Debates

Dr Tony Grewal argues that consensual relationships with patients should not be banned, but Dr Surendra Kumar says they should be avoided

The Government is right to propose this, argues Dr Peter Weaving. However, Dr Ahmed Nana says the latest prescribing initiative is poorly thought through and could put GPs at medico-legal risk.

Why start to prevent a cardiovascular event only when a patient has had one, asks Dr George Kassianos. However, Dr Matt Hughes argues we need better data.

Forcing PCTs – and GP commissioners as their heirs – to separate commissioning of community services from provision is the wrong direction of travel, says Dr Donal Hynes, but this has given GPs a new opportunity to develop community services everyone wants, says Dr Joe McGilligan

A failure to engage with GPs has left PCTs unable to innovate, says Dr Stewart Findlay, but PCTs have made real improvements and GP commissioners will need to learn how they did it, counters David Stout

Moving the target from 7% to 7.5% may see some patients miss out on best care, says Dr Martin Hadley-Brown. But Dr Richard Lehman argues that the 7% target should never have been introduced and it is right to scrap it

Nobody is more qualified to handle the lion’s share of the NHS budget than GPs, says Dr Michael Dixon. But Dr Keith Holton argues that the system is set up in such a way as to make it a poisoned chalice

The huge changes ahead will only be effective with a GP contract that includes commissioning responsibility, says Dr Jonny Marshall. But Dr Brian Balmer argues that coercion might well threaten the innovation that GP commissioning could deliver

Dr Tonia Myers believes general practice is a fantastic option for women wanting to combine family life with a rewarding career. But Dr Clarissa Fabre says until pregnancies become cost-neutral for a practice the temptation to discriminate will remain.

Dr Beth McCarron-Nash says moving towards 15 minute appointments – or more flexible times – is a logical way to improve patient care. But Dr John Chapman insists the suggestion is bot5h impractical and unecessary

Dr Jonathan Steel says the 18-week target is not primarily responsible for the reduction in waits, and has had serious unintended consequences. But Dr Jennifer Dixon argues the 18-week target is a vital safeguard, and that its removal may send waiting times creeping back up.

Professor Helen Lester's recent research on US clinical incentives suggest removing them QOF indicators could have mean a decline in clinical care. But Dr Terry McCormack argues that care can only start to improve when some indicators are culled.

Yes- argues Dr John Havard, as too many patients end up seeing their GP anyway. No- says Dr Brian Gaffney, the evidence is growing showing these services save the NHS money

Acute trusts will pay for remediation to keep senior clinicians working but that's not such an easy option for practices says Dr Brian Keighley, while Dr Mary McCarthy argues that if GPs pay for their professional exams why not remediation?

PMS was a contract of its time, but now looks outdated and is set to be a victim of the economic crisis, says Dr Jane Lothian. But Dr Peter Smith is robust in his response, insisting PMS will survive and thrive provided GPs withstand bullying against them.

QOF targets for continuity might be tricky to arrange, but would rebalance the framework in favour of the doctor-patient relationship, says Dr Matthew Ridd. But Dr Carolyn Tarrant believes they would do exactly the opposite, by eroding trust in a GP's motivations for developing that relationship.

Generic substitution is just the kind of safe but money-saving medicine that the NHS needs, argues Dr Andrew Perry. But Dr Peter Fellows disagrees, insisting that the policy would damage compliance and harm the pharmaceutical industry

GPs on the front-line are much better placed than PCTs to monitor out-of-hours care, argues Dr Charles Alessi. But Dr Ravi Mene disagrees, warning that if GPs take back out-of-hours it is bound to be underfunded.

The new fast-tracked rollout will soon make the care record part of our normal working practice, says Dr Phil Koczan. But Dr Peter Swinyard is unconvinced, believing expensive but inflexible national schemes can never deliver solutions for local health needs

Improving access to specialists might seem a good idea, but it will undermine the role of the GP and damage continuity of care, says Dr Clare Gerada. But Dr Anthea Lints argues that paediatric GPSIs are intended not to reduce the role of the GP, but to strengthen the ability of primary care to deal with complex problems

Entrepreneurial GPs are essential to modern general practice, mixing knowledge of care with the business nous to keep the private sector at bay, says Dr Thomas Reichhelm. But Dr Louise Irvine says too many of the new wave of GP organisations prioritise profits over professional standards and are damaging patient care

Being open about pay - and how much GPs invest in their practices - is essential to regain the trust of the public, says Dr Michael Dixon. But Dr Krishna Korlipara warns publishing practice accounts would lead to unfair comparisons of GPs working different hours and funded by different contractual models

The entire NHS faces cuts and GPs cannot expect to be spared. Rather than being protectionist, we must show we can deliver value for money, says Dr Johnny Marshall. But the RCGP's Professor Steve Field argues a strong, well-funded general practice is essential to deliver care closer to patients while keeping costs down across the NHS

The BMA should follow the Royal College of Nursing and end its opposition to legally assisted dying, says Dr Colin Lennon. But Dr Tony Calland argues GPs should take into account patients' views in offering treatment and pain relief, but helping them die would be a betrayal of trust

Will online GP ratings help people make an informed choice about practices or be a dangerous platform for disgruntled patients? Two interested parties offer their opposing viewpoints

Are practice boundaries a barrier to choice or essential for controlling patient demand? Dr Mark Hunt and Dr Mark McCartney argue their cases

GPs are among the priority groups for the swine flu vaccine - but are they duty-bound to have it or does the lack of evidence make it reasonable to refuse it? Two GPs argue their cases

The NHS is facing soaring demand and a squeeze on funding. Charging all but the poorest for appointments could help the health service deliver to everyone who needs it, says Dr Paul Charlson. But the GPC's Dr Chaand Nagpaul warns charging for appointments would be a tax on illness, and might discourage those who most need healthcare from seeing their GP

It's hard to argue that we should use lifestyle interventions across the population but not highly effective medication, says Professor David Taylor. But Dr Terry McCormack argues the polypill is cheap and cheerful medicine but lacks the flexibility we expect in the developed world, or the evidence base for its individual components

Would the interests of salaried GPs be best served by staying with the BMA or finding an alternative organisation? Two parties battle it out

Antivirals are important for easing the peak of illness and, as we can't identify who most needs them, a blanket approach is the only option, says Professor David Price. But Dr Helena Newman argues that the policy of blanket antiviral use is costing the NHS a fortune, inappropriately cosseting patients and risks fuelling drug resistance

A QOF based on process measures has taken general practice as far as it can - it's time to reward GPs for achieving improved outcomes, says Professor Azeem Majeed. But Professor Richard Lilford argues health outcomes may be what matter to patients, but they are far too unreliable to be used as the basis for GP pay

A national vascular checks programme needs to be as broad-based as possible if it's to work, argues Dr David Haslam, and must include lifestyle measures. But Dr Gillian Jenkins questions whether including questions on weight, alcohol intake and exercise is really a good use of GPs' time

Until the pros of the Summary Care Record have been shown to outweigh the cons, we should opt all our patients out, says Dr Prit Buttar, who's doing exactly that. But Dr Manpreet Pujara warns denying patients the benefits of a care record by opting them out without consent is a throwback to the bad old days of 'doctor knows best'

Acupuncture may be an ancient treatment, but in 4,000 years no one has managed to produce any proof that it actually works, says Dr Euan Lawson. But Dr Andrew Hamilton counters acupuncture has good scientific evidence for its effectiveness and none of the side-effects associated with drug treatment

The choice agenda is intended to offer patients a real choice as customers of the NHS. Is it a boon to the patient experience – or do patients not really want a choice, just good local care? Two GPs argue it out

The inequity between partners and salaried GPs is corrosive for general practice, argues Dr Daniel Franks. But Dr Yealand Kalfayan says salaried GPs have no long-term investment in practices nor incentive to work beyond the minimum necessary standard.

NICE has led the way in the transparency of its processes and has built in checks to ensure GP views are heard - but it has been let down by the failure of GP organisations to engage, says Dr Rubin Minhas. But Dr Simon Bradley argues NICE is a flawed organisation that panders to the interests of specialists and lacks the overarching, generalist perspective

A return of the Medical Practices Committee might not be popular, but it would be better at distributing partnerships than market forces, says GPC chair Dr Laurence Buckman. But Dr Richard Fieldhouse says the MPC didn't work first time around and the push to restore it is just another attempt by the BMA to exert control over the medical profession

Federations will provide a career structure for GPs and allow them to be distinguished by their roles and not their type of contract, says the RCGP's Dr Maureen Baker. But Dr Mary Hawking argues that federations do not address the profession's problems and would level down by reducing the autonomy of partners to that of salaried GPs

Real budgets are the only way to get PBC kick-started, says Dr Dinah Roy – but Dr Ian Greener argues that they would create more problems than they solved

The QOF has to change to keep driving up quality and would become unwieldy if indicators were not moved out as well as in, argues Professor Helen Lester. But Dr Stephen Gardiner says a rolling QOF would simply lumber GPs with greater and greater workload for no new money, and would breach the terms of the contract

Prescription charging is an unfair and illogical tax, and one that prevents many patients getting the medicines they need, argues BMA chair Dr Hamish Meldrum. But Dr Mark Oliver warns that abolishing charges would put further pressure on the NHS budget and encourage abuse of the prescription system

Local QOFs, with indicators differing not just at PCT level but between practices, are essential to tackle hugely varying needs, argues Professor Chris Drinkwater of the NHS Alliance. But the GPC's Dr Richard Vautrey warns local QOFs would take money from evidence-based national quality indicators and use it to fund local priorities that are often determined on a whim

The Tories are right to believe GPs are ideally placed to assess local needs and they would be trusted by the public to make rationing decisions, says Dr Paul Charlson. But Dr Caroline Chill argues that asking GPs to ration treatments would damage the doctor-patient relationship and leave practices vulnerable to legal challenge

The new diabetes targets may not be achievable, will be too aggressive and won't target those at highest risk, warns Dr Martin Hadley-Brown. But Dr Jonathan Graffy argues that by setting targets across a range of blood sugars, the indicators will extend benefits to more patients and drive improvement

GP-led health centres offer the resources and opportunity to improve access to services locally, argues Dr Phil Yates. But Dr Andy Black counters that they will be staffed by salaried GPs, nurses and locums who will have none of the long-term commitment of a GP partner

The QOF’s success in improving patient care has come at a high price for taxpayers. It is right that future versions should be demonstrably cost-effective, says NHS Alliance chair Dr Michael Dixon. But the GPC’s Dr Brian Dunn believes the QOF provides the resources to ensure GPs can offer high-quality care, and judging it on costs threatens to take that funding away

Only radical changes to the model contract for salaried GPs will make it attractive to partners while preventing a two-tier general practice, warns Dr Clarissa Fabre. But Dr Judith Harvey argues that renegotiating the model contract would just be a way of making exploitation of salaried GPs appear legitimate

GPs have an ethical responsibility to identify patients with modifiable risk factors, argues Dr Elizabeth Goyder. But Dr Jim Newmark warns screening for pre-diabetes will increase the use of weight-loss drugs and distract attention from the need for wider societal changes

Paying GPs to review and reduce referrals is perfectly ethical, says LMC chief executive Dr Paul Roblin. But the GPC's Dr Simon Poole says rewarding reductions in referrals is grossly simplistic.

In uncertain times, it can be sensible to employ GPs on flexible contracts - as long as they are not substandard, says Dr Charles Alessi. But the GPC's Dr John Canning warns that too often, fixed-share partnerships exploit GPs and may simply be a way of avoiding national insurance payments

Dr Gurmit Mahay says email consultation will improve access, but Dr Trevor Stammers says the move will leave GPs at greater risk of legal action.

With proper safeguards, access to patient records can open up a new era of medical research in which GPs take the lead rather than relying on academics and hospital doctors, argues Professor Frank Sullivan. But Dr Mark McCartney argues that using confidential personal details risks undermining the doctor-patient relationship

The JUPITER trial showed statins have major benefits at far lower risk levels, says Dr George Kassianos. But Dr Andrew Bamji argues the benefits of statins are marginal in low-risk groups.

Dr Tim Scott says for far too long the formula has penalised practices in areas of high disease prevalence. But Dr Adam Pringle argues that although it is not ideal, scrapping it wholesale will make things worse

The extra money spent on PMS practices may be wasted on reports and renegotiating contracts, says Dr Hank Beerstecher. But Dr Jane Lothian says if there is evidence PMS practices get too much money, let's hear it - if not, let them get on with tailoring services to local need

The decision to supply an OTC antibiotic will be made in exactly the same way a GP would, claims pharmacist Colette McCreedy, but Dr Maureen Crown argues pharmacists are not diagnosticians may miss something.

Community pharmacist Noel Baumber says the system has been abused and it's time for a change. But Dr Lisa Silver argues that the one-stop shop service offered by dispensing practices should be a model for the NHS, not a relic to be phased out to appease the pharmacy lobby

Dr Richard Fieldhouse says there is no evidence that continuity of care makes any difference, but Professor Roger Jones argues it is a core value of general practice and - if lost in the rush to modernise - will be gone forever

It's a fact that the best out-of-hours services are GP-led and it's time for GPs to take responsibility for them everywhere, says Dr Krishna Korlipara - but Dr David Lloyd says the out-of-hours opt-out came at the right time

The fastest way to treat almost any lesion is GP excision followed by histology and referral if necessary, says Dr John Adams, but Professor John Primrose argues the quality of surgery done by GPs is poor, too often unsafe and usually unnecessary

Dr Stuart Laurie argues that NICE is preoccupied with promoting the use of the cheapest statin rather than the one that will best lower LDL, but Dr John Ashcroft says NICE guidance is right to focus on 40mg simvastatin first line, and should go further

Pharmacists are growing in their ambition and can play an important role in chronic disease management, says Professor David Taylor. But Dr Lal Mandal argues that moves to let pharmacists supply simvastatin and OTC antibiotics are all about profit rather than patient care

Two leading GPs consider the claim that an influx of women has unbalanced the workforce

Not only do patients like the concept of polyclinics, they also like them in practice and are already rushing to sign up, says Dr Tom Coffey. But Dr Rohit Goel disagrees, insisting that the Government refuses to listen to the mounting opposition from patients

Knee-jerk reactions to policy threaten the profession’s reputation and its relationship with patients, says primary care tsar Dr David Colin-Thome. Dr Robert Morley disagrees, arguing that challenging politically motivated, unjustified criticism isn’t playing the victim, but standing up for the profession

Competition between GPs for patients is an essential driver of innovation and quality and good practices should have nothing to fear from it, says Dr James Kingsland. But Dr Prit Buttar doubts whether practices will attract patients by improving quality of care - arguing they are likely to just offer extended hours instead.

Framingham equations overestimate risk and should be replaced by QRISK, argues Professor Julia Hippisley-Cox. Professor Paul Durrington counters that there are good reasons for continuing to use it in a modified form for now, counters

Practice accreditation is about professionalism and standardising quality – not a stick to beat GPs with – insists RCGP chair Professor Steve Field. Not so, says Dr Dermot Ryan, who argues it is a soulless scheme that will place a heavy burden on GPs and play straight into the Government's hands.

MP Dr Evan Harris argues that restrictions preventing provision of abortion in general practice are unnecessary, outdated and deny women the chance for integrated care. But Dr Andrew Fergusson counters that expanding access to abortion would be precisely the wrong response to the rising numbers undertaken.

Legalising assisted dying would weaken the commitment to palliative care, and blur the boundaries between easing terminal symptoms and hastening death, argues Dr Idris Baker. But Dr Colin Lennon disagrees, arguing allowing physician-assisted dying for patients who are suffering unbearably would engage doctors in the care of the terminally ill and improve standards

Patients in a 21st-century NHS are happy with and expect electronic care records, but before it is fully implemented the system must be robustly tested in GP practices, says Dr Jon Orrell. But Dr Lisa Silver is sceptical, arguing questions over confidentiality need to be answered before GPs get involved

A structured programme of cardiovascular risk assessment would be highly cost-effective and save 2,000 lives a year, says Dr Mike Knapton. But Dr Malcolm Kendrick strongly disagrees, arguing screening would fail to accurately assess risk and cause a multitude of adverse effects.

Access to GPs is getting worse and frustrating patients, argues Dr Michael Dixon. But Dr Peter Bower believes only a minority of patients value extended opening – and that for most seeing a doctor they know is much more important.

The NHS is changing rapidly, and GPs cannot afford to shun private sector partners if they wish to compete successfully, argues Dr Julian Neal. Not so, counters the RCGP's Dr Clare Gerada, who insists the private sector does not hold a monopoly on innovation and efficiency.

Nurses are as good as doctors at delivering many aspects of care and could take on as much as 70% of GP work, argues Professor Bonnie Sibbald. Not so, insists Dr Dermot Ryan, who argues that while nurses are good at following protocols, they are entirely incapable of the high-level problem-solving that is the hallmark of a doctor

The MPIG is disadvantaging most GPs as well as their most vulnerable patients, and action must be taken to phase it out, argues leading NHS manager Alastair Henderson. But the GPC's Dr Kailash Chand disagrees, arguing that getting rid of the MPIG would destabilise general practice and hit forward-thinking GPs hardest of all.

The RCGP's Professor Mike Pringle insists the system will be fair and transparent. But GMC member Dr Krishna Korlipara believes assessment by staff is an inappropriate way of judging clinical competence.

Professor David Nutt believes that psychological therapies lack the evidence base required for licensing drugs and carry hidden risks. But his views are opposed by NICE advisor Dr Stephen Pilling, who insists psychological therapies have been rigorously evaluated as safe and effective.

The decision to withdraw co-proxamol was cruel and has left many patients with inadequate pain control, argues rheumatologist Dr David Walker. Dr Peter Frith counters that most patients can be managed on alternative analgesia and that GPs do have options even for the most difficult cases.

GPSI services are likely to be more expensive than hospital care and may not cut waiting times or be more convenient for patients, argues Professor Chris Salisbury. But Professor Ram Dhillon disagrees, insisting GPSIs dramatically cut waiting times and improve care, and should not have to constantly justify their efforts.

The well note would streamline sickness certification and make life easier for GPs, patients and employers, argues Professor Sayeed Khan. But Dr John Canning disagrees, arguing that expecting GPs to assess eligibility for work would compromise their core role in making patients better and might put confidentiality at risk.

New risk tools are allowing community matrons to target patients more effectively, and their efforts are starting to bear fruit, argues the King’s Fund’s Natasha Curry. But Professor Ruth Boaden disagrees, arguing that matrons will not have any effect on admissions until they are available 24/7.

Professor Roger Jones believes the opt-out from out-of-hours care, along with resistance to extending hours, has left GPs looking lazy and greedy. But the GPC’s Dr David Bailey insists the out-of-hours opt-out was essential, and that it is funding cuts that are responsible for the decline in services

Drug switching schemes constrict a GP’s clinical freedom – and we still don’t know whether they are safe, says the GPC’s Dr Bill Beeby. But prescribing lead Dr David Russell counters that switching schemes are essential to free up resources, and are mostly run perfectly safely.

Private companies can enhance patient care by treating the customer as king, argues GP Dr James Heath, managing director of Aston Healthcare. But Dr Peter Swinyard warns there is a real risk that privately run franchises will disrupt the doctor-patient relationship.

Primary care tsar Dr David Colin-Thome says extended hours are essential to meet the needs of six-and-a-half million patients unhappy with their access to a GP. But LMC chair Dr Andrew Mimnagh argues it is unethical to take money from care of the sick to provide care for the worried well.

PBC is general practice's last defence against private firms, argues the NHS Alliance's Dr Michael Dixon – whereas Dr Jonathan Heatley counters that it is destabilising hospitals and has delivered GPs mountains of paperwork

Where GPs agree to work in polyclinics, they can provide a wide variety of services to patients without losing the personal touch, argues Dr Charles Alessi. But Dr Max Levy’s patients wanted nothing to do with a planned polyclinic, and he believes the proposals threaten the principle of personalised care.

Some partners are systematically underpaying their practice staff and keeping profits for themselves, argues healthcare management consultant Steve Williams. But GPC member Dr Terry John counters that GPs are just adapting to tough financial realities.

The CBI's Neil Bentley argues general practice has not responded to the needs of a modern workforce and must be overhauled urgently, but Dr Nigel Watson counters that change for change's sake will disrupt traditional general practice and prove detrimental to patients.

The debate moves on to the evidence base for switching, whether the switches being suggested are concordant with NICE guidance and whether drugs other than statins will be targeted next.

In the second part of our drug switching debate, the panel considers the appropriateness of PCTs pressuring GPs, use of incentives and the legal issues surrounding switching.

The eight panellists drawn from general practice, the pharmaceutical industry, NICE and ScriptSwitch, which supplies software to facilitate drug switching, consider the effect that the increasing focus on switching has on GPs'' practice and the doctor patient relationship.

The Department of Health, under both the current and previous government, has had an Orwellian tendency to dream up names for its policies that bear little relation to their true purpose.