagues in BMA , please remember that it is a fine line between negotiation and extortion.
Kill the chicken before it can lay any egg. The government gets nothing !
Had a good conversation with my LMC secretary this afternoon . These are my understandings:
(1) NHS England has certainly surprised many people as they took an unconventional ( clearly contentious ) approach of bypassing GPC before releasing this draft on 23/12/2019 with the deadline of consultation/feedback one week from today (15/1/2020) . A significant number of LMCs in the country do not routinely have a meeting in January ( Liverpool LMC is one of them).
(2) Allow me to be judgemental, this ‘testing the water’ act was disingenuous but also imperious . Of course , this government is now holding a strong majority in the parliament facing virtually zero , pathetic opposition. So if it is to exercise their autocracy , there is no better time . And I do not think it is just targeting at PCNs.
(3) The grand plan is always about changing our terms and conditions as well as moving secondary care in a different direction simultaneously. Hence , these new PCN service specifications are , in fact , consistent with what NHSE would want to impose in secondary care . In a way , we (GPs) are to be sacrificed to ensure the sustainability of hospitals . Whatever obtained from vanguard sites is now used as ‘evidence’ to take the rest of us for granted . Thanks to those enthusiastic protagonists in these sites which were obviously funded excessively to ensure some successes .
Call me critical and cynical but ‘a scholar prefers death to humiliation’ (士可殺不可辱）（Book of Rites 禮記) . Please do not insult our intelligence anymore.
You are clearly NOT Dr Madan . But these waves of reaction from GPs are phenomenal and only expose the hypocrisy of this new five year contract . The ideology of these requirements mentioned in this service specifications aiming to release more GP appointments, is fallible and arguably delusional. The state of general practice ,worn down by this progressive crisis of retention and recruitment, is nearly irreversible. Are NHS England , Improvement and Digital prepared to bear this responsibility of totally destabilise primary care and hence , NHS ? Please wake up . Alice .
You see . Typical government propaganda media . The issue here is not whether GPs are being paid ‘excessively’ in the eyes of the public . In fact , many GPs prefer to earn a lot less for much less workload, especially unnecessary workload which does not benefit our patients directly. If the money( and the pension) was really so ‘good’ , it would be much less likely to have this worsening retention and recruitment crisis . That is logical thinking .
It is like ‘ I am giving you £5000 every week but you have to drink poison in a variety show everyday ‘ .
If this study is reflecting the real picture , any ideology to move primary care ‘forward’ e.g. PCN will be met with serious questions of feasibility and practicality. Once again , idealism is confronted by reality .
And the reality is primary care or GP land is a piece of ‘scorched earth’ as more and more experienced GPs taking the early exit . Mr Johnson and Mr Hancock , you can say whatever you would like to say in front of the public ignoring the voices of frontline GPs . This is another time bomb in addition to the others (Brexit transition period , staying ‘close’ to Mr Trump etc )
I tell you what
This will be another mess for PCNs to tackle ?!
Further points :
(4)’’NHS England said it(SMR)expects the service will lead to a number of GP appointments being prevented’’ .
The logical question to ask here is,’ Can you please show us the evidence and how this conclusion was derived ?’
(5)We want names of the persons in NHS England who had written these details of requirements. Better or worse the outcome is , these people are to be held accountable, either given New Year Honours in 2021 if this succeeds or punished for destroying NHS for the prime minister ?
Several points :
(1) The fact that this document was released only just before Christmas and for feedbacks with a deadline just over two weeks in the new year , raised serious question of the sincerity and hence , the actual motive of NHS England and Improvement( which is virtually one body now) . Despite what happened in Madangate , NHS England was supposed to show some kind of ‘olive-branch’ to ,at least , try repairing the badly damaged relationship with GPs . Well , I am afraid that this kind of subterfuge and chicanery of pushing a policy through swiftly , has simply insulted our intelligence and dignity once more .
(2) I understood that the original negotiation between the government and GPC was ,quite frankly , a trade off for some concessions by the government , one of which was the state-backed indemnity. The ideology of PCN was then accepted by GPC . (Please correct me if I am wrong)
Question now appears to be ,‘ which side has sacrificed bigger concessions ?’ Has the real face of this Trojan Horse finally revealed itself?
(3) BMA/GPC ( perhaps RCGP as well now) must make public statements sooner rather than later and clearly need to declare a scorched earth policy ; the number of GPs will go down instead of up with more practices closing very soon , should these requirements rubber-stamped . This policy will rapidly turn a GP retention and recruitment crisis into a broken promise of sustaining NHS as far as the PM is concerned . His choice .