Beth is correct, however the reality of the situation is that while GP practices swiftly become the only "fixed cost unlimited volume" providor contract in the NHS there is not the political will to address this.
The system places us in contract jeopardy for failure to see a person with a cold the same day , as well,as more "proactive health promotion" and a community role of day to day management of indiciduals with complexities of their co-morbidities that used to be in the realm of a general,medical outpatients department.
The only perspective clinical comissioning has taught me is the the "owner operator and small business" component of the NHS is doomed because:-
bears a disproportionate provider risk, has to struggle to,get any kind of resource based on throughput
, runs the largest "quality target" related pay component,
Can have its contract withdrawn and close without a ripple in the health economy,
Whilst in contrast :
large foundation trusts have joined the banks in the "too big to fail" and are supported by unbounded bailouts for failure and poor performance from central government.
And the end game - we all end up,salaried in HMO type organisation with an explicit"
get more clinical contacts than last years organisational average or pick up your P45" hamster wheel.
And by all I mean primary and secondary care medical staff, Nursing and professions allied to medicine.
I am with David Lewis, it is a quirk of history that medical Professionals are the only professional group(apart from professional footballers as a colleague recently advised me) who do not have formal assistants in the model of practice. I am very interested in the University of Warwick Physician Assistant program, and I too think a redesign of our medical model of practice is needed. it is utterly unique that so much medical tasks have ended up being transferred to a Nursing Profession.
Please do not take this as saying Nurse colleagues perform poorly, they do not , but they do start from a different professional value base and system of practice compared to a medical model.
Thomas is correct, we cannot predict an outcome of the " who has the blame when it falls over"
I love the "Better dead standing than living on your knees" tone of anonymous 11:02 reply.
Please excuse me if differ,I choose to live to fight another day.
The measley 30p/hr I also worked for, was won by industrial action of a generation of Dr's in the BMA who had to work compulsory overtime for no pay "to make them better Doctors".
Battle plan: stick together with the BMA and do our utmost to ensure when the NHS goes belly up the politicians carry the can.
Play it right we may actually win , but importantly if we loose it is at pyrrhic cost to the political classes.
I think it is a very good piece by Peter Swinyard.
I do have to disagree with Thomas, the reality is that the service our patients expect-,admittedly fuelled and directed by politiical rhetoric- is not that which we are currently contracted to deliver.
Mass opposition " Trade Union Action" to attempting to change to match expectation would make the BMA (or any other body attempting it) subject to the full ire and resource of a nation State.
As the National Union Of Mineworkers showed us the government can destroy a union, fatally weaken its sector of delivery and decimate its membership.
The most secure position for the BMA and ourselves is ensuring that the resource to deliver the expectations of our patients to our patients is available to implement the changes.
When the Government cannot fund the expectation they have created, the BMA and profession needs to be holding the moral high ground of " we where willing , you where too penurious/incompetent" .
Let the public take their ire on the politician not the medical profession.
Peter is correctly saying pick your territory for conflicts and the profession should move to a position we we can maintain initiative and advantage.
By collaborating our efforts we take away the "I must do" that makes the proposed workload impossible.
"We can do , but The Government must resource approprioately"- including remuneration for performers.
I am intrigued as to Dr Kingslands comment in the article.
I am a little concerned that provision for the f£40-00 figure may depend on the starting baseline remuneration.
With a range of "per head per anum" remuneration in my area from GMS 54 to APMS 160 I can see that 40 onto 160 can easily deliver a full 3 shift working , but the the 54-00 GMS practices might not.
Would Dr Kingsland feel able to advise his per capita per anum baseline from which he makes his assertion please?
Revalidation is a necessary protection for the public. It does not add value to the individual practitioner , a decent postgraduate education plan and peer appraisal process "add value to the individual"
Revalidation " revalidates" the content of the individuals custom personal postgraduate educational attainment.
It assures the public the learning undertaken by the individual practitioner means they are fit to continue to perform the roles they perform.
Revalidation should and must become the only definitive source of "ongoing fitness to practice " evidence.
The current " sends us you certificates to prove... "type requests from multiple external agenices must stop.
Continuing fitness to practice can be either "on request" or by revalidation process;- Not both.
"one capable of meeting the health needs but broadly within the same resources"
The NHS started as a "working hours service" with round the clock emergency hours cover because the public would not pay the taxes necessary to fund a 3 shift routine cover staffing.
it was barely affordable on that system and from 1947 to 1969 required the medical staff to work compulsory unpaid overtime to balance the books, till the "brain Drain" and medical industrial action brought in a system of overtime pay at a fraction of the day rate.
is it not funny how history has a habit of repeating itself?
Compulsory unpaid overtime sound familiar to you?
I am intrigued by the way this thread has run.
there is no doubt that many primary care colleagues (but far from all) have introduced a telephone triage service.
I recall my excellent Colleague Dr Chris Peterson of the Elms Health Centre Liverpool talking about this many years ago and presenting evidence of the quality improvement in patient experience and 30% increase in consultation slots required.
Her Majesties Government then launched a National Telephone Triage service for the NHS called NHS 111.
Why does this look, like a trick to obtain cost neutral service of a quality that should have been originally specified for 111 for it to actually work for the benefit of patients?
Revalidation is a 5 year cycle , so the whole system workforce effect is a 10% loss per year- easily replaceable with an enlarged medical school entry.
The steady state position of the effect would be a younger, less expensive workforce running harder to meet a rising standard, basically the same as the rest of us on the service delivery hamster wheel today, but at a lower cost to the exchequer.
Despite being "Full time+" I have total sympathy with Gavin Jamie comment.
Beth Cameron Nash is spot on- the most important issue facing us all is adequate remuneration for our time on task.
You can bet if the politicians are looking at "continuity of care issues" - a concept they did not rate and declined to remunerate in 2004 contract OOH split, then have actively briefed against for two decades (" it does not matter who I see just as long as it is timely"),
the only possible interest they have in the concept is to increase disharmony within the profession.
We dance around the same basic issue.
Being "in work" is a function of :-
"Impediment" vs "motivation" the product of which must leave sufficient positive balance to overcome "demands of work".
I note the accounts of the terminally ill motivated to work to the point of death, add a beautician requesting long term certification for a wart on the finger but declining therapy as"waiting for it to go , treatment might leave scarring".
As a GP I am excellent at the diagnosis, have a reasonabish pecking order of likely range of impediment tarif for any given diagnosis, spend a lot of time exploring the patients perception of where they sit in the range of impediment, form and can no longer report a subjective opinion on the patients motivation(remember the old "Pink Med 6"?),
However the one thing I am specifically deficient in is the assessment of "the demands of work"- this is the realm of the occupational health specialist who can make direct observation of the workplace, which is not an NHS GP role.
I like many colleagues suspect some patients report higher demands of the workplace than is the actual fact, have lower motivation than they are prepared to admit to and claim an impediment at the "higher end of the range" than may be the actual fact if I made a continuous observation over a prolonged period of days.
I issue the certificate.
Why? because my professional body and good practice require me to.
. The point at which you stop believing the patient is truthful in their history is the point the medical model falls apart.
I am required to make a
"could the impediment sum presented to me add up to more than the work requirement presented to me" reasonable balance of possibilities decision.
In a profession where 70% of the loading is based on the uncoroborated patient statement, this is highly subject reporting dependant.
recurring suggestions the medical profession become more searching in our suspicion, become the state interrogator of financial determination fatally undermine my prime objectives,
Heal the Sick, comfort the dying.
Completion of ESA 113 is definitely not chargeable to patients. Anyone doing so is in breech and should stop immediately. A major part of the difficulty is that it is filled in "without examination" on the basis of medical notes held for the purpose of diagnosis and treatment.
Unsurprisingly these are not to the standard of a "functional assessment"I used to do DSS assessments for some years and it is a different skill set.
The current contractor to the DSS are trying to obtain the information without an appropriate examination for the specific purpose.
The statement to an individual declined benefit starts " on the basis of a written report from your doctor" but does NOT say the DSS made the call on the facts presented and is detrimental to the doctor patient relationship.
I hope 1:35 was an on call GP.
It might be a bit of an eye opener for the public if we all logged on at some point during OOH shift to comment.
And before some anonymous Daily Wailite suggests its a waste of taxpayers time, do remember medical staff do need hydration and physical needs breaks too!
A massively strong field of contenders, it would be interesting to know the voting.
A milder temprament than Dr Buckman, but definitely no less passionate nor eloquent.
Challenging times, I wish him well.
Anonymous 8:31- the provision of this report is a statute requirement under terms of service and a fee cannot be charged- there are about a dozen such " have to do as many as asked without charge to the individual " reports ,( fitness for jury service military pension, severe mental impairment for council tax,) but they are all factored on an "agreement as to time taken block payment". The readjustment for the extra work/time is supposed to come from the independent pay review body at the end of the year.
The Governement has never felt there was a compulsion to follow the DDRB recomendation and usually does not.
The difficulty facing General practice is the available time to do all the required work, we appreciate HMG does not value our worth.
The March Consultation document Doctors use of social media makes it clear it is an advisory document.
the GMC explanation is:-
"There is a bit of judgement involved here. For example, if you want to blog about football and incidentally mention that you are a doctor, there is no need to identify yourself if you do not wish to do so.
If you are using social media to comment on health or healthcare issues, it is good practice to say who you are.
However, in the guidance we say 'you should' rather than 'you must'. We use this language to support doctors exercising their professional judgement. This means this is good practice but it is not mandatory."
The GMC says we should be mindfull of our posting given the reponsibilities and priveledges of our profession.
If you are expressing a professional opinion the public and GMC expect it to be factual, accurate and couched in moderate terms.
The good news is if medical professionals sign their posts on healthcare issues , the unsigned may be subject to action.
Those that where really medics by the GMC; those that where faking by the police for offences under the Medical Act 1983 .
Any worried Trolls out there yet?
I agree in part with both anonymous contributors.
The reality is that with an indisputable need for primary care expansion for NHS delivery.
Clinical comissioning is a poison chalice in press coverage terms.
GP comissioners have the pernicious alternatives of growing the provision including work activity from NHS GP's and enduring the "lining your pocket "cheap jibes or taking a moral high ground by not comissioning primary care services from NHS GP's (as every NHS GP "must" be a member of a CCG by statute.)
The sole alternative is then the independent healthcare sector and "GP's Privatise the NHS".
May I ask Anonymous 1:15 which alternative they would not criticise and support anonymous 3:15 that non-recurrent time limited funds are not a robust ground to deliver a stable recruitment and retention program for GP medical staff.
I would also remind any non GP contibutors that "bloody instruction once taught comes back to haunt its inventor" and when there is no Medical GP staff in the NHS and they are "in charge", this political trick will be used to destroy them also.
Sensible and balanced reporting of facts.
I await the Karma balancing coverage of the "Dally Wail"- (yes I wimped out of legal action) with its allegation this is GP's lining their pockets against all evidence that the answer to the NHS ill is to boost primary care spend.
We are getting into a chalk and cheese arguement without facts.
I note my own observation an increasing number of applications from Doctors in training grades for posts appear to have spent time abroad and that I do not recall a colleague having completed specilaist training ,who once left the UK returned to practice, and one who has retired back to the UK.
Without the collection of reasons "it is a fact" but with no meaning.
We cannot berate the government for poor data handling and mendacious commentary on data, then simply play a spin game ourselves.
Two wrongs have never made a right.
Flawed model of investigation.
This is a political sop to find something to beat us with and reopen the issue that patients in work wish to consult in the morning late evening and weekend.
This works in a market economy by those organisations that do respond to the need being able to generate more profit.
At the minute "extended hours" remuneration is a financial loss for the practices already hard pressed.
I refer the competiton regulator to the "irish rover folk song containing a line "custom like yours I can get any day" in its context of no cash exchange no service.