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GPs go forth

Just who is the NHS working for?

Dr Charlotte Alexander 

In the potpourri of patients in my surgery yesterday, one was a retired GP.

He was most apologetic when asking me to write a private referral to a cardiologist, but that’s what his insurance company required.

He and his wife, a retired nurse, ‘wouldn’t be without it’. ‘Well’, I thought, ‘he should know’.

Then there was our lunchtime meeting, where one of the only allergy specialists in our region gave a talk. As her team looks after patients in Kent, Surrey, Sussex and Berkshire (for context, this represents half of the ancient Kingdom of Wessex, and there were only two kingdoms), it’s no wonder that a referral placed now wouldn’t be seen until June 2020.

This is nothing to be proud of, especially when set against her statistic that the UK features in the top three countries in the world for allergy incidences.

Add to that our inability to get hold of any adrenaline auto-injectors except Epipens (and that isn’t even enough adrenaline for the adult anaphylaxis protocol), all we could do was sit there and raise an eyebrow, or in the case of my colleague, joke about how Grazax to treat hayfever was ‘eye-wateringly expensive’. (Geddit?)

With this done and dusted, I strolled back to my room ready to tackle a referral for adult ADHD that had been sitting in my inbox for three weeks.

In a world of ‘computer says no’, writing makes no difference

It was rejected the first time round because there wasn’t enough information - my detailed referral letter was deemed inadequate. What I hadn’t done was tick enough boxes or complete enough questionnaires.

Listening carefully to the patient and judging that he was most likely somewhere on the spectrum and that getting a diagnosis seemed very important for him and his daughter wasn’t enough.

So an extra hour of admin was required, and I had to send the patient two self-reported questionnaires and then score them (but it can’t be too easy, just in case the doctor or patient are trying to play the system, meaning that questions 1, 3, 5, 9 and 10 are scored differently to the others).

Then I had to fill out some boxes about his functioning, considering I’ve only met him once, until finally, when all meaningful information had been reduced to a protocol, it was ready to go.

But that was followed by an additional phone call from a patient who had been booked into see a male colorectal surgeon, which ignored what I'd specified. She had phoned the hospital, but they had no record of the request. I'd written it, of course, but in a world of ‘computer says no’, it had made no difference.

To round off the day, I did a bit of social media surfing, and came across Dr Tony Goldstone, the BMA's pay and pensions advisor, explaining at a Royal College of Physicians conference that only a tiny proportion of people truly understand the pension tax problem.

Not for the first time that day, I had to ask myself ‘just who is the NHS working for?’

Dr Charlotte Alexander is a GP in Surrey

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Readers' comments (11)

  • Before my wise colleague Dr Ho pitches in, your question is not half as rhetorical as you want it to be.

    Statist bureaucratic enterprises are run chiefly for the benefit of state-salaried bureaucrats.

    However, to touch on your point about so called 'Adult ADHD', the only ones who benefit from endless labelling of normal human life and experience are the people in 'mental health industrial complex'

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  • Ivan Benett

    The NHS should work for all, at the point of need irrespective of personal affordability. It is not for the Private sector, doctors, or medical insurance companies.
    Unfortunately, it does not work as well as it might, even though clinical and managerial grades are working individually flat out.
    There remains inequalities, the inverse care law persists, the rule of halves still fails those who have chronic diseases. Access is woefully poor for acute but non urgent (need to be seen same day). Preventive and health promotion services are under resources. Staffing levels are too low and skill mix is inappropriate.
    So should we turn to a Private system of care.
    All evidence suggests these systems disadvantages those least able to speak or pay for themselves. Make huge amounts of money for their managers, share holders and senior doctors. They leave large swathes of people without cover, including those with long term conditions.
    Our system isn’t perfect, but because of chronic under resourcing, pitifully managed reorganisations, and incoherent workforce planning.
    Apparently we will be treated to a large cash infusion for buildings - desperately needed - what we need is not pre-election give always, but planned and thoughtful development

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  • I agree with what you say about the NHS however I think there were more than two ancient kingdoms. Wessex, Mercia, East Anglia & Northumbria spring to mind, from my reading of Bernard Cornwell's books.

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  • Holy Smoke
    Please don’t pontificate upon issues/diagnoses of which you are ignorant. I realise mental health can be used as a catch all for life’s difficulties, however adult ADD is undoubtedly a thing (I am generally sceptical) Having seen chaos turned to order in several young undergraduates, we must remain open minded.

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  • And Kent

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  • |Ivan Benett | Salaried GP|02 Oct 2019 11:32am

    To counter you - NOTHING works for all.
    You can have 2 out of 3 of - Universality, Affordability, Quality.

    You want the NHS to be universal and "high quality/low waiting times"? You bankrupt the country. You want to keep it affordable? You have to ration, i.e waiting times. A private system provides competition, and that promotes affordability and quality. You also incentivise the public to strive to cover their own invidividual health responsibilities and maybe those of their close ones too. (Are you going to tell me that promoting closer familial ties is a bad thing?) You might even convince the more fortunate in life of the utility of generosity towards strangers.

    Compelling via a 3rd party/the state results in 1. LESS altruism. 2. abuse/misuse. 3. ANY state comes with "under resourcing, pitifully managed reorganisations, and incoherent workforce planning" - inefficiency comes with the territory, as "it is always easier to spend someone else's money".

    "All evidence suggests these systems disadvantages those least able to speak or pay for themselves." - Please cite some. I've seen loads of evidence that people are not "dying on the streets" for lack of healthcare in countries with more privately based health systems.

    Finally - You, Ivan, are free to contribute more tax to the Treasury, if you feel the state is under-resourcing the NHS, and that the state would spend it efficiently. Don't be telling, or worse, compelling me to do the same.

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  • Philosophical question: is the NHS working at all, let alone for whom? I don't think so. Doctors are trying to do too much (because orders are orders) with too little, and it has been ever thus. Otherwise how come NHS reorganisations never fix the system and never have?

    Let's knock all the bricks out of the wall, and start again, not least by considering what doctors will not do. See my book "Mad Medicine" ( to understand my concept of futility medicine...

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  • The answer to this excellent article is found in newspaper headlines and BBC News
    FAT CATS ON MEGA PAY Staggering 325 nanny state public health bosses raked in over £100,000 a YEAR just to say drink less and exercise more The Sun
    PARKING MAD Hospital parking fatcats made £500k in one year thanks to scheme that sees NHS staff having to pay to park at work - THE millionaire couple behind one of Britain's biggest 'rip-off' parking firms raked in £500,000 between them in just one year. The Sun
    More than 600 health quango chiefs on six-figure salaries amid NHS cash crisis The Telegraph
    As the NHS implodes, fat cats cash in: Number of health penpushers on MORE than PM's £150,000 salary doubles in three years Daily Mail
    On and on the list goes, but the biggest bonanza came with useless Lansley's tragic reforms that saw NHS chiefs playing lucrative musical chairs.
    Newspaper headlines: 'Fat cat pay of NHS bosses' BBC

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  • Holy smoke I think adult ADHD might be another item to add to your personal development plan next year. It is definitely a ‘thing’ and you are doing your patients no favours at all in your ignorance of mental health issues. Stigmatising.

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  • Oecd hard outcome measures show the NHS is an unimpressive way of arranging health provision.
    There are lots of European alternatives with better outcomes that involve patient contributions yet have full coverage.

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