Guidelines that focus on treating individual patients with depression, rather than treating the factors in society and our belief systems that provoke depression are unlikely to make a lot of difference to the prevalence of the problem.
Hosting volunteers - advocates, befrienders, care-sharers - to do this work seems a good idea if it frees up GP and practice nurse time. Health authorities or NHS England could set up an enhanced service. A rearrangement of QOF and enhanced service money could lead to improved care with no change in GP income.
There's a cycle that used to go: clinical professionalism, conspiracy against public, outcry, consumerism, managerialism, alienation of clinical professions, recruitment problems, atonement by government, clinical professionalism.
But now, the government is not in a mood for atonement. Professional alienation is acceptable, since they regard the health service as unaffordable anyway.
Having the local hospital run some practices but not others, may make the others look less attractive to patients. The hospital trust will be under pressure to offer patients priority for secondary care if the trust runs their general practice.
So the hospital had better make it attractive for the other practices to join in. Perhaps they could offer the GPs family-practice consultant status, with clinical responsibilities in triage and intermediate care, and offer physiotherapists, counsellors and clinical psychologists sessions in practices to reduce demand on GP time.
Paying for the health service by insurance costs more in transaction costs.
Where is the evidence that the money can't be raised by taxation? Have you considered Land Value Tax, transaction tax, and higher taxes on alcohol, tobacco, unhealthy foods, diesel, gambling, and air passenger duty that would reduce demand for the NHS
GPs should choose their partners carefully. Are they likely to be partners, or will they be cuckoos in the nest, seeking to establish themselves as sole proprietors, with salaried doctors doing the work, they fruiting off to meetings, earning the bulk of the proceeds, owning the goods and chattels and benefitting from the carrots that HMG will give to "partners" when they amalgamate within accountable care organisations. It's gone sick! Emigrate!
Nothing wrong with the NHS and social services that £30Bn pa from more tax on alcohol, tobacco, sugar, betting shops, saturated fat, diesel and petrol wouldn't cure. Oh and that would cure some of the demand too.
A GP from the patient's own practice is the best person to do the telephone triage. S/he has access to the patient's GP record, able to authorise a script from the late night pharmacy or an early morning face to face consultation, or relevant tests, to reduce the need for night visits which we could authorise from the night and weekend visit service. Back to the good old 1990s. If we were in practices of 30,000 we could provide this with a 1 in 18 rota. Busy on the night, but you could get the next day off. Can we get the money right? It has to be worth more than the 6% deduction for opting out?
Resign - hand in practice contracts en-masse?
Pros- Makes Gov attend to needs of GPs and others in Primary Care.
Dangers? = Gov recruits docs and health professionals from elsewhere - but not fluent and not acquainted with NHS and not skilled in medicine.
Patients suffer and lose trust in docs.
Yes - Undated resignations to strengthen BMA's hand in negotiations.
GPC to require:-
- money to follow the workload
- GPC to be final arbiter on guidelines for practice
GPC to offer
- better mutual management within partnerships
- bigger local partnerships serving populations of 30,000 to provide OOH and GP specialism and other services such as physio and counselling by direct access without need for referrals
Pros and cons of collaborative working serving populations of 30,000.
Cons - More management and uncertainty while arrangements bed down.
- Confusion among patients.
Answer. Patients will need to be able to choose "My doctor". The personal list system will need to continue as an option.
- Doctors and nurses lose influence and feel excluded from management.
Answer - Practice agreement must require all doctors to be appointed as partners after no more than a year on a one year employment contract - and to be assigned areas of admin work for which they take responsibility in collaboration with admin workers.
Other clinical and admin and reception workers to have an annual bonus scheme based on practice profits - like John Lewis Partnership does.
out of hours care shared among local GPs in an appropriately sized organisation. Money must follow the patient.
GPs can become specialists for a range of out-patient procedures without the formality of referral. Money must follow the patient.
Physio and Counselling can be provided within primary care more effectively - and with direct access thus saving GP time. Money must follow the patient.
Less duplication of managerial functions - savings - but redundancies among practice managers.
All complaints should be directed to the subject of the complaint in a personal letter first. If that does not resolve it, direct them to practice manager/ unit manager, then escalate via health authority, eventually to GMC if need be.
GMC needs to offer service of inquisition and mentoring - perhaps at a cost to the subject of the complaint. Only f that does not resolve the matter is the legalistic approach needed.
There are immediate needs and long term needs.
The immediate need is to get doctors back to being willing to be GPs.
- end time wasting - unproductive screening exercises, approving consultant appointments, using computers for things that are simpler by hand.
- persuade GMC and RHAs to offer direct inquisition and mentoring of doctors who make a mistake, rather than the legal process
- government pays for medical indemnity
- bring CQC and NHS Improvement to realism
- sanction on patients who waste NHS time or bring about their own ill-health - community service, suggested donation, undertake mentoring and keeping a log, or adverse publicity and public shaming.
- admit doctors to GP who pass MRCGP regardless of training.
- bring back and increase seniority allowance
- include language skills of the local population in calculating deprivation allowance and increase deprivation allowance
- NHS no longer to be responsible for prescribing over the counter medicines and pharmacy list items.
Long term -
- re-integrate GPs and hospital doctors by having more routine secondary care provided by local GPs with staff grade accreditation in the specialty.
- OOH community care to be provided by co-ops of local GPs.
- base social workers and community nurses in general practice.
- enhance democracy within practices - allowance for mutual management and wide-ranging partnership agreements
- base some payment to both secondary and primary/community care on approval ratings from patients.
The idea from the anonymous doctor of mass non-compliance with appraisal and revalidation in its current form was good too - but it won't have HMG quaking.
What will the government do with our resignations?
- hand our practices to local hospital trusts and management companies to run
- import GPs from Europe and S Asia.
They'll be gearing up for this now.
In three months from now their plans will be well ahead.
What other sanctions do we have, that will not incur loss of patients' sympathies, nor put patients in danger, nor put us at risk of misconduct claims?
- resignations from CCGs - Probably ineffective as those on CCG committees have more to gain by compliance with government policy.
- mass resignation from referral management schemes. Worth polling on this one.
- mass refusal to pay GMC subscriptions? - difficult for BMA to implement - perhaps the money could be sent to BMA to transfer to GMC when it thinks appropriate.
- mass refusal to pay CQC fees? - as above.
- mass refusal to make referrals from one consultant to another. - BMA to ask for agreement to this policy.
- mass refusal to prescribe medicines when effects/side effects are monitored by others - eg warfarin, methotrexate. BMA to ask for agreement for this policy.
- Safety first policy - investigation and referral on minimal pretext. non-compliance with hospital efforts to offload follow-up to GP. BMA to ask for agreement for this policy.
- Use of trademarked medicines on minimal pretext. Ineffective as government will instruct pharmacists to do generic substitutions.
Let's keep thinking.
There was nothing to stop that patient demanding diazepam from contacting his own GP and asking for a script to be sent to him. That way his own GP would know how much he had obtained. We should call a halt to supplying scripts for drugs of addiction to unregistered or temporary patients.
I'ld like to address Tony Gu's concerns about the adverse aspects of continuity of care:-
Unreasonable requests - Forewarned is forearmed. Guidance is there for a reason. Follow it unless there is good reason not to.
Patients delaying to see the doctor they know:- Publicise details of all the doctors and other clinical workers in leaflets, waiting room and website. Talk them up.
Better medical records make it unnecessary to see the same doctor. Practices need dedicated time for partners to comment on each others' records and learning points from patients' subsequent consultations with a different doctor. Otherwise doctors' blindspots and sloppy record keeping goes unchecked.
Complacency - seeing a different doctor leads to different problems coming to light. See answer immediately above.
Mass resignation won't happen. What other handles does the BMA have?
- a mass petition signed by those attending general practice provokes a debate in Parliament. The opposition is asked to debate the cause vigorously.
- sympathisers in the TUC and left of centre parties organise days of protest about the NHS
- we form a nationwide c0-op, of NHS workers to bid for contracts. It becomes so big, it has genuine power to negotiate effectively with the commissioners.
- and yes - we agree to provide n consultations/1000 patients per week. Seventy has been suggested by NHS Executive. Might this include telephone consultations, and nurse consultations? If so it can be done - but in deprived areas more may be needed, and extra time for lack of shared language in metropolitan areas.
Which'd you rather?- Trident or a better NHS and social services?
Which'd you rather?- free financial transactions or a better NHS and social services - i.e.how about the Tobin Tax like other European countries have?
Which'd you rather? tax-free profits on gains on land when planning permision is granted or roads and railways are built - or better funded NHS and social services?
Would NHS be more cost-effective if run like John Lewis's? i.e. a workers' partnership?
Does NHS need to provide scripts for OTC medicines?
We need to think big.
There are other ways way to reduce the need for GPs.
- make the task of prescribing generic OTC and Pharmacy drugs one for pharmacists rather than doctors.
- direct access to practice counsellors and physios
- end the commercialisation and the item-of-service culture in the NHS, then we don't need referral management centres, and consultants can be trusted to inter-refer without being suspected of doing so because they want to maintain their hospital trusts.
I gathered recently that the LMC regards 70 consultations per 1000 patients per week as a reasonable standard of service for general practice. Defining standard of service by that sort of criterion makes more sense than setting a target for maximal wait. Maximal wait for a patient with severe pain or sudden breathlessness needs to be in hours, while for a cosmetic skin rash it can justifiably be more than a week.
Having GPs work for a care organisation that is led by a single hospital trust will deny patients choice of hospital, and increase referrals as trusts dumb down primary care and impose guidelines to maximise referrals in order to maximise income from items of service.