Hancock just needs a new “thing” to make him special and different from Hunt as health secretary - so he has decided on technology. There is literally no more depth to his interest and understanding than that.
Agree with Yellow, Doc, Dylan and others. This is an imaginary amount - it has no relationship with the real world. In effect we overbooked patients - it's impossible to see patients properly in 10 minutes, so when people DNA it just allows us the necessary time to do the job properly. If all the patients turn up then I would guess there is hardly a GP in the land who does not end up running late. If someone can see all patients in 10 minutes, and not run late, I would contend that there are things they are not doing right - it’s simply not possible to address the patient’s agenda and concerns (often more than one thing and not always appropriate to insist on one problem only as they could be related or both be important), the GP “agenda” including QOF alerts, health promotion and prevention, chronic disease management issues, medication review, attending to the bio-psycho-social dimensions present in every illness, being alert to all the safeguarding issues we are supposed to keep in our minds (DV, child and adult safeguarding, FGM, etc.), as well as our elderly patients who arrive (quite rightly) dressed in many layers against the winder cold who, if they need to be examined, will take 10 minutes to dress and undress, never mind those who don’t speak English as a first language. Why do some GPs perpetuate the myth that 10 minutes are sufficient as if it is some kind of macho competition? Let’s me honest and say that 15 minutes should be the minimum and that every DNA is a Godsend. There is no money to be saved by fewer DNAs.
I take your point about failure to address the shortage of midwifery and HV care and, of course, GPs should not be used in a tokenistic way, substitute for inadequacies elsewhere, and as a bottomless pit of resources. But I still think that, medically speaking there is value in a dedicated appointment with the GP for maternal and child health at 6-8 weeks. I could be persuaded that the post natal appointment may not be needed if there were sufficient midwives and health visitors to do the job, who would only refer those women who had a medical problem to the GP. But I do think there is important medical input for the child 6-8 week check. Not only do we sometimes pick up conditions that have been missed or that don’t present til that point, but it's also an opportunity to advise about less serious problems but which are worrying for parents, and for which they value medical input. I am thinking of conditions like infantile eczema, feeding difficulties, reflux and bowel function problems, persistent crying/colic, concerns about weight gain, minor skin abnormalities and blemishes, all the odd little movements and snuffles that parents worry about but are usually normal. All these things come up regularly in the 6 week check (and at other times in infancy) and they are the kinds of things that health visitors refer the child to the GP for anyway. Occasionally one of those things turns out to be something serious but usually they are normal and the parents can be reassured. Does no-one remember Illingworth’s “The Normal Child”? And does the GP not have a role in helping parents distinguish between disease and normality and major and minor illnesses and give them confidence to manage their child’s everyday problems?
This is from the introduction in the BMJ review of Illingsworth’s “The Normal Child”:
"Variation in humanity is so great that it is sometimes challenging to tell the normal from the pathological. This distinction is critical in paediatrics, where variation in children’s growth, physical appearance, behaviour, and emotional development can be enormous without amounting to disease. Recognition of the normal child is an acquired skill; one that is fraught with the dangers of overinvestigation and of the failure to reassure parents. Ronald Illingworth’s The Normal Child, a landmark in the paediatric literature, saved countless doctors—specialist and non-specialist—from the perils of misdiagnosing normality in children."
I like doing baby checks. But that’s not the point. I think it is a good use of our time. It’s an opportunity to discuss and advise about baby’s health, and to pick up things like post natal depression if it has been missed. There are far fewer postnatal midwife and HV visits so post natal depression is in danger of being missed. And please note, we hardly have health visitors any more. Their numbers have been cut and there are more cuts to come. In our area they are an endangered species and I suspect its the same everywhere as the public health cuts are universal. General Practice does have a social and health promoting role and I think that for young parents, especially first time mothers, its really important that they have that one dedicated appointment where they can talk about their health concerns and any concerns about their baby. It is also a good opportunity to explain about and motivate for vaccination, and parents tend to trust the advice of a doctor so it helps with vaccination uptake. I think talk of “lack of evidence” is a bit rich as there is so much that we do for which there is not hard evidence. But absence of evidence is not evidence of absence. The UK has one of the worst child health outcomes in Europe. We know that prevention and health promotion are important. With cuts to all the other preventive services the GP is often the only one who is in a position to pick up problems. Instead of arguing ourselves out of our role, how about demanding proper funding so we have enough time to do this important work?
Sorry my comment should have said one can’t conclude that salaried GPs earn half of partners for “same amount of work.”
In response to PulsePower(less)50 one can’t conclude from the data that salaried GPs earn half of what partners earn as the data is not comparing full time equivalent earnings. It is based on headcount and includes full and part time GPs. As more salaried GPs are part time this would mean their average earnings are lower. This is a quote from page 13 of the NHS Digital report: "Data used in the analysis are for both full and part-time GPs as the analysis is on a headcount basis. It is not possible to estimate the average earnings of full-time GPs or their average full-time equivalent earnings.”
Interestingly, NHS Digital provide a link to more data which analysed earnings by gender by bands of hours worked for both contractor and salaried GPs and found that in each band (less than 22.5 hours, 22.5-37.5 and over 37.5 hours, for both contractor and salaried GPs, men earn more than women. Now that really is food for thought......
By undermining patients' trust in GPs' motives this will actually cost the NHS more in the long run. It is recognised that one of the reasons that the NHS makes such "efficient" use of specialist services is the GP primary care role e.g. not everyone with headache needs to see a neurologist. The ability to do this is based on the patient trusting the GP's judgement and accepting that if a referral is not necessary then it really is not necessary. Research shows that continuity of care with a trusted GP reduces referrals, investigations and medications - but based on rational medicine not financial incentives. The way to reduce unnecessary hospital costs is to invest in proper general practice, ensure enough GPs to have the time for patients and to provide continuity of care. Sensible referring is part and parcel of being a good GP and should be what we do anyway, not something we only do if we are paid. If it's not happening in places then that should be dealt with through continuing professional education. It is a false economy to think that undermining the essential foundation of general practice - trust in the doctor-patient relationship - will save the NHS money - rather it will cost the NHS massively! Only people who have never been GPs or forgotten what it's like to be a GP could possibly think these financial incentive schemes are the answer and not part of the problem.
The same is happening in Lewisham where the Council is cutting funding for CAMHS. It too claims it is improving services. What I really don’t understand is why these Labour controlled councils keep justifying the Tory cuts by claiming that the cuts are improving services. Why don’t they tell the truth and say that the Government is slashing their budgets and they are having to make hard choices, including cutting some services, for which they are truly sorry as they know it will make services worse, but that the blame should be placed squarely on the shoulders of the Government? The electorate would understand and appreciate such honesty instead of the attempt to con them by saying that cuts improve services.
Hunt, you’ve failed. Resign now!
It is not the “same excellent level of treatment and care”, even if they have access to the medical records. The medical records do not substitute for knowing the patient and their context. I doubt such GPs have time to read through the records anyway.
Even if patients see different doctors in the same practice the fact that they are in the same practice and there is communication between doctors in the practice means that there is the opportunity for dialogue about patients, especially those with unusual or difficult problems, complex health needs, or who are severely or terminally ill or where there are safeguarding issues. Most practices have regular formal and informal opportunities to discuss patients if necessary. In other words, as a practice we “know” our patients in a way that a random GP in an extended access setting cannot. Furthermore the context of being in a practice means there is support and advice available and an evolved collective learning about how to practice clinically. This is lacking in the atomised isolated extended access GP model. The few of our own patients that have seen such extended access GPs have too often had care that falls below the basic standards of general practice. For example I saw a patient who had been asked to have a battery of tests, including TFTs, because he had a sore knee. The patient came to see me a little later, still with sore knee (so it didn’t save on any of our appointments), but now with the statistically predicable “abnormal result” from having unnecessary tests. Of course, he was worried about those results and reassuring him took me extra time. So the silly new “service” has actually cost me more time, while not meeting patients' needs, and making them anxious to boot.. It’s the kind of thing I teach my registrars to avoid - indeed knowing how and when to investigate and refer are amongst the competencies that GP trainees have to demonstrate to become GPs - so sad that these extended hours GPs don’t seem to practice these competencies. I suspect it’s because they are practicing defensive medicine as the circumstances are a bit scary - a patient you don’t know, whom none of your colleagues knows, whom you cannot personally follow up and will never see again - hence the over-investigation and advice to see own GP for follow up. This extended hours service is not general practice. It’s a pastiche of general practice. It is ineffective and wasteful but serves its primary purpose, which is political.
"Dr Bawa-Garba was a registrar at the Children’s Assessment Unit at Leicester Royal Infirmary on 18 February 2011, when a six-year-old child with sepsis died. Dr Bawa-Garba continued to work at the hospital trust up until she was convicted of manslaughter by a Crown Court Jury in November 2015.”
If it was safe enough for her to continue working for nearly five years after the child died why is it suddenly unsafe for her ever to work as a doctor again? Am I missing something?
The GMC does not seem to be open to reasoned criticism or open to change The only way we can force change or get the GMC abolished would be to have mass refusal to pay GMC fees by all doctors. If only a few did it they could pick us off. All of us, or a very substantial majority, would have to do it to have an effect. But what would happen after that? The government could simply impose another GMC type body on doctors, with exactly the same attitudes and behaviour. So perhaps boycotting GMC is not the solution. Another approach, as someone above said, would be for the BMA or medical royal colleges to define safe staffing levels, workload etc. If this was breached then doctors could refuse to work under those conditions. Or having given notice that they have complained about the conditions under which they are being forced to work they should not be accountable for any clinical errors they make in those circumstances. I am not sure what the solution is but there must be a better way than the current system. Doctors should not be punished with criminal charges for errors, especially those made under adverse circumstances.
This article doesn’t make much sense. In the first place, I don’t understand how a 30% reduction in admissions for diabetic keto-acidosis can be attributed to a new system for managing type 2 diabetes. Can someone explain?
Secondly, I really do get angry when GPs are expected to do the work of hospital doctors with a fraction of the time. 10 minutes is just not long enough. Hospital consultants get much longer. The reason that it was possible to eliminate the much valued general physician role from hospitals is that GPs are now the general physicians, managing the bulk of chronic diseases in a fraction of the time with a fraction of the resources and training for those roles. Practice nurses also have an important role to play in managing these conditions but there is no proper training and career pathway to produce the practice nurses we need. So the whole things is being done on the cheap with GPs taking on massive risk due to the increased likelihood of making mistakes as they rush through their complex cases. (Or run late and get complaints). It all creates huge stress. No wonder GPs are voting with their feet. I’d love to have the time to manage problems like diabetes properly. The same goes for the other chronic conditions. But you would need to double the number of GPs and practice nurses to make that possible.
All international evidence on charges shows it deters the poorest and sickest more than it deters the better off. It does not selectively deter trivial use. Germany tried it with a 10 euro fee for GP consultations but then dropped it as they found it led to health inequalities, deterring those in most need, and cost so much to manage it wasn’t worth it.
Am I right in thinking that partner GP earnings are calculated as full time equivalent but salaried GP earnings are based on average of actual earnings, of which many are part time?
Good article. The junior doctors should have the wholehearted support of the entire profession. They are not taking this action lightly and they are not demanding more of anything. They are trying to defend their conditions of service from the imposition of a contract that will make what is already a dire situation with staffing, recruitment and retention far worse, especially for the specialities with the most arduous anti-social rota patterns, like A+E medicine (which are also the ones having the greatest difficulty now with recruitment and retention - and this is leading in some cases to services having to close). The long term consequences of this imposed contract will be far worse for patients and the NHS than the cancelled elective work that will happen with these strikes. I am sure most consultants, SAS doctors and GPs, as well as our nursing and other health professional colleagues, will do their best to minimise risk and harm to patients as they understand that this struggle is about more than just the junior doctors. It is about the quality and safety of care across the whole NHS which is being seriously undermined by current underfunding and understaffing, and will not be helped by imposition of a 7 day NHS (whatever that actually means) with no extra funding or staffing. The JDs are simply asking for negotiations to resume and for the Government to stop the threat of imposition. Hunt said on TV that the way forward is talking not striking -so is he willing to resume meaningful talks?
They've not saved any money. They've simply shifted costs to GP. All those extra hours our manager and staff have spent trying to sort all this. And their future plans look like they intend to shift more work our way.
To the person who asked if the Capita/NHSE contract had specified all the tasks that needed doing the answer is we most likely can't know as the contract will be "commercially confidential." This prevents proper public and professional scrutiny of such contracts. And I doubt that NHSE has the resources to do proper contract monitoring. Just as previous research by Pulse showed most CCGs do not do proper contract monitoring. There is the additional fear of litigation if these companies are challenged or their contracts removed - and they have deeper pockets than NHSE or CCGs. We should demand that all public sector contracts are open to scrutiny, in the interests of transparency. That is the only way that we can start to hold these companies and the people who commission them to account.
Sorry for typo in first sentence of my comment. (Annoying predictive text!) I meant to say "As GPs we are indeed aware of....."
As GPs we are index are of how many of our elderly patients are lonely. In the past I used to encourage them to attend some of the very good local day centres in the area. But these were closed down due to cuts, Some were demolished and land sold to property developers for flats. There are few services for lonely old people. There are charities but they don't have many resources. It's very telling that the article doesn't mention what we are supposed to do as GPs for these lonely old people. And the fact that they admit there is no evidence base for this initiative. I like the weasel words " evidence informed" as opposed to "evidence based". Do they think we won't notice? I know what needs to be done to help the real problem of loneliness in old age - restore funding for social services, which has suffered a real terms cut of about 20% in funding for the elderly, and restore grants and support to charities.
"Mr Stevens said that while the new funding would be attached to specific programmes rather than delivered into core practice funding, GPs would feel the benefit of it.” Hmm... I somehow doubt it. This money will all be tied to us doing the things the government wants us to, which will be to pursue their pet projects - and we know all about those, don’t we? Why not put it into core GP funding? The government clearly still does not trust GPs. And it makes me sick to hear Stevens saying “there’s been a ‘sea change’ over the past year in the health service from ‘denial to acknowledgement’ of the effects of underinvestment in general practice.” Who was denying the effects of underinvestment in general practice? Not the “health service” whatever that is, not general practice. It is successive governments that made the political decision to starve general practice, knowingly. They were told repeatedly over the years that was happening but ignored the evidence. So having starved us they now decide to give us a bit more and we are supposed to think that is generous. The damage done to general practice over the last decade will not be so easily undone. And, finally, let’s be clear. This is not new money. it’s the same money that was announced by Osborne with such fanfare in the Autumn review. The same meagre amount for the whole NHS, just redistributed more towards general practice. This funding settlement amounts to 0.9% per annum in real terms. It is not nearly enough to meet the estimated 4% annual rise based on changing demographics and health technology inflation. These are the lowest annual increases in NHS spending for decades and represent the biggest fall in NHS spending as a percentage of GDP since 1951. The total funding settlement is for everything: secondary care, specialist services, mental health care, community health care, public health as well as primary care. A large chunk will be handed over to local authorities as part of the Better Care Fund. So if GP gets a higher percentage the other services get a lower percentage. And those services are all really struggling financially too and this is impacting badly on patient care - just look at the dreadful trolley waits in A+E - and don’t tell me more money for general practice will prevent those! There is no evidence at all for that notion. Robbing Peter to pay Paul and then dressing it up as if it’s something wonderful and repackaging and re-announcing the same money in different ways - that is the main skill of this government. Great PR. We should not fall for it. We should demand that the whole NHS has adequate funding. And we should demand increased funding for general practice with no strings attached.