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Ten-minute consultations 'must go', says NHS England director

The age of 10-minute GP appointments ‘has got to go’, as the limit is ‘unsafe’, a senior director of NHS England has said.

Speaking at the main debate rounding up the Pulse Live conference in London today, Dr Mike Bewick, NHS England’s deputy medical director, said this must ‘undoubtedly’ happen.

However GPC chair Dr Chaand Nagpaul said GPs could not lengthen consulations without reducing patient access to appointments.

Responding to a question from the floor, Dr Bewick said: ‘I think the age of the ten-minute appointment has got to go, undoubtedly. As a commissioner, I think it is unsafe as well.’

‘I think you have got to manage what comes in through the door as well, at least make an attempt to put something in that stops people getting through in cases where self care would have been more appropriate.’

‘I think that requires training, as an issue for practices, not necessarily for individual GPs, and probably a training issue for larger providers of general practice.’

The BMA voted in favour of abolishing the 10-minute appointment at its annual representative meeting in Edinburgh last year, declaring it a thing of the past, and GPC chair Dr Nagpaul, who was also on the Pulse Live panel, said: ‘Ten minutes is a total insult to so many of our patients… I would like to offer 15-20 minute appointments but if I do that I would have to tell them that they have to wait two weeks to see me.’

Questions from the floor also focused on reducing expectations and demand on GPs from patients, to which Dr Nagpaul responded that he would like to see schools educating children what to expect from GPs, as well as how to manage a cold.

He said:‘Demand management and self-care is very important – educating patients and the public about how to use a limited resource effectively and responsibly. I think children in school should be educated about the role of GPs, the role of the pharmacists, and actually how they can manage colds and sore throats themselves.’

Readers' comments (58)

  • Vinci Ho

    It is good for Kissinger to play the good guy and say what should have been said long ago.
    But where is the commitment and actual investment to make this happen ?

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  • The whole debate is meaningless, some patients need 30 mins, but others only need 2-3. We need to run flexible systems, that is the challenge

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  • Chris Kenyon

    Longer consultations will mean appointments per GP so we will need more GP's whatever (as we will need to also be on the phone keeping out things that don't need to be seen). We are constantly being told about a looming manpower crisis - large numbers of GP's retiring in the next few years but trainee places not increasing. It doesn't add up, it can't happen.

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  • Dr Mustapha Tahir

    One cap never fits all! The NHS bosses never think so!!

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  • The RCGP has been calling for longer appointments for years. Good to hear NHS England is on message. Wait a minute, though how to fit the same number of patients into the working day to maintain access
    Now where did Hermione put her "time turner"?

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  • Drachula

    Yes, I need a time turner too!
    More investment for more GPs and prescribing nurses - ours is excellent and we hate it when she is away on hols!

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  • Bob Hodges

    Give me just a little more time, and our love will surely grow!

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  • 15 minutes should be the standard we all aspire to now. We need to be brave enought to get on and just do it - it actually works really well.
    If you are still getting 2 -3 minute appointments your systems are not working - a GP should not be seeing those in 21st century - they should be elswhere or not in the system at all.

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  • I disagree, lots of practice do telephone consults lasting less then 5 mins , you can't really solve stuff in 1 appt anyway.
    Follow up appt can be done in less then 5 mins , eg blood test normal, prescrbing contracpetion etc etc
    Bp review,
    Obviously for complex problem you need longer and flexibility is key which frankly is far more important and works much better.

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  • Everybody blames the patient - absolutely wrong!!!
    It us - our tools and our expectations - professional and paymaster.
    The classical patient with single problem, GP diagnosis and advice and treatment fit nicely into 7.5 10 or 12 minutes - which ever suites you best.
    It's the agenda from behind- QoF, guidelines, check lists etc... that add to the length. The new generation of computer software is also a major consumer of valualble time - both looking for information and the burden of record keeping - both adding 3 -4 minutes before and after consultations at worst.
    Mike Bewick is absolutley correct - in this complex multiple co-morbidity world 10 minutes is no longer safe.

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  • As Geoff Schrecker (30 April 2014 6:37pm) has already commented the entire debate is meaningless as the amount of time we actually spend with the patient can vary depending on the problem.The real agenda here is to permit patients to discuss more than one problem during the consultation and to eventually penalise those GPs who refuse.This obviously has time and resource implications for us all.

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  • Balint (1950's) - 7 minute for the patient
    Pierera Grey (1996) - 40 minute per year
    Nobody seem to have explored Denis's great idea in depth - may it's time to ressurect it and be more truly hollistic and safe and sensible and effiicient and proactive..... I could go on....Our thinking is 60 years out of date....

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  • All parties will be happy if we have a contract that pays per consultation time 10 min or 20 min - patients chose depending on how many problems s/he has, doctor/ receptionist can extend 10 min to 20 min depending on complexity and then claim ( Aussie system allows that to happen). To me it sounds more fairer than current bottom less unlimited contract, I propose this to morning session at Pulse live but speakers seems to think that this is too revolutionary !!!

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  • Sounds like NHSE should put their money where their mouth is re negotiate the contract pay per consultation, even better pay by the minute time spent with the patient.You will need a lot more GPs,Youls need a hell of a lot more money.Will you get any benefit,not without controlling demand.Which planet do these people live on one with limitiless time and limitless pockets full of money!

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  • Una Coales

    Why should patients learn how to self manage minor ailments when they can pop into their GP surgery and see a GP for a free checkup, free prescription and free refills?

    Ever wonder why patients are discharged from hospital or sent out from outpatients with a hospital prescription but do not fill their prescription in the hospital pharmacy (as they would have to self pay) but instead take it to see their GP to exchange for an FP10 to get meds for free?

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  • I'm sorry, which planet is Dr Beswick on?

    You cannot train the practice staff to triage appropriate and inappropriate attendances. If you could, NHS111 would have worked. You can train clinicians to do it - there are system such as Doctor First but as any caller all get clinical contract, strictly speaking it's not reducing burden of work for practice.

    As pointed out longer appointment is a pie in the sky without funding and work force to go with it. Can we please have a realist at the helm and less of ideologist please.....

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  • I think people in the helm has few more years in the NHS (more than 80% of them will retire in less than 5 to 7 years), hence leaving this mess for all of us who has to work at least 25 years before we can think of our retirement! call me ageist, but this is the reality, we need new blood in the system who have guts to challenge age old not fit for purpose funding allocation formula.

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  • No-one, GPC, BMA or any other body should be advocating increased work-load in the present financial crisis faced by primary care. There should be no barrier at the family doctor's door-if you want this-redesign the whole service.

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  • More of everything. You know what will happen - it will be 15 minutes but 45 consultations each day or more as people get older - we could be soon seeing 50+ patients a day - almost 11 hours of consultations. Safe - what is safe ? I have done over 700 weekends starting at fri 9 am to mon 5 pm - 80 hours with little or no sleep. This NHS has never ever been safe - it has always run on doctors working to the bone. The ULTIMATE question is this - WHO should define safety ? Our union ? Like pilots and bus drivers ?
    Remember and like it or not - it was the European WTD that regulated junior hours. Left to our so called Union they would still be doing 120 + hours / week as a lot of us oldie goldies have done. Who will define safety in patient numbers seen and consultation times. If not us, Why NOT ?

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  • Una Coales

    Being a NHS GP partner is like a double edged sword. You are self employed so exempt from the EWTD of 40 hours but at the same time employed by govt and subject to unilateral variation of the contract with a trade union whose hands are tied up in legal knots and rules. The only way out is individual or en masse resignation from a contract that will either drive you to an early grave or bankrupt you.

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  • You can't have longer consults without more resources!
    This is a joke.
    10 minutes isn't a 'limit', it never has been, just some sort of spurious guideline to enable appointment lists to be conveniently constructed.
    If everyone in my practice got a 15 min appointment, we would be fully booked by five past 8.
    I would then have to instruct my receptionists to divert more and more patients to a/e and the local walk in centre - which I would be happy to do!
    Patients need what they need, whether it's 2 minutes or 30 minutes, you just have to let them get on with it.
    Those with unmanageable lists of problems can be asked to rebook and I will do the rest next time.
    This is just more madness from more idiots who are not GPs.

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  • I would love to be instructed by NHSE to offer 15 minute consultations as a routine as long as there is a genuine assessment of the resources required.
    Please remember that, within a partnership, there are different agendas. Those that are happy to fire fight and do the minimum to increase their own income and those who are prepared to give patients longer and earn less.
    The iniquity in the system is that the more you give, the less you earn. This needs to be addressed.

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  • Just because that thinker without a thought norman lamb moans that he can't get all his agenda into 10 mins we have to offer 20 mins . People have problems getting appointments as it is . Double the workforce or go private .

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  • 10min appointments are unsafe - thats the question - so what is the answer ? And please dont make it 'working smarter'.

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  • Una Coales

    @9:01 the answer is to address demand. Start charging £10 a GP appointment to reduce demand. And start charging £100 for an A&E visit as Ireland does to stop overflow to A&E. And if left wing socialists chant that the public deserve free medical care at point of access, you chant right back that GPs deserve fair working conditions and fair pay, we are not gonna take it anymore!

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  • I'm not usually the first one to pipe up with conspiracy theories but doesn't all this look suspicious!
    ...Suddenly patients are allowed to book any length of appointment they want with no corresponding reduction in access targets.

    This would mean that GP surgeries would have to provide more appointments assuming several patients do book the longer ones (i.e. open longer to provide the same access).

    This could easily mean that smaller practices are in breach of contract and forced to close and larger ones have to employ more doctors (not a financially viable prospect) or work into the weekends and further late evenings.

    I would advise that we do not engage in this discussion without the removal of current access targets.

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  • Una Coales - just so nice to hear someone speak out. But there is a clique in there that stops the majority view. I know, I have been there.
    GP list size has to go. It is outdated. It used to be 20 appointments at 5 minutes in the whole day, followed by interminal on call.
    Now it is 40+ at 10 minutes on an upward spiral to 50+ 15 minutes and so on.
    ICS gives us some freedom, but list sizes do not reflect workloads.
    If we retain NHS ICS status, bad as it is, we have to go to a numbered appointment system. Or we resign.
    Our take home pay [ worked out by my accountant ] is now, on average, £ 3.00 here in NI.
    It is time to resign. The Eire model is readymade and easy to copy.
    GPC, please ballot. If we stay in the NHS, at least it the majority and not the GPC decision.

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  • £ 3.00 per consult that is at 60 % consults and 40% paperwork.
    40 consults x 3 = 120 . + 80 for paper work per day = £ 200
    200 x 22 days per month = 4400 per month x 12 months = 52000 x 2 [ tax, NIC etc ] = £ 104000 a year.
    In NI we don't even get that, it is about 84000.
    In reality, we do not even make £ 3.00 per consult.

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  • Interestingly here in Ireland the government (who are even more anti-doctor/GP as they are in the UK!) are trying to force us to sign a contract for free care at the point of delivery for all under 6 children which is unsignable and potentially ruinous for most practices and they don't believe us when we tell them that we will be overwhelmed with demand for appointments despite plenty of evidence from the UK that demand is hard to manage when there is no disincentive to attend your GP. Why not when it is totally free.
    Personally I would be in favour of everyone paying a small fee for each visit (around the £10 or €20 mark) which for those genuinely in hardship could be claimed back through the social welfare system, but politically it's a non-starter it seems.

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  • Although there are many merits to charging.What I imagine would happen is that there would be many exemptions and then this would undermine the system very quickly.

    Charging could work but it would have to be an absolute rule no exceptions

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  • Why charge patients for GP appointments when they have already paid via NHI deducted from their wages!
    Instead, why not charge those who DNA. We had 97 last month in a 5,000 patient practice. If this was applied throughout the country, there would be no need to even consider charging patients to see their gp which I re-iterate, is NOT free. We are all paying for the service.

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  • Una Coales

    @1:56 you have a point. The Australian health minister is announcing today that they cannot afford free health care on the current scale (Medicaid/Medicare).

    @2 pm yes I would also support charging for DNAs but that would again mean a change to the NHS contract to allow charging patients.

    The bottom line is the way things are going, there will be no GPs for the NHS and the only ones who stick around will be private GPs charging full price for consultations.

    With a semi private system, the poor and elderly get reimbursed by the state, so this cuts down on trivial visits, and thus reduces demand as it is UNSUSTAINABLE currently.

    Yes I can see some try to abuse the free medicaid/medicare system but without some provision for the poor and elderly, we would not be a modern society?

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  • The unemployed/unemployable classes should be entitled to emergency health care only

    Those who are paying taxes should have a choice if they want to go private or opt into a National Health Insurance Scheme.Either way the insurance payments should be tax deductable

    The retired ex-taxpayers who opted in the NHS during their working years can continue with free health care (+/- co-payment) provision.Those who opted to go private must pay if they decide to swap over to the NHS in their old age.

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  • Anonymous | Practice nurse | 01 May 2014 2:04pm

    Do you send appointment reminders? If you have the patients mobile phone number you can send an SMS reminder which can be extremely effective in reducing DNA's.

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  • Surely patients should get the time they need, giving them ten minutes now only to have them return in a couple of days with the same problem is pointless.
    In the time it takes to triage patients by phone, they could have been seen at the surgery anyway. If triage takes tow or five or ten minutes, that is the time the doctor has had to spend with that patient so surely a face to face appointment costs no more time and allows the GP to do a visual examination ... which should be the first part of any examination.
    Rather than stipulate times, why not allow the GP to decide what is right for each patient, after all, he /s he knows the patient better than anyone?

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  • Just Your Average Joe

    I never believed in a fee paying NHS - but am slowly seeing where Una Coales is coming from.

    10 pound a visit to GP and 100 for A&E to prevent overflow from demand is the straw that will break the NHS philosophy forever. Unfortunately thanks to Tony Blair and successive governments and the Mail stoking up expectation and demand - the flood gates of access are open.

    Without closing access requirement - so cough/colds and sore throats are left to develop beyond the <24hrs that patients now seem to wait before they ring to get appointments, the workload is unmanageable.

    If you don't charge everyone fairly - then those who get subsidised would still flood the system with demand for minor self resolving ailments or to get the free script of OTC medication, because they can and will demand the right to do so.

    We don't have to charge patients - we could simply announce to the DOH a unilateral variance in our contract - we now will bill them 10 pounds an appointment and 75 for a home visit, and let them have a national DOH advertising campaign to reduce demand - let the government fix their own mess.

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  • Stop paying A&E for seeing minor ailments.

    No money no incentive to see patients. Just like minor injury units no longer see under 2's, major trauma and MIs, the patient is seen where they are meant to go.

    Hospitals will just have signs up saying this is an A&E, we don't see anyone who hasn't been in an accident and is not a major emergency. If they still turn up then see them and charge them 100 pounds.

    The waiting rooms will be empty in a month.

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  • well well we never thought 10 minutes was long enough..what a genius! so lets do 20 mins on average instead..oh hang on when do we do repeats scrip requests hospital letters referrals check results..oh of course lets do it through the night..between seeing patients 24 hours with urgencies of convenience...gps dont need sleep.
    well dr bewick i would like you to pilot this......

    talk about stating the obvious..it cannot happen though like so many other pieces of obvious motherhood and apple pie.
    the only solution is more gps.
    end of.
    (plus a cull of 90 per cent per cent of the nhs 'management' structure....more useful retraining as gps)

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  • I find this really annoying. We run an open access service to our patients - busy but patients love it.

    On a Monday I can see about 45 patients - at 15 mins each - that is nearly 11 hours of surgery alone in the day!!!

    Some patients simply need a sick note (you might argue it will give you time to discuss issues) or a virus or a pill check (should be nurses!)

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  • @3.12 am - please go and get some sleep. Your alarm will go off in 3 hours!

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  • Una Coales

    I spoke to a GP who is still alive and was present during the infamous 1966 GP strike. He said their bargaining tool then was to refuse to sign any sick notes.

    Scroll forward and in New Zealand doctors went on strike and refused to sign cremation forms. You can imagine that the strike only lasted 48 hours as the mortuaries filled up.

    If the government has bound the BMA in legalities preventing a strike, then we need trade union barristers like John Hendy QC to take on government as every trade union should have the right to strike or take action to ensure fair pay and fair working conditions,

    If you think it is greener on the other side, I just chatted with a young female who has completed a summer bank internship and said bankers are in the office from 4:30 am when the markets open and are there until 9 pm and then go drinking with clients until 1 am so many live on 3 hours sleep! And the money is not as good as it was 10 years ago (when our economy was in the black).

    I guess the bottom line is that the only way out is being your own boss and go private so you are not stressing over intolerable work demands, bureaucracy, reducing pay, etc. When there is a housing shortage, house prices go up. When there is a GP shortage, govt cuts GPs pay! Until then, we can demand a ballot for en masse resignation as we are no longer doormats!

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  • I retired much earlier than I had planned( to live a less materialistic but greatly more satisfying life) mainly because of the rise of telephone triage. The only way we could manage demand for appointments was to triage all appointment requests. My all time record was 130 calls( plus scripts,results,the odd home visit and walk-in). I used to lie awake at night worrying about all the wrong decisions I might have made. It seems inevitable that as demand grows more practices will be forced into this way of working. Prescribing over the phone without face to face assessment is asking for trouble. I sleep much better now, going to bed knowing I'm not going to be gambling with someone's life.

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  • I'm not sure why GPs are against being independent private contractors with a contract with the patient directly and payment directly or indirectly (insurance schemes etc). Why are we so adamant that we must stay with the NHS contract when it is causing more harm than good?

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  • Because many of us still believe at heart all should receive half decent health care?

    It may be hard to believe this as partners are always going on about the money. But the truth is, most of us are not trying to be mega rich on back of being a GP - we ask for appropriate income as a professional and at the moment we often look to balance our income with service levels so that both the patients and provider (us) are satisfied. In order to do so, we always have to look at money.

    Many of my regulars will not be able to afford any form of health care if each of them was liable for it, even at subsidized amount.

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  • One of my anxieties when I see my GP is the fact that I need the appointment in the first place.

    I have a variety of health problems and MY GP is the very best indeed, but I feel guilty asking for his help because he works flat out.
    At times my GP looks exhausted but always is every kind and caring offering me the very best of care ... but i do sometimes feel he is so overworked that going to A&E is a better option taking the pressure off my GP!

    How sad it is to have to do this, but who is actually looking after the health of our GP's? Some GP's may be single parents, are they expected to abandon their children to visit someone with a snotty nose, or an old lady in care home, that could quite easily be brought to the surgery?
    If GP's treated their patients like the NHS teat GP's they would be facing disciplinary action!
    The government have promised patients so much but have hope in hell of delivering ion that promise so are happy to blame GP's for not being able to work 24/7.

    Time the GP's had a seat in parliament and shook that lot up!

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  • Una Coales

    For surgeries on the brink of bankruptcy and closure, GP partners be aware of TUPE, as employers you may be liable for the redundancy of your long-serving staff even when left with no option but to close and liable for the ongoing tax liabilities for the next year or 2. So instead of gratitude after decades of service to ensure access for all, you will have to pay out of pocket in the end for the privilege of having served the NHS.

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  • gps have always been very flexible,practices have always been doing large amounts triage and have been trying to educate patients.
    as ever the problem is nhse..living on another planet,not resourcing and in fact reducing primary care resources,encouraging consumerism and access to minor issues that should be self managed ,facilitating by multiple short sighted means reduction in numbers.. by encouraging early retirement emigration lack of recruitment etc etc.
    the first requirement of enlightened good management is to spend time at the coal face to see reality before even opening one's mouth.i understand dr bewick does one or two gp sessions a week..if so he must work in an extremely untypical practice.

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  • Una Coales

    http://online.wsj.com/news/articles/SB10001424052702304279904579518273176775310?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304279904579518273176775310.html

    Here is an article in the Wall St Journal mirroring what is happening to NHS GPs. In the US, govt health insurance called Medicaid/Medicare is mandating a while series of electronic health record tbox ticking that is driving physicians mental and cutting reimbursements. The context is the same as in the UK. Both nations have HUGE national deficits and are looking at ways to control government public expenditure on health. Here the govt health insurance is called the NHS and over the pond it is called medicaid for the poor and medicare for the elderly/disabled.

    Poignantly this physician writes of retiring early and suggests physicians not accept any medicare/medicaid patients. This is similar to us asking for an en masse walk out from the NHS GP contract.

    At the end of the day self paying patients means you are in control of your own business and keep your ICS. The longer you remain working for the public healthcare sectorr, the more you are likely to feel stress as the government continues cutting expenditure.

    Plan for more pressure and mandates to be dumped on remaining GP partnerships, to force them to amalgamate and move into new builds as feds to then be able to decommission them and commission APMS or US/UK healthcare giants to take over the government burden.

    A ballot for en masse resignation is to ask government to give GPs a lifeline, semi private, state+private sellf pay, else the public will only have 100% private care and who will look after the elderly and the poor?

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  • Una Coales

    Apologies for the typos. Can't find my reading specs and typing on an ipad. That's 'whole' series, 'box' ticking, 'sector' and 'self'.

    Fascinating rebuttals by another physician in Once more unto the breach http://theincidentaleconomist.com/wordpress/once-more-unto-the-breach/

    This physician compares the burden put on public sector physicians to that put on public sector teachers in the US.

    The bottom line is either we need a stronger trade union led by the likes of a Bob Crow pushing for en masse resignation or strike or we vote with our feet.

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  • Una Coales

    http://youtu.be/5cvHgGM-cRI Dr Pamela Wible US family physician explains on Tedx how 400 US doctors are now committing suicide every year due to the stresses of bureaucratic govt medicaid/medicare mandates and box ticking to receive reimbursements rather than face to face human patient encounters.

    This is happening with the NHS. Her solution was to call a town hall meeting and ask the public what their ideal GP surgery would look like and within a month created it! Before the overhead was 74% paying for the large building, the practice staff, admin, etc. and now her overhead is 10% as a sole practitioner and she offers 30-60 minute appointments via online booking! No queues of patients inside and outside the building! She even says she does not turn away anyone who cannot afford to pay! So like lawyers she mixes pro bono with PMI and self pay income. She can even work part time!

    I surmised that if she charged $70/30 min appt and offered 8 appts x 30 mins or 4 hours a day, she could earn £100/h or £400/day or £100k per year for what amounts to part time work!

    All NHS GPs have access to approx 2000 patients each on their list and they could write to them and say they are now going private and easily make double the living seeing 200 patients. The dr/pt ratio would be a lot safer and GPs would be happier.

    Her ideal clinics have spread like wildfire across 50 states of America and is saving doctors' lives from burnout.

    It would certainly increase GP recruitment if budding GPs saw a future for general practice in the UK and the public would be safer.

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