We are our own worst enemies because we have always selflessly put patients first and try to do the right thing. I did the BMA burnout questionnaire and it came back as high risk so I had a holiday and did it again and the same result. I asked my colleagues to do it and they all came out as high risk and instead of addressing the issue stated the test must be wrong! Didn't like the answer shouldn't have asked the question is the normal response. As a practice we have employed a community pharmacist since without help from NHSE. The Australian RCGP is much more proactive in helping their members who have a much lower workload and have a strap line "I'm not just a GP. I'm your specialist in life" Little wonder colleagues are emigrating. In one way I hope we become fully salaried because then employment law and basic human rights laws will apply. My fear is Maverick (0:48am should have been asleep) makes a very good point about the destruction of NHS Primary care. Backbone of NHS and as Simon Stevens has said no primary care no NHS.
The country can't afford the pensions of the public sector particularly the NHS workers. The drive is to get people employed by private firms who will have sweetened deals to lure the workforce away from the public sector. The NHS will exist in name only as it will still be free to the end user but via tax breaks or insurance provided by the state as outlined in Direct Democracy. The profession will be salaried and the family doctor concept will disappear. Only continuity will be if people are willing to pay privately. Can't run a socialist ideology of the NHS with capitalist business models and not have casualties.
In 1948 they didn't nationalise GP's because they didn't think they would be needed in the utopia of universal healthcare. Since then there have been waxing and waning of the importance of Primary care. Simon Stevens has said no primary care no NHS. A couple more years and Jeremy's desire to denationalise the NHS will happen and the blame will lie with the Doctors who left the service. Patients still want a family doctor but will have to pay like pre 1948.
Fewer people having private insurance is a sign the economy is struggling and adds more pressure on the NHS. Activity is always up treating more patients than ever but funding not keeping up with activity. As practices struggle to recruit demand just grows until the tipping point is reached. The new junior contract in trainees is already impacting capacity as GP day is 8am to 6:30 yet trainees not allowed to cover that time to reflect real practice. I am in favour of working a 40 hour week but that would need more personnel and capacity particularly if the push for 7 day Primary Care continues.
I have trained my last trainee and have not renewed my trainers accreditation. The whole process with peer review of videoed tutorials, pages and pages of evidence that the practice is suitable was akin to the CQC inspection. I had a fantastic trainee who failed his CSA first time almost destroying his confidence. It appears that you have to preform to the narrowest criteria set down by the RCGP to pass. So churning out clones of what the college determine makes a good GP. The eportfolio took up so much time and getting all the evidence prevented him developing his skills in the time available. The pressure to attend courses and meetings with little ability to back fill means the work waits to be completed at the expense of family time. Much as I enjoy teaching the whole training process has ground into a tick-box bureaucratic quagmire. Sad days ahead.
What the new contract is doing is to wake Primary care up to accepting a fully salaried model of delivery of care. As a Partner it is my small business that I help run and so devote a lot of time to ensure it works well. I leave when the work is done or else profit falls and I suffer financially. If I were salaried I get paid for the hours worked and any unfunded work would be altruistic. Developing a purely salaried model has to involve a seismic shift in what the role of a GP will be in the future. Moving towards the ACO model patients will see the next available doctor with little choice and we will serve up McDonalds rather than Michelin star medicine.
There is no transparency in how primary care is funded and the payments to practices vary hugely even in the same area. Having been forced to disclose on our website how much we earn we have more sympathy from our patients. The direction of travel is towards a fully salaried model with no continuity of care like they have in the US in some of their ACO's. I have patients that travel back from the US to see me as it is cheaper and they can be assured I am not medicalising their problems in order to get repeat attendances. No-one has asked the public what sort of primary care they want and how much they are willing to pay for it. Most are shocked that their annual care costs are so low and that primary care is so poorly financed and under valued. Once bigger practices start to fall like a house of cards we all will because demand will rise in those that are left until they too collapse. Then it is those terrible doctors who left the NHS which is why it will have failed.
I had a patient who googled their symptoms of abdominal bloating and was directed to a site which said Seriously Bloated warning signs you should not ignore. The first condition was for ovarian cancer which mainly affected women over fifty(no mention of who it did not affect). All the typical symptoms of bloating feeling full faster and pelvic pain affected my patient who was convinced they had it. I gently explained it was impossible because he had no ovaries. "how do you know I don't have ovaries doctor?" He asked perplexed and sadly I had to use the time honoured phrase Trust me I am a doctor!
Now let us see a joined up BMA supporting all doctors equally and stop the denigration of our noble profession by self interested politicians!
" cuts to funding will force local NHS leaders ’to make tough decisions about priorities "
The politicians dictate how much funding then pass the buck of making the unpleasant and challenging rationing decisions to front line NHS leaders to carry the can when patients start suffering because of insufficient resources. Called a hospital pass in Rugby Football!
Until the public are made to realise the NHS is not "free" and the tax payer pays for it the problem of demand outstripping supply will exist.
NHS leaders should forgo their gongs and speak truth to power and put and end to the perennial funding problem.
Congratulations Mayur! Well deserved.
Prof Peter Morris 11:15
" which shows growth in activity over and above the growth in the population,"
quoted from last paragraph.
Everyone has a bed and it is at home! We need to use hospitals only for acutely ill patients or scheduled treatment. There is this obsession about numbers and more is better. Once a patient is in hospital they are institutionalised and problems that did not exist suddenly appear. Not knowing where the toilet is and being afraid to ask until too late and the patient now has incontinence. Poor disturbed sleep leads to confusion and then questions about can they be safely discharged. Means tested social care leads to assessment by the continuing healthcare team at greater cost. Sir Muir Gray talks about a value based healthcare system which is allocative technical and personal value, a test we should apply to all the plans rather than the knee jerk make savings at all costs! The STP's appear to have just re-hashed all the existing plans but not fundamentally challenged the "why" we are in this situation. The determinants of health are housing education and employment yet we focus on the number of beds, which is a political hot potato. There needs to be honest debate as to what is affordable and what is not. Continuing with the charade that it will all work if we had more money makes no sense. The country is bust. the current debt is £1.8 Trillion!!www.nationaldebtclock.co.uk/ and rising at £5170 a second. The plans will never address the basic flaw that a tax funded free at the point of delivery business model is unsustainable.
Idea of accountable care organisations in the NHS is fundamentally flawed! ACO's only work because the patient pays to join and behaves by the rules set out by the ACO. The more services the greater cost. There's also rationing which is politically unpalatable in the UK. When the money runs out they go out of business will that be allowed? Who will decide how much each will get and who will set the priorities and be responsible for rationing?
There has never been joined up thinking at any level in planning for the future. Housing just want more houses and get section 106 money from the developers to build surgeries without the understanding that surgeries have grown organically over many decades and no new practice can start without a lot of pump priming money. The build it and they will come mentality works in housing not in primary care.
Can I understand the guarantee of 1% pay rise? Is that for all GP's including partners who have rising costs before increased drawings can be taken. Are we moving towards a fully salaried service? As you said Nigel it has failed your test and the increasing demand remains unchecked.
My concern is that the £2.4billion promised to primary care is the same amount missing from the social care budget. Will the expectation be that Primary Care will have to fix the social care problems as well? The Five Year Forward View is almost half way and on the ground not much has changed. The Vanguard and Devolution schemes cost more to manage and the only bright hope is the Primary Care Home from the NAPC but that too needs funding to survive. All the models are pushing the profession into a fully salaried system but will kill off continuity of care and the personal doctor/patient relationship. The push for 7 day working means spreading everything thinly into shift like working. What should be commissioned is an urgent care system that meets patients expectations. Patients only know two places to access healthcare GP's or A+E. Rather than adding complexity and competition have proper triage at the front door and have the right skill mix to deal with the urgent care. Long term conditions need more time to be dealt with properly as well as the forgotten about prevention agenda. The new contract will have a sting in the tail to do more or lose funding.
Primary care is like a house of cards one blow from caving in, and the business model is no longer sustainable. The corner shop self employed small business partnerships worked in the 1940's to 1980's but since then the move has always been to a fully employed salaried model. All the new models of care rely on a standardised delivery of primary care which you can't get with multiple independent small uncontrollable providers. One strength of GP's is the ability to say no and not be fired, but the establishment needs to be able to control the whole system and order it to perform along pathways. The STP's are trying to do this but the thorn in the side is convincing primary care to deliver when there is no control. MCP's rely on a fully employed hence controllable workforce.
The 2004 contract was to put right all the wrongs of the previous contract. Alan Milburn wanted to help GP's allowing them to relinquish the 24hr commitment so patients were treated by happy well rested and safe doctors. What the Government negotiators failed to recognise was that Saturdays would be out of hours. PCT's at the time then had to hurriedly find an out of hours provider as everyone flooded to A+E. The QoF also came then and no one expected GP's to perform so well yet most achieved maximum points forcing PCT's to find the money to pay what was promised for quality primary care. Since then there has been a vendetta to "correct" the mistakes of government negotiations. Others are quite right Hunt is only there as no one else wanted the job and his mandate is to denationalise the NHS. To get the public on his side blame the contract and greedy GP's causing the A+E crisis and bed blockers then offer everyone access to private service by "giving" them money towards insurance policies to avoid the NHS queues. Hopefully the public will see through it but then again....
Beards are cool or hipster at the moment!
Speaking the truth to power hurts, but it is usually the orator that suffers! Simon Stevens is right to speak up as it has always been robbing one part to fund another but now it is very much divide and rule. The £2.4Billion promised to primary care is exactly the sum taken from the social care budget, co-incidence?? What is fundamentally needed is a rationalisation of how the business models and rules work in the quasi market place that is the NHS. Always believed buy cheap buy twice. The care system is in disarray because the public is not prepared to fund high quality care as standard. The care homes I visit are staffed predominately by non British born workers who are willing to work for the low pay offered. Either there has to be a tax or NI increase or rationing because the service can no longer provide the safe high quality care expected.