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GP partnerships will be gone in ten years, says NHS England official

GPs’ independent contractor status will be ‘probably be gone’ within ten years, NHS England’s deputy medical director Dr Mike Bewick has claimed.

Speaking at the Westminster Health Forum conference in London yesterday, Dr Bewick said that the current organisational structure of primary care is no longer ‘sustainable’ or ‘desirable’, partly due to the ongoing GP recruitment crisis.

He added that he expects new provider organisations to develop within a decade because the current model will not serve the patients’ needs, adding that the difficulties of recruiting GP partnerships will consequently mean that ‘we’ll have to think of something different’.

Dr Bewick told delegates: ‘The current organisational structure of primary care is no longer sustainable or, increasingly, desirable. I am going to say just two things that I think are going to be true: one is that in 10 years’ time the term independent contractor will be anachronistic and probably it will be gone. And the second is that we won’t talk about primary care, we will talk about out-of-hospital provision and out-of-hospital providers.’

He also said that he expects each new provider model to accommodate around 300,000 patients - similiar to CCGs

‘In primary care at the moment, more than 50% of doctors are salaried,’ he said. ‘There will be a force majeure that will move away from a partnership type organisation because it will not serve them and equally when you can’t recruit to partnerships, it will mean we’ll have to think of something different.’

However, despite proposing a move to larger primary care organisations, Dr Bewick said that this would not be at the expense of local healthcare services.

‘I don’t think we should confuse that with not delivering healthcare by people you know in your locality. Localism is in my blood.  

‘We should be forming organisational mergers with either community trusts or secondary care, or with other providers from other sectors. Providing they have the values of the NHS at their heart, I am not too worried about who delivers but more how it’s delivered and the outcomes for patients.’

Professor Clare Gerada last year said that all GPs should become salaried in her last speech as chair of the RCGP, comments that her successor Dr Maureen Baker rebuked shortly after taking office,

 

 

Readers' comments (69)

  • Vinci Ho

    Kissinger , let's have a referendum on this.

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  • GP's will be gone, never mind partnerships

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  • Will not have functioning primary care or community care before this time thanks to the meddleing of the torries and the commisars.

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  • Dr Bewick speaks as if he has no part in this. On the contrary, general practice will be gone because he and his dirty cronies are driving the whole system hard in that direction to suit their personal ideologies/spites/agendas

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  • Una Coales. Retired NHS GP.

    Today I heard of a newly qualified GP accepting a salaried post for £6.5k a session, yes that's £52k! And wait another practice offered £6k, that's £48k. Ay dios mio!

    Make a plan B pronto!

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  • It's almost like it is nothing to do with them. The NHS has stolen our livlihoods. It is prepared for big business to move in , once GPs have been bankrupted.

    It seems there is no concern for the GP, should they lose their family's assets . He thinks we will dust ourselves off and work for peanuts for a private primary care provider.

    Given that treatment I predict most of our GPs will be patients, consuming the resources of the mental health team. I doubt they will be working in this country.

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  • The Agenda of NHS England is finally out in the open.

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  • Its hardly a secret. NHSE have been obsessed with economies of scale and this is part of that noise.

    The little thing they forget is cost, any model outside partnership is hugely expensive - including nurse led services.

    Berwick is a part of the problem. The medical education establishment also need to be blamed.

    If anyone's worked in countries where there is no structure you realize what NHSE are trying to create. The dogma of chaos - pure right wing fantasy stuff.

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  • Bring it on Berwick.

    EWTD
    Only one pension contribution
    No year on year organisational changes and hassle
    No need to take responsbility for a building or such problems.

    If you try and put forced evenings and weekends on us me and my GP wife will both be out of this country pronto.

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  • They will need 1.5 salaried GPs for every current partner in the UK.

    Let's see how they achieve that in a recruitment crisis.

    Divide and Rule lives on, propogated by NHSE QUANGO doing Govt's dirty work.

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  • Their plan is to replace the GP with nurses,HCAs and algorithms. So the remaining GPs will be given a list size of 4,000 +

    They think it will work. We know different.

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  • "...the difficulties of recruiting GP partnerships will consequently mean that ‘we’ll have to think of something different’..."

    No, it doesn't. Instead one could think about why there are suddenly difficulties recruiting to a previously popular profession (both with doctors and patients) and take action accordingly. Better that than deliberately making something intolerable and then "having" to think of an alternative

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  • This has always been the plan.

    Nicholson hinted at 'getting rid' of cornershop mentality, labour talked about reviewing independent contractor status, RCGP backed move to salaried work force. At least Mike Bewick has been direct about it BUT it is a recruitment crisis of their own making. It's amazing that GPs are basically being blamed for the recruitment crisis as well !

    There has been a clear strategy of;

    1. dumping as much as possible on GPs targetting partners in particular
    2. pushing partners to retire, quit, emigrate or sell up
    3. for those that want to serve their patients a list of never ending politically motivated and non-evidence based check lists are made which generates frustration and confusion forcing those GPs into early retirement.
    4. those practices that fold are going to be converted to temporary contracts thereby locking those lists from independent GPs.

    i suspect once all independent contracts are converted to temp contracts they (NHSE) will go after locums and salaried drs and set targets for them - if they don't comply they will not be hired or effectively blacklisted.

    within a few years we will all be salaried working for large corporations as it is 'desirable'. some may say a 'certain person' is a sell out as he would be happy for us to work for Virgin but not for ourselves. I won't say it though as i need to work for another 25 years.

    no point asking for a vote as we can rely on gpc, bma to look puzzled, raise thir hands up and put a motion on possibly saying something but backing down as they don't want to rock the boat as for alternative models - it's too late.

    RIP general practice - a once noble and respected profession :(

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  • There is so much to write about this article, I don't even know where to start.

    Yes - the sustainability and workforce issues are entirely down to successive governments, with their poor workforce planning, micro-management and exponential piling of on more work which is poorly defined in our contracts. Sadly, we have neither the leadership or representation to reverse any of this.

    The reality is glaringly obvious to me; NHSE have no interest in a quality service. If they think they can manage primary care health needs with a conveyer belt style of a few nurses at one end, a few physician's assistants at the other and a salaried GP in the middle, then they may also be able to turn wine into water.

    The knock on effect on secondary care will be quite spectacular with this model. Admissions, referrals, investigations....they will all sky rocket. Defensive medicine will become an even bigger monster and I dread to think who will be paying for this.

    GP Partners are a bit like stay at home parents; working endlessly, no terms and conditions and having round the clock responsibility. It's only when the parents go back to work, you realise how expensive child care is.

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  • The whole government agenda all along has been to enact a wholesale constructive dismissal of the entire profession:you make things so difficult that GPs have no choice but to leave.On the other hand there is a part of me,and perhaps this is my disillusionment speaking,that feels that doctors would be better served working in hospitals where the truly sick patients are.Most of the crud we see in GP land can be done by other professionals and dealing with crap has meant that we have become deskilled and lost respect with joe public.

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  • He did not say he wants rid of the profession. GPs will still exist just not the independent contractor model

    A bit of realistic introspection might be useful. It's no longer credible to credit all the positive things about primary to GPs and blame all the failings on others.

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  • 8:09

    Easy for you to say that but they are proposing to leave GP partners with huge liabilities while they move on to a new system.

    Do you think it is fair that a GP lose his house and life savings, simply because the DOH has decided they want another system ?

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  • Waits will grow, personal relationship with a GP will deteriorate.

    Sounds like a perfect recipe for more private GPs in future. Some patients will pay for this.

    Sound like dentistry in the UK?

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  • It doesn't have to be like this. If we stop fighting amongst ourselves it would be relatively straightforward to pull the plug on the NHS and move to an affordable Denplan like system. European co-payment systems deliver far better outcomes and they continue to look after their poor.

    We are actually quite a powerful lobby group if we stand united. The patients are far more likely to trust us than the usual ragbag of government contractors. However, if we allow the government to sell us to the private sector via the back door, costs to the taxpayer will rise massively because the HMOs require so much extra infrastructure.

    Fancy algorithms and practitioners will never be capable of managing medical risk and complexity which will be passed on to hospitals at greater cost. If this model was so great it would have been used extensively elsewhere but it's not. For many cultural and historic reasons, the doctor brand is way too strong for the public to trust anyone else with their healthcare.

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  • 'Dr Bewick told delegates: ‘The current organisational structure of primary care is no longer sustainable or, increasingly, desirable'

    I agree - The disastrous organisational chaos of NHS England and CCGs while destroying the few good parts of PCTs, with the consistent cuts in quality and funding have left things in a dire state.


    There is an epidemic of Ivory Tower former GPs and doctors who are destroying the NHS - and leading the path towards Private US style healthcare giants taking over Primary care for the profit of the lobbyists and politician who will end their careers with those turn coat GPs/doctors as directors on the boards of these companies.

    I predicted the move to privatisation back in 2004 and was dismissed by the GP leadership, and told it was overreaction, my the same people who believed and sold MPIG as guaranteed in perpetuity.

    Watch the Rats jump ship - just a sad prediction that will be ignored by the BMA and our representatives until its too late.

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  • This comment has been moderated.

  • Looks like we may be Last of the GPicans, my Partner friends. If we are to become extinct within a decade, I think it's only right we go down taking as many scalps of the enemy as we can, starting with the enemy within that is the current pulse power 50 (give or take a few notable exceptions). I would like to start with General Berwick, who seems to be talking (rather than sitting) bull.

    DGPP 1.5yrs

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  • This comment has been moderated.

  • Shaba Nabi... If as you say Partners are like kindly stay at home parents, toiling away to take care of their kids, a significant majority did manage that with cheap childcare by making the neighbouring parents chip in to benefit their own households, I am sorry to say. Its like the sins of teh parents descending on the heads of the innocent children. All good things must come to an end. For many, the whole workforce becoming salaried might make absolutely no difference to their current way of work, as thats what they are doing anyway. Lok at one of the posts where its mentioned that salarieds in London are now being offered a mere 6K/ session. A pittance for years of hard slog post medical school.The gravy train may be stopping, but the ones responsible, who made their pile, will be stepping off nimbly whilst the rest will be left stranded, hoping to thumb a lift from somewhere and limp home to retirement.

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  • Right. As a GP partner in my early 40`s where does that leave me? We own our building, and are in positive equity. Will the Goverment/ Big Medical buy us out? Surely the Goodwill clause would have to go also? Is there anyone looking at a Dental type setup also? I have heard of one practice that rebelled when taken over by a big company when told they literally had to wear the polo shirt, with the logo emblazened. I foresee a lot of retirements /emigration/no trainees, over the next few years, then us that are left, doing the same as the Dentists. By the way, we have refused to train Physcians assitants as requested by our local Medical school.. We believe poorly experianced stopgaps is not the way to go either

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  • i agree,
    its outdated model.
    should be sooner rather than later.

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  • Peter Swinyard

    Anonymous | Sessional/Locum GP | 10 September 2014 10:51pm - you have a point.
    The main sticking point is that private GPs cannot use NHS prescriptions.
    If ALL the doctors and practices in an area (like Swindon, or even West Swindon) resigned their NHS contracts and offered private services, I dare the government to deny patients their right to an NHS prescription. We are strangely in a position of strength at present as there would be no chance at all of NHS England being able to commission enough new APMS practices to cover a 250000 population at 3 months notice if all the local doctors said no. We could - and the economics are fairly straightforward - offer a year's care at about £150 per head - and then have the resources to provide half decent care instead of the mess we are left with now.
    What say you all???

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  • Its official:- GPs are the turkeys that voted for Christmas!
    Who would have thought 'GP Led' healthcare reform would lead to the destruction of the profession and a move from Family GPs to 'provider organisations'?@ Anonymous GP Partner 8.25am this announcement makes your partnership virtually worthless - what they expect is for you to take the loss to create the savings required! i guess they will then require the 'out of hospital providers to then take the losses to make the further savings required ad infinitum, as Foundation trusts and PFI projects increase their income ad infinitum!

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  • Either we should all be independent contractors and share the load of managing the business properly or all should be salaried and have properly trained effective managers in place allowing us to concentrate on the fantastically rewarding job with patients that we have been trained for.
    The days of cake and eating it are gone.
    We can't have it both ways.
    There are too many other professionals who can do a lot of our job now for a third of the money and everyone else around us can see this apart from us...

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  • The question I struggle with, is if there are not enough GP's to go around now (leaving Locums to charge basically what they will) how will this situation change if 'Bigco' take over?? Personally I would support some constraint on the amount Locums can charge, as they surely do nothing to help the cause financially and with continuity of care, and who has heard of any other 'self employed' person having their pension contributions paid for by their 'contractor' complete nonsense.

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  • Why is anyone taking what Berwick says seriously?
    He's a minor player - he does not set policy. I remember health policy managers talking about partnerships ending in the 90's. Its what they dream of because they imagine a docile passive salaried GP population, but they will be around for years. not because they're perfect but because the alternatives are far worse.

    Many more people will leave. There are so many doctors leaving the profession right now I don't imagine it will be difficult to find work

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  • Tanya Smith | GP Partner | 11 September 2014

    Quite wrong. Very few people can do our job. What people do is a very limited case mix with the legal liability still with a GP.

    Look at all the NP's or 'nurse consultants' - virtually none work independently and their productivity is very low. In effect their real cost per patient seen is often higher then that of a GP partner or hospital consultant.

    The problem is the changing demographic of general practice has introduced many problems which no one is willing to face up to. Losing continuity of care being the main one, the role of eportfolio in GP training etc

    If you don't realize our worth look at countries without primary care -the health economics side of things starts to collapse very quickly

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  • Bob Hodges

    Given the frequency of 'massive top-down reogansiations of the NHS', I still reckon GP Partnerships have got a better chance of surviving the next 10 years than NHS England.

    The irony is obviously lost on Dr Berwick.

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  • But in the absence of doctors willing to work the hours I have worked or at the rate I have worked ( quite sensibly I must add) the economic difference will be less and even a full time doctor is now only available for 50 hours of a 168 hour week we can't really claim amazing continuity....

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  • 11.49 The reason doctors are 'only' available for 50h continuous care a week is because we are now obliged to do huge tranches of work most of which is not real, hands-on medicine: QOF, appraisal forms, LES, DES, CQC, CCG, PPG, PSQ, unnecessary audits, - I could go on. Full-time doctors are literally drowning in paperwork and have to put in many more that officially recognised hours just to keep their careers.

    All this stuff dreamed up mainly by non-doctors comes at enormous expense to the tax paying public but there is no recognition of the damage it does to real patient care. You can hardly blame GPs for looking for a way out, this is entirely rational since we all have our own lives to lead as well.

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  • Dr Smith:
    Adequate continuity is not about being available a full week of 168 hours, as you should know. It is about ensuring there are enough resources available to manage patients, and allow those with ongoing medical issues to see a regular clinician. That means weeding out the minor illnesses to self-care, Pharmacy etc, or minor illness nurses.
    Continuity is an aspiration nowadays, because the public only care about what they can get free of charge, what they WANT, and not care about society as a whole....me, me, me. The suggestion that they should only be allowed to have what is needed ends in outcries and needless complaints.
    Aspects of what we do can be done by others, at lower salaries, but as already suggested in posts, they don't take the responsibility, and their experience and remit remains limited, in comparison. Often, they have recourse to GPs for back-up.

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  • Ivan Benett

    I agree, the days of sustainable independent contractor status are over. Might as well get used to it and wind down you capital account. The public will not support such variability in service provision as is the case at present, or resistance to change. Dr Findlay died a long time ago, and what follwed him is also dying. The public will want an out-of-hospital system that is public facing, that is responsive to their perceived needs, and integrated with other health and care services
    But, we will always need GPs, however organised and employed. So smell the coffee GPC, RCGP and partners. The pace of change is acceleration not slowing. Stop the populist rhetoric we read in these columns. Face the reality.
    I know some reading this column will get angry, bluster or be rude. Some will call for a strike or resignation, and other will imaging the grass is greener in Australia (it isn't, it's dry and brown).
    You can take out all your frustrations in these columns, but it wont change the truth.

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  • Ivan,

    I'm afraid the truth you speak off is manufactured by those in the power. And I count you amongst them from your work and your previous posts.

    I still believe partnership model can be saved and it will serve as a better health care model but only if the medical profession unite together. Sadly Ivan is right in pointing out it's as good as gone as you can see from the article, we have been betrayed by those the power.

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  • I disagree with the opinion expressed above but I am prepared to put it to the test. Ask patients what they want (including the silent majority rather than just listening to the vociferous minority) and spell out the practical options - local surgery, continuity of care and normal opening times v distant surgery, any time but no continuity. Should a fully-informed public choose the latter, it'd be interesting to see what happens to GP recruitment.

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  • I mean the opinion above the one above now (Ivan Benett)

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  • Peter Swinyard has raised the point that we could probably fund sustainable care for patients if we charged £150 per head.
    ...My calculations would put it nearer £200 per patient. If you take current expenditure on staff and consumables at 60% of gross practice income and a list of 2000 per whole time partner this would work.

    Even if expenses rose to 70% a figure of £200 per patient per year would provide some buffering for practices.

    I think these are real sums that could work if the issue of patients accessing NHS prescription subsidies was sorted out.

    In answer to your question Peter I think your proposal could work... it is high time that documented proposals for private practice were put forward to the profession. If only we had a functional union... sadly we only have the BMA!

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  • 4:10 £200/head sounds about right - that's about the same price as replacing a set of car tyres or a replacement mobile phone so is probably affordable to most of the population. This is a debate that needs to be had and not suppressed by the BMA.

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  • Why such righteous indignation? People (myself included) have been saying exactly this for the last 4 years at least. It`s not completely due to what GPs have done and it`s not completely due to successive incompetent governments but everyone who has meddled or adopted self-centred postures in the last 65 years has played a part in the likely failure of a model that was flawed in the first place. A bit of honesty might now be called for. Politicians should stop interfering and promising things to get votes and Practice Partners should stop pretending that they are the most cost-effective means of treating minor ailments or referring more significant health issues on to secondary care. While we are at it patients should also stop shouting about their rights while ignoring their personal responsibilities. The truth often hurts - irrespective of who is saying it. The only worry is that if we all wind up paying directly for healthcare I bet out taxes won`t go down even one penny!

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  • and there was me thinking that numerous studfies have shown UK GP to be the most cost effective. This talk is really going to tempt medical students to consider GP......................idiots the lot

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  • Ivan,

    usually I find your posts mildly amusing. I find this one offensive and insulting to partners.

    I agree with one of the posts above - if a non GP led workforce was desirable, why isn't the rest of the world doing it?

    There are only 2 options for the profession; retain independence or go private/co-payment. A totally salaried profession will be the end of us.

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  • Wouldn't be a problem if the salary pay matches the current partnership( potential ) earnings.
    As if that's likely to happen.

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  • Practice Partners should stop pretending that they are the most cost-effective means of treating minor ailments

    If anyone can demonstrate a more cost effective method they should , wait they have tried that repeatedly for the last 12 years and each time they spend more money then they would have done if they has invested appropriately in primary care - darzi walk ins being the prime example !

    So many APMS providers have handed their contracts in early because even with1.5 times GMS levels of funding they can't make it work.Shouldn't we be learning from this?

    People forget some of the support for health care reforms in the USA comes from some of the insurance companies who need to find a way of controlling cost.

    The reality is it wouldn't need much for partnerships to become attractive.There are plenty that are still doing very well its just that new trainees can't see that and don't understand anything about basic business and are being scared off.

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  • This is not a principal versus salaried argument. Divide and rule always works. The fact is the Deregulation Bill will allow US corporates to maximise profits by delivering dumbed down care provided by unqualified people. UnitedHealth and other multinationals are waiting in the wings to grab the profitable aspects of the NHS. The HSCA gives enormous discretion to CCG to decide which services to provide. As the transition to insurance model continues, insurers will try to attract the fit and young with free gym membership etc whilst the sick and old will be kept away by Personal Health Budgets until the majority have taken out their top-up insurance which they will need in the contracted NHS.
    QIPP 2009 sets out the sell off of 2/3 publically owned hospitals. The reduced access will be the driver for the insurance industry.
    We are continually being softened up by 'zombie' policy suggestions by the pro-privatisation think tanks and groups eg King's Fund and Reform.
    The evidence of the Commonwealth Fund report 'Mirror Mirror' ranked the NHS 1st for quality, access and efficiency. This means nothing to our media or greedy political elites who do the bidding of the Corporations. Their betrayal will be made irreversible with the adoption of the Transatlantic Trade and Investment Partnership (EU/US trade deal) which elevates corporations to the level of sovereign states and will sweep away protections on food safety, environment and employment rights.
    Medics need to get informed and become active defenders of the NHS themselves. Don't sit back waiting for the BMA or GPC to act. They have been shown to be impotent and complicit prior to 2012.

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  • bewick you are a judas and my views on you are unprintable
    keep on destroying general practixe while you creep for your knighthood.

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  • Una Coales. Retired NHS GP.

    As some GPs meet with their local MPs to fight for our profession, here are the cold hard facts.

    The BMA were supposed to be the doctors' trade union, the national voice to stand up for GPs but instead have chosen not to allow the right to be balloted on some form of strike action to GPs and so we must watch the end of general practice.

    Once upon a time, 1000s of Indian doctors were allowed into the UK (each year) but now only a trickle, ie the spouses of those already working here. The NHS cannot survive without the huge workforce support of IMGs. GP training relied heavily on BMEs/IMGs who made up 45% of GP trainees. Even now an IMG who passed MRCGP is facing hurdles to get CEGPR to work as a NHS GP.

    And so GPs only had until May 2015 to strike to save the profession....but the BMA is blocking this. And will not consider helping GPs transition into private practice or fight for semiprivate GP status or strike to renegotiate the NHS GP contract (one option is Peter's to increase the annual concierge rate from £60/pt to £200/pt) or allow private GPs to write a FP10 NHS rx.

    Our profession is doomed and when we have no control, do not feel valued, and are overworked and underpaid, burn out is normal.

    GPs have been abused for far too long and now the only way out is by making a plan B, an escape plan as we advise domestic violence victims and try to unblock their fear of financial poverty by leaving, as many GPs in their 40s are now trapped with HUGE mortgages (a 1BR flat in Brixton went for just under £500k) and some with added private school fees. Think outside of the box on how to supplement income to survive. A career in NHS general practice may not be financially viable.

    As for all GPs becoming salaried, I cannot think of anything worse than lay managers cracking the whip over GPs to work harder, faster, tick more boxes, performance manage, refer less and micromanage them day after day after day?

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  • The practice with worst health care outcomes were the pct led , therefore if you wish to get worse healthcare with huge spends eg like in America then I agree partnerships should go. Reg variability it's mostly due to patient populations and a patients postcode and mpig factors

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  • GP land is unsustainable, but not for the reasons given. It is unsustainable at £70 profit per patient year, with ever increasing consultation rates, a doubling in 12 years for the same/less pay. Even the USA is finding it hard to get primary care physicians because of escalating costs. Nurse practitioners etc are being tried, but until patients pay a small fee and/or there is a payment per appointment, GPs will fold. For certain. There cannot be a year on year increase in workload for ever diminishing returns. Berwick and his cronies are the cause of the problem, not the solution.

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