Dear Dr Patel
No MDO will cover criminal charges.This would always need to covered through self pay.
We are already one of the most stringently regulated professions in the UK with members of the public able to complain under the NHS Complaints procedure, to the General Medical Council, NHS England and pursue medical negligence claims.
Many GMC investigations of GPs then lead to review by NHS England and trigger more local investigations under the Performer’s Lists Regulations. This double whammy of regulation has affected many GPs since the advent of NHS England and local area teams.
There is evidence to show that many doctors are now practising more defensively for fear of legal action by patients. One survey by the Medical Protection Society showed that four in five GPs said that fear of legal action lead to them ordering more tests and making more referrals and almost half prescribing medicine when it was not clinically needed.
This defensive behaviour clearly has important implications for good patient care and indeed serious financial implications for the NHS Budget, when it is already tremendously stretched.
Sharing information about claims made against GPs with regulatory bodies will undoubtedly fuel this defensive practice further and undermine GPs faith in the new indemnity system.
Complaints and legal claims made are already discussed on an annual basis with GP appraisers who have the means to escalate serious concerns to NHS England if this is deemed appropriate. It is unclear therefore why this additional layer of reporting is thought necessary or fair on the doctors involved. There is evidence to show that receiving a complaint not only leads to a significantly higher risk of mental health problems for the practitioner involved, but a wider halo effect where their practitioner colleagues alter their clinical management to become more defensive. At the practitioner health programme we have all too often witnessed the devastating and fatal consequences that prolonged regulatory processes can have on doctors and their families.
Doctors have a right to legal advice and representation which would by any other means be privileged and not disclosable to regulatory bodies.
It is unclear why this fundamental legal right thought of as an issue which can simply be waived in the public interest.
At a time when the NHS faces a worrying shortage of GPs and a recruitment crisis, it is difficult to see how this new arrangement will encourage GPs who are currently just about managing to stay on to retirement or make the job any more attractive to those considering a career in general practice.
I wil do everything in my power to make sure that evidence underpins this policy
Its unfair on the GPs to be told they could have prevented suciide
Sadly, not even those closest to an individuals can. - its sad, but true. The only way of preventing suicide (what ever anyone tells you) is by addressing the populations back ground risk and improving it.
Suciide is a very rare event.
Also from a paper I recently published
Preventing a very rare event (completed suicide), and identifying those who will go on to complete a suicide act from those who express suicidal thoughts is extremely difficult, if not impossible. A systematic review of risk assessment for suicide by Large et al concluded that the overwhelming majority of people who might be viewed as high risk for suicide will kill themselves, and about half of all suicides will occur among people viewed as low risk. Carter et al found similar results in their systematic review of instruments aimed at predicting high risk of suicide and concluded that no high-risk instrument was clinically useful.
From a paper
Bottom line. - predicting suicide is difficult
Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research.
By Franklin, Joseph C.,Ribeiro, Jessica D.,Fox, Kathryn R.,Bentley, Kate H.,Kleiman, Evan M.,Huang, Xieyining,Musacchio, Katherine M.,Jaroszewski, Adam C.,Chang, Bernard P.,Nock, Matthew K.
Psychological Bulletin, Vol 143(2), Feb 2017, 187-232
Suicidal thoughts and behaviors (STBs) are major public health problems that have not declined appreciably in several decades. One of the first steps to improving the prevention and treatment of STBs is to establish risk factors (i.e., longitudinal predictors). To provide a summary of current knowledge about risk factors, we conducted a meta-analysis of studies that have attempted to longitudinally predict a specific STB-related outcome. This included 365 studies (3,428 total risk factor effect sizes) from the past 50 years. The present random-effects meta-analysis produced several unexpected findings: across odds ratio, hazard ratio, and diagnostic accuracy analyses, prediction was only slightly better than chance for all outcomes; no broad category or subcategory accurately predicted far above chance levels; predictive ability has not improved across 50 years of research; studies rarely examined the combined effect of multiple risk factors; risk factors have been homogenous over time, with 5 broad categories accounting for nearly 80% of all risk factor tests; and the average study was nearly 10 years long, but longer studies did not produce better prediction. The homogeneity of existing research means that the present meta-analysis could only speak to STB risk factor associations within very narrow methodological limits—limits that have not allowed for tests that approximate most STB theories. The present meta-analysis accordingly highlights several fundamental changes needed in future studies. In particular, these findings suggest the need for a shift in focus from risk factors to machine learning-based risk algorithms. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Private dentists are having a tough time. Many are employed by large conglomerates. They have to do production line dentistry. It’s best to be in the NHS family.
So if partnership were so great - why is it the current generation are not becoming one.
PS I speak to hospital doctors every day. Their stressors are different. And there is a general malcontent amongst all doctors.
GPs though - are suffering +++
We have had 5% of all GPs in England through our service in 2 years.
What does that tell you?
The vast majority are partners - struggling to make ends meet. The other group are locum GPs, feeling isolated and lost.
What is the current advantage of partnership ?
We cant open when we want, have curtains we want, change our hours, change our referral criteria - we cant even decide who we team up with as we are forced into PCNs of CCGs or Federations making.
Please tell me where the autonomy is?
Maybe the solution is to have an honest appraisal of the current way we are employed.
Partners are suffering (see last week’s report). This is because we are the only professionals in the health system who have to bear the increased costs of locums, cost-of-living increases, meet all demands for more work with less resource and so on.
An AE consultant does not take home less money because their department is having to rely on locums or fill the shifts him/herself to dangerous levels. Yet GP partners do. I think we are still being punished for having the pay rise in 2004 and for the ill-judged comments made by some of those who negotiated the pay rise.
Sensibly, this generation of GPs are voting with their feet - they are not becoming partners (many are not even becoming permanent salaried doctors).
And before I am shouted down - I said this in 1991 when i first became a partner and wrote about it in an RCGP publication in 2008 - well before my own practice became a 'super practice'.
I think we should be all salaried to PCNs - with funding matched against a hospital consultant with a Bronze ACCA (or whatever they are called nowadays). We should have our face to face clinical time capped at maximum 5 sessions and the remainder of the time should be management, teaching, training and so on. We can still work in small 'partnerships' but within the PCN and if funding is not enough to meet the salary requirements then it is not our responsibility to box and cox and work harder. It would be those who provide the funding to the PCN - so the CCG I suppose or NHSE or whoever are our pay masters at the time.
F/T should be capped at 8 sessions per week (as it is with hospital doctors) and we could even decide that one of these sessions is an out of hours one (maybe with hospital doctors also helping us deliver out of hours care).
Just some thoughts
The answer my friends, is blowing in the wind.
We need to ensure geographical foot prints for PCN's and Federations.
We must integrate with secondary care - i.e. either create joint vehicles (with GPs as majority Board members) or find some other route and there must be a law that does not allow co-payments (unless universal applied).
This is nothing to do with Digital - digital will make AP a billionaire as he will sell it to highest bidder. The issue is the owner of GP@H will then own a massive GP list and with it the secondary and primary care budget. We worry about privatisation - its happening under our very noses and yet we cant seem to stop it.
What will come next is offering patients registered with them the ability to 'top up' their care for certain services (first it will be physiological treatment, physiotherapy and fast access to specialists). This top up will be via a top-up insurance. To begin with everyone will feel winners - GPs will have more money, less work, and patients will think they have more care for only a little extra money per year. Then the down side. GPs will become production line doctors - patients removed to the NHS if they cost too much. We will all be losers except for Babylon. I worry about this - and its all made possible sadly through
a) Tariff being the same for out of area and in area
b) Ability too register out of area patients
c) PCNs allowing for commissioning budgets to be held (primary and lucrative secondary care0
d) PCNs not insisting [as I argued above] for geographical foot prints - only. No compromise
I predicted all of this in 2010 when I became Chair.
I asked Primary Care at DH - 'whats stopping a single handed GP registering 1 million patients on a single list, delivering care through a combination of digital [remote] and face to face done through a network of GPs located in pharmacists etc. I was told 'it could never happen'. I knew it could and there was nothing in the legislation to stop this. There still isn't.
But it can be stopped if we get red lines in place
a) Geographical only PCNs
b) No top up 'co payments' allowed unless nationally sanctioned and therefore universal
c) Reduce tariff for out of area patients to 10% of in-area
d) robust governance of PCNs - including not allowing single providers
For CCG read PCN
From patient advocate to gatekeeper: understanding the effects of the NHS reforms
Br J Gen Pract 2011; 61 (592): 655-656. DOI: https://doi.org/10.3399/bjgp11X601532
For over two decades GPs have been encouraged to engage in the financial, as well as clinical responsibilities of health care. While it makes sense for GPs to be involved in health planning, such as expanding the number or location of surgeries and services, acquisition of new technology, and so forth, it does not make sense for GPs to spend their time negotiating contracts with other doctors, managers, and hospitals, and even less to bear financial risk for their expensively ill patients. Firstly it turns GPs into rationers of care and away from their professional role as patient advocates. Secondly, it does not save money. Experience with managed care in the US shows that it increases the need for administrators and managers. Finally, putting clinicians at financial risk does not improve quality.1
Clinical commissioning groups (CGCs) are similar to North American health maintenance organisations (HMOs), with the UK government allocating resources to CGCs based on the number of enrollees (patients registered with constituent practices), from which secondary care services will be bought. Originally conceived as a way to pre-pay for preventive care in addition to acute and hospital care, not-for-profit HMOs were introduced in the 1970s.2 Despite their progressive origins, they were rapidly transformed in the 1990s into for-profit corporations.
HMOs profited by avoiding sick patients in increasingly deceptive ways; for example, by cherry-picking the healthy, dumping high-cost patients from their plans (known as ‘recession’), and limiting referrals and treatments on financial rather than clinical grounds. This new breed of HMOs created opportunities to control medical care before it was delivered, diverting 20-30% of revenues to overhead and profits along the way.3
HMOs, as with CGCs, will create perverse incentives, as well as placing barriers to joint working between primary and secondary care practitioners.
While primary care physicians are put at financial risk to reduce care, specialists (in hospitals, any-qualified providers, and third sector specialists) will be dependent on the number of patients and intensity of services (treatments, imaging, hospital days) for their funding, not, as with the system pre-NHS market reforms, on grants from the national purse. Thus, as in the US, specialists will have an incentive to increase activity, inevitably leading to over treatment and over investigation in an attempt to increase revenue and pay their overheads (including staff wages).
Thus, primary care physicians will be pitted against hospitals and other secondary care providers in a market-based scheme that diverts funding from clinical care to overheads and profits. The complexity of putting restrictions in place on who, where, when, and why patients can be referred; the implementation of referral management and gatekeeping systems; performance management and utilisation review; and even firing of practitioners with more than the expected number of expensively-ill patients, along with the many other functions that will be required of CGCs, will come at a high price. In practice, CGCs will have to hire new firms (the giant insurers from the US are already in line) to manage such a complex array of tasks, and based on the US experience, they may be expected to consume 20-30% of funds for their services.
CGCs, as with HMOs, will implement risk-stratification systems, identifying potential high-cost patients and high utilisers of health services, whose care will be outsourced to third parties, such as disease management companies. Patients with complex comorbidities may find their care being managed by a multiplicity of disease management systems, all designed, not to improve their care, but to increase the management firm's profits. Care to the patient will be fragmented4 and continuity compromised due to the perverse funding arrangements. Mergers between different CGCs will be inevitable, as the unpredictability of ill-health (for example, small numbers of patients requiring high-cost treatment) takes its toll on the budgets of smaller CGCs, or worse still, CGCs will become bankrupt. GPs will become corporate employees, expected to perform according to rules dictated by the CGC hierarchy.
SELECTIVE PATIENT LISTS
CGCs will inevitably impose different schemes on participating practices and patients, with the move towards personal health budgets (vouchers for year-of-life care) and away from budgets based on geographical populations facilitating this. Fit, healthy, and younger patients will be targeted in the hope that their cost utilisations will be less, leaving more profit for the CGC, either to reinvest in clinical services, or as is currently proposed with the Health and Social Care Bill, to provide financial reward to the participating clinicians. As the new Act is removing Parliament's duty to provide a comprehensive health service, CGCs will be able to determine what services they provide as standard (that is, free-at the point of use), with other specialist services dependent on co-payments despite their disastrous consequences for care.
Evidence from the US shows that co-payments reduce access to necessary care as much an unnecessary care, and, in the only randomised study in this area ever performed, disproportionately increased death rates among the poor and chronically ill.5 Furthermore, they increase bureaucracy and don't save money: the US has the highest cost-sharing in the world and also the highest healthcare costs.
The NHS works. It produces some of the best health outcomes of any modern health system. It is a universal service, with risk pooling across the entire population. GPs are paid according to capitation, and financial incentives, where they exist, are to keep patients well. Before the market reforms of the 1980s, hospitals were paid a grant to cover their budgets, with no incentives to increase activity or maximise costs by up-coding or gaming. Rather than trying to implement the US's failed market-based model and put corporate profits and bureaucrats at the centre of our health system, the UK government should improve and protect the NHS and its achievements in providing health and security to our nation by ending the experiment with market-based care and focus on what matters to patients: continuity, access, caring, and coordination.
excellent piece. Thanks
I wonder how long it would take for someone to personalise things towards me.
You don't even give your name - let alone what conflicts you might have.
I speak as someone who has worked in GP since I was 14 year old - first as my father Saturday receptionist (he was a single handed GP, then group practice), then as a GP - first as a GP in a single practice, now as multiple (not sure what you mean by 'corporate').
For the record, I only just gave up out of hours work - last year, including red eye shifts. This year I will only do Christmas Day but no more (but I will be 60 years by then).
This means for 30 years I have done in, and out of hours work, as a GP.
Far from telling someone how to survive in GP who hasn't done the job - I have done the job, and survived and thrived.
I also care for now 20% of all the GP work force in England in my GPH service so understand the pain and distress of my fellow professional.
Lots is wrong with GP at the moment.
We can't provide continuity - which is the only unique feature of general practice and the tool of our trade.
We have a demoralised, over worked work force- working iMO in the wrong places.
We have endless expectations and too little time or energy to deal with (or maybe I am speaking about myself).
So lets work together to find ways out of this.
I could postulate that the rise in burn out - which is across the board - is because of the rise in peripatetic working not protected by it. We all need to ‘belong’ and have a stable base. Flexible working is best done if securely attached to a practice. Continuity is best for GPs and patients. Locum working is becoming the norm yet GPs are more unhappy. I think if we were salaried to provided core clinical work then we would not have the massive fluctuations in income and could negotiate safe Working condition.
Maybe medicine is becoming more akin to barristers chambers - sad as continuity is what makes general practice work and enjoyable and fun. We are at risk of throwing away best part of our profession and making the problem worse. Sadly - locums increase work load for permanent doctors & do not add to continuity.
HMRC won’t allow long term locum with same provider. Locums & employers risk massive fines of work in same place for over 3 months. IR35. Rules
The problem is - and I know that I will be shouted down - is that we are independent contractors. If we were salaried for our clinical work as hospital consultants - we could control our work load and then develop our other areas of interest. Instead we are victims of our own success. Throw work at us and we not only deliver - but over deliver. I Am not against partnership - but think we need to redefine it.
GPs were 'specialised'
My father was a GP
He did general practice, school doctor, doctor to a girls remand home and a session in hospital.
i think years ago it was easier to do 8-9 face to face clinical sessions per week and an out of hours on call session or two. Thats impossible now - impossible, and we have to accept that.
i used to do 8 clinical sessions
I used to start at 8am, finish by 11am, home visit done my midday. Then restart evening surgery 4-6.30pm
I used to fit in a meeting 2-3 days per week at lunch time and pick the children from nursery and give them lunch.
given the same surgery and Same patients this would be impossible
Lets get the language right
Many GPs are working full time – but not all in clinical practice (ie face to face clinical care). You would never say a consultant surgeon who only did 3 operating lists per week and one outpatient clinic as part time – or a psychiatrist who did 3 outpatient clinics and a ward round. Yet a GP who might do 5 face to face surgeries, a session as an appraiser, do a session as a lead for mental health and one as practice lead for QOF will be called ‘part time’. GP often mix their time between one place (GP surgery) and another role – so GPWSI or leadership etc. They are not part time.