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At the heart of general practice since 1960

Jeremy Hunt, consider this your empty chair

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For weeks, Pulse has been asking the health secretary for an interview about his plans for general practice, but he has miserably failed to respond. Considering his claim to be the ‘most pro-GP health secretary for 50 years’, it is pathetic that he could find no time for the magazine most of them read.

And the Conservative Party manifesto is just as much of a let down. One of the only times GPs are mentioned is to press them to ‘come together to provide greater access, more innovative services, share data and offer better facilities while ensuring care remains personal’.

Inevitably, a few paragraphs later, comes a reiteration of the Tories’ myopic drive to open up all surgeries seven days a week – but this time with a tighter deadline. Let’s just ignore the contradiction of being ordered to provide more ‘personal’ care at the same time and also the glaring absence of the party’s longstanding promise to recruit 5,000 additional GPs.

To be fair to Mr Hunt, we have seen neither hide nor hair of his Labour counterpart either, and I wonder whether even if we did interview him we’d be unlikely to hear anything but the same old tired soundbites.

None of the parties’ manifestos addresses the GP workload crisis

Our zombie politicians don’t seem to get the demographic timebomb that is ticking under the health service. Even Labour’s big-ticket idea to spend £12bn more a year on the NHS by 2022/23 would barely touch what it will cost to treat an expanding and less healthy population by then.

Today, we sketch out what general practice may have to cope with by the time of the next election and it makes sobering reading. The average GP will have to work an extra session a week just to keep up by 2022, and this does not include the additional admin and other work that a larger and sicker patient list will bring.

Even if the unmentionable 5,000 extra GPs were delivered, the profession would still have to work harder. The real solution – as GPC chair Dr Chaand Nagpaul explained in his speech to the LMCs Conference last month – is to reduce GPs’ workload.

But don’t expect any help from politicians. None of the manifestos (and I’ve read them all) addresses the GP workload crisis. Some initiatives in the GP Forward View may help, but the profession is losing faith that anything will change.

So what is the solution? I am no sage, but the profession needs to try to put limits on its workload. The plan to ballot all GPs on simultaneously closing their lists could be a start. I first suggested a year ago that practices should be able to declare a ‘black alert’ in a similar fashion to hospitals and refuse to take on new patients.

Sure, it would be controversial and largely symbolic, as practices are likely to be forcibly allocated new patients by NHS England anyway. But it could send a powerful message that general practice cannot safely take on more patients until the Government sorts out the GP shortages, funds practices fairly and drastically reduces workload. And unlike mass resignation, this would not put GPs’ livelihoods in danger.

If Mr Hunt (or his Labour party equivalent) doesn’t care enough even to have a 20-minute interview, they are not about to come to the profession’s aid if they win the election. GPs are on their own and need to start taking control of their own destiny.

Nigel Praities is editor of Pulse  

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Readers' comments (8)

  • Just do it.....

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  • We should all agree the limits of safe working and stick to them. Nobody could disagree with that approach.

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  • Just Your Average Joe

    Sorry - for once I disagree, as closing lists to just get them allocated by NHS England is a pointless waste of time.

    Closing and seeing the rising numbers without care would make headlines and force politicians to acts as hundreds, thousands start to struggle to find care - embarrassing the PM and politicians to do something to save face.

    And the BMA/LMC conferences wasted an opportunity to do this before the elections - forcing it to the top of the agenda politically.

    BMA couldn't organise a p!ss up in a brewery, for fear of upsetting the DOH.

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  • I work in an area where there is a very realistic prospect of tens of thousands of patients without a GP. Reallocation won't work at that scale. The answer is simple. We do what the rest of the planet does and accept the need to co-pay for some services. The bulk of risk eg cancer and heart surgery will still be born by the tax-payer. However the over 65s have vast amount of wealth locked up in housing that is under-utilised. Mrs May recognised the need to use it to pay for care with the £100,000 care cost limit - i.e. the state is insuring a portion of peoples inheritance. People will be forced to use equity release plans if they wish to stay at home. Likewise this equity could be used for quality of life enhancing things like hip replacements and so on that the tax-payer is already unable to fund. GPs simply need to arrange themselves into organisations ready to manage these new resources on fixed capital budgets. We could call them Accountable Care Organisations...

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  • Redirect excess demand to a&e. Stop asking patients to call back tomorrow. If they particularly wish to see a GP then it is up to the patient, not for us to suggest this to them.
    Win back control of your time for yours and your patients sake.
    Simples
    Fund GP don't fund GP. It's up to the system.
    Our job is to be honest that we are doing our best and then not 2 minutes more!

    - anonymous salaried

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  • Vinci Ho

    21 May 2017 1:50pm
    The certainties and unpredictabilities of an extraordinary general election Part One


    ''The people of England regards itself as free; but it is grossly mistaken; it is free only during the election of members of parliament. As soon as they are elected, slavery overtakes it, and it is nothing.'' 
Jean-Jacques Rousseau, The Social Contract 
.................................. 

Some really long thoughts before I could write this comment. The time is about right as all parties had made pledges through their manifestos. Some critics would say these pledges are promises never to be delivered. As Rousseau alluded , an election was merely a game of politics to grant people power to dominate others . He , hence,advocated direct democracy rather than representative parliamentary politics . While I cannot totally agree but this is still a very good substance for academic debates. 
But we have extraordinary circumstances right here , right now . The EU referendum last year , by definition, was an exercise of direct democracy(though only on a single issue)which did not come often as far as political culture in the country is concerned (Scottish independence referendum was arguably only voted by people living in Scotland). 
Rather than providing solutions, this exercise of direct democracy generated more questions for us to think about our future and coming generations. A revolutionary idea always comes with prices: resignation of a fully confident prime minister , severing a long term relationship with our neighbours(people called it a divorce but that logically ,should require agreements to go separate ways from both sides!), economic uncertainties with a depreciated English pound(with pros and cons) and an early call of a general election while many people are probably exhausted mentally. 
Ironically , we need to revert back to indirect democracy and let our politicians to 'mop up' the mess made by this result of this EU referendum. 
So it goes back to the old , boring question, ' which party am I going believe?' 
If you are die hard fan, you perhaps have an easy answer(or not ??). Or if you are convinced by the media polls , the winner is too obvious even though there has been some catching up by Labour in recent days.The odds offered by the bookies are like : 6 to 1 for Corbyn to be PM , 10 to 1 for no majority win , 20 to 1 for Labour majority win and they are not interested in bets for May to be PM. Given the results of the recent local election , there should be no second guess technically and Tories should be preparing themselves for the exuberance and even 
debauchery of a landslide victory. 
So is that it? 
................................ 

''This is the best reason to learn history: not in order to predict the future, but to free yourself of the past and imagine alternative destinies. Of course this is not total freedom – we cannot avoid being shaped by the past. But some freedom is better than none.'' 
Yuval Noah Harari, Homo Deus: A Brief History of Tomorrow 

From Home Secretary to Prime Minister , May remains in the comfort zone of a technocrat , strong and stable easily . She is long way from being charismatic and visionary (at least superficially) . Denying the existence of 'Mayism' somehow shot herself in the foot when one started to compare with long serving PMs like Thatcher and Blair. In a way , one has to respect her 'honesty' because quite frankly, the Tory 'manifesto to win big majority' was stitched up by her aides. The changes in social care funding could potentially become their ' Achilles' calcaneum 'shot by Paris in the Trojan War. 
My mate Simon said ,'she does not have any children and is not qualified to be a PM!'. My take is while it is unfair to dig into personal matters , it is important to understand how our elderlies see their own as well as their children's future. There is a Chinese saying,'when there is a new policy from the top , there will be strategy to counteract from down below.' The threshold of £100,000 after which you have to pay for your social care without a ceiling (the total cost was capped at £75,000 currently, a policy from Cameron in 2013) will simply enforce old people to rethink and sell their properties to cash out and give away anything in excess of £100,000 to their children and relatives. This , of course, can generate uncertainties or even rivalries amongst family members . As GPs long enough in this business, how often did we come across similar stories when our elderly patients die? Ultimately, people would not let the State retrieve this money after death . 
One would wonder why this policy even needed to appear on the manifesto. The answer perhaps goes back to the single objective of winning a majority of seats in House of Commons so as to produce a strong and stable leadership and accordingly, would deliver a 'good' deal on Brexit negotiations. A landslide fallacy can be negated by a landslide victory. So technically, for May , she needs to win back votes from UKIP(relatively easy now) and confiscate those from Labour supporters (and the undecided). Somebody called her the 'Red Tory' and indeed ,her views on the Just About Managing (JAMs) might sound like justice. The truth is she had to succumb to her true colour with no freedom. On Brexit , she had to surrender to the far right brexiters in the government. On domestic issues , she ended up with a row with her Chancellor(rumours suggested he swore down the phone),as there was no alternative to raising tax or national insurance to solve a genuine problem of social care funding. Thanks to Cameron again with his 2015 manifesto. 
On NHS , she dared not use a different health secretary , burying the head in the sand for all the crises on going in the health service . Repeating all the rhetorics used by Cameron is the best she can do. On education , she loves the old Tory ideology of grammar school and clearly drew blood with the ex-education secretary (well entertained by the cat-fight stories about how much their pants and handbags cost!). 
May be , just may be , as Enoch Powell once said , 
'For all prime ministers , their human flaws are inevitably amplified by the stresses in office , eventually end up as failures.' 
At least,I now do believe Auntie May is not Auntie Thatcher 2.0 , just as Uncle Trump is never Uncle Reagan 2.0. 
.............................. 
Trying to move on with lives after the local election , Labour simply produced a manifesto to 'please' . It is always easier for the oppositions if the ruling government is dogged by all sorts of contradictions. Clearly , the distraction of Brexit is perhaps so far reaching that May and her cabinet are putting more doubts in people's mind. 
But once again , history sticks(especially if people involved in the stories are still alive). Corbyn and McDonnell are both haunted by their old selves . The former cannot shake away from his affiliation with anti-nuclear campaigns and still stuttered on the question whether he would 'press the button ' in life and death crisis . The latter's faith on Marxism(he wanted to call himself socialist now) is questionable. And both were named in a The Telegraph's report(19.5.2017)about M15 opened a file on their links to IRA. 
While the prime minister and her party are willing to continue austerity on public sectors with low taxation , Labour is to open the cheque book with at least higher corporation tax . Typically, the latter wants to swing the pendulum all the way to the left with policies like nationalising the mail , rail and energy firms. Even my mother-in-law would say the answer to these is simply raising the tax. Question is how desperately have these domestic issues deteriorated over the last few years? And , yes, Brexit is once again blocking in the way as far as solutions are concerned. 
Ultimately, it is about the lives of common people. This general election cannot be just about Brexit. In fact , recent surveys suggested the 'fever' amongst voters is dying down . 
Interestingly , even The Economist published a critique on McDonnell's attachment on Marxism(13/5/2017): 
'Labour is right—Karl Marx has a lot to teach today’s politicians' While the author clearly supported a landslide victory of the conservatives,absolute capitalism will harm people and the economy. Quoted from the article: 
''the number of listed companies has declined at a time when profits are close to their highest levels ever. Concentration is particularly pronounced in the most advanced sectors of the economy '' 
'' Average wages are still below their level before the financial crisis in 2008 and are not expected to exceed it for several years. The rise of the Uber economy threatens to turn millions of people into casual workers who eat only what they can kill.'' 
The pay gap between company CEOs and ordinary workers is widening and middle class is on its way to extinction. 
Bottom line is 'do you believe a strong and stable government only for the sake of Brexit will be up for these more essential deep-seated domestic issues?' I don't have the answer. 
Confucius said ' one cannot stand if people do not trust' ,Analects. For modern politics, it is perhaps more about who and what you trust the least . 

PS : one has to excuse my relative lack of attention on Lib Dems and UKIP. The former is struggling with their mission of redemption and atonement as far as the young voters are concerned. The latter , mmmm, internal fightings with actual physical brawl ,only ex-MP went through mutiny twice and a short lady leadership of only 18 days ,tell you all about the virtues.

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  • Vinci Ho

    04 Jun 2017 10:38am

    The certainties and unpredictabilities of an extraordinary general election Part Two


    Originally chose today , 4th of June 2017(four days from the general election) , to write this comment for my emotional baggage every year on this date since 28 years ago....... 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1836939/pdf/bmj00242-0061.pdf 
But adding to the list of atrocities against humanity and civilisation in history book , another terror attack happened in London last night ,less than two weeks since the Manchester evening area bombing incident. Early figures suggested . Six people were killed with about 48 injuries. All three attackers were shot dead by police. 
Violence had become a recurrent haunting every time we had a big election or referendum. (Once again , I would mention the name Jo Cox . ) This latest London attack had a resemblance to the Champ Elysees incident in Paris before the first round of French presidential election in April. 
The reflex question is whether we , as a country, have done enough to protect ourselves from these violences as well as stopping an ongoing 'world war three under the cover'. How much resources should have been invested in police , security, intelligence and military? There is no straight forward answer . Perhaps liberty and globalisation had brought prosperity in some parts of the world but liberty did take equality (social , cultural and religious) for granted .The resultant human differences were allowed to ferment into division and prejudice. Arrogance and bigotry provide a catalyst to actions against others betraying civilisation. Then the reflex action is the rise(or return) of protectionism. A vicious cycle is created as less international cohesion will make individual country more vulnerable to more violent attacks. My impression is foreign and domestic issues are inseparable and interrelated.Hence , one cannot take the other for granted. The words, from one Manchester victim's family , were:'open its eyes' ,as far as the government is concerned. 

    ................................... 

    Since the prime minister , to everyone's surprise, called for this general election, numerous serious incidents took place . The attack on 22/3/2017 on Westminster bridge and now virtually becomes a distant memory but was in fact , the preface of this horror book of terror . 
This general election has to be the most extraordinary in UK parliamentary history given all the circumstances...... 
28 years ago today , thousands of people were killed in pursuing true democracy 5000 miles from here. Yesterday (3/6/2017) , our established democracy was threatened by extremism once again. 
................................ 

Went yesterday morning to watch the first performance of Wonder Woman in 3-D IMAX. She was the only strong and stable woman to me as an acne stricken 14 years old teenager . Linda Carter was immaculate but this latest version played by ex-Miss Israel(as well as two years of military service) ,Gal Gadot , ticked all the definitions of 21st century superhero in a chaotic real world . Not surprisingly, the film is currently banned in Lebanon. 
Purely for entertainment, the film was charismatic and charming but more importantly, deep messages resonate at different levels as far as justice ,war and humanity are concerned . Human conflicts are not just about getting rid of one big bad guy or the rise of a single hero.(sorry about the spoiler). 
The final message of the film still echoes in my ears , especially after the terrorism we have been exposed to : 
''it is not what you deserve but what you believe'' 
I hope there will be a high turnout on 8th June...........

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  • Vinci Ho

    The certainties and unpredictabilities of an extraordinary general election Part three

    This general election has become an event horizon where the gravity is so condensed that the warping of space-time virtually turned five weeks into five or even fifty years in our 'real world'...........
    The number of serious incidents taken place in this 'short' six weeks(since the PM announced the date of election)was incredible and unprecedented.

    Firstly , the cyberattack on NHS exposed how inadequately the government had invested in IT system of the health service. It fortified our message to the public all along that the so called 'investment' in NHS by government is a camouflage for real time cuts and withdrawal of funding commitments. The PM was too busy with her election campaign but also conscious of the poor reputation of her health secretary that she ordered her home secretary to brief the public instead . Amber Rudd has subsequently become a household name as she proved herself to be the doppelgänger of Auntie May on numerous other situations .
    The whole funding of resources in NHS had become a sugar coated poison with the word 'investment' on the surface and 'cuts' in the core. In similar tone , one can imagine the underlying agenda on reading carefully the Naylor Report about NHS properties .The health secretary , of course , was a strong protagonist.
    https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/607725/Naylor_review.
    I can understand some colleagues who had involved with commissioning in CCGs ,would have felt obligated to fulfil a duty of utilising taxpayers' money effectively and efficiently . Efficiency saving might have been a silver bullet at the very beginning after the legacy of fat bureaucracy created by previous governments(Labour included) . But there is always a threshold that one cannot go below before the core of a system will be jeopardised . I would not dispute that there are still some wastage scattered around in the health service but the truth is the line of this threshold has been crossed by clandestine cuts made by this Tory government . One one hand , it is pushing the myth of more utilities or quantities (e.g. GP appointments) will improve satisfaction and quality of services(in fact , the ideology of quantitative changes leading to qualitative changes is part of the Dialectic Materialism of Karl Marx!)
    And on the other hand , it wants to play a 'smaller state' by withdrawing funding commitments consistent with its philosophy that economy is far more essential than public services of our society. Sadly and obsequiously , critics like Sarah Wollaston has to keep herself quiet in this critical time of a general election for the sake of her party and its leader . Once a Tory, always a Tory , I suppose ?
    The bottom line is we , medical professionals, should not bear the responsibility for the politicians of how resources( money , manpower , expertise and time simultaneously) would be provided . The arguments about huge national debts mounted are academic and forever going .Japan had been in recession for over 20 years since 1990 with only just a glimpse of recovery recently(the Lost Decade). It had not given up looking after its own people domestically and it has remained as the third world largest economy (as per nominal GDP). The economy of China may be very strong as one can perceive but both official and unofficial debt figures are beyond imagination and so are the amount of money retrieved from corrupt officials. Needless to talk about the debts US is bearing all the time , I believe UK will still remain as fifth largest economy in the world.
    If there is a political will , there is a political way . Unfortunately, this Tory government has a political will to pass the responsibility of a failing NHS to the medical professionals as the most respectable, Julian Tudor Hart concluded in BMJ.

    .............................

    Then the story of election campaign was taken into fast lane . The Manchester Evening Arena bombing and killings on London Bridge took us by surprise repeatedly and the extraordinary circumstances certainly changed the nature of the narratives of all political debates. Controversially ,Corbyn questioned the relationship between the government's foreign policy in this war on terror and the recurrences of these terror attacks. In the last few days , the questions are circumventing the required number of police on the streets to deter these violences.
    The PM defended the cuts of police number on the street under her as Home Secretary and claimed that number of crimes had declined as well as police had been working more effectively and efficiently. Sound familiar to us , GPs?
    The other issue is legislations to be changed so as to apprehend potential extremists sooner rather than later and the strong and stable voice of the PM declared the will of changing human rights laws for terror fight .
    To me , any politician can put forward a draft to bring changes in legislation in House of Commons tomorrow. But building up a strong police(armed and unarmed) force need time and resources. If you do not have the means to look after a baby properly, the child could suffer malnutrition and disease sooner or later. If a normal baby presents to us with some initial symptoms e.g. fever , it is open to debate how serious you take this symptom to prevent further complications. Which issue is more essential, I would leave it to the readers to make that judgment.
    My own question to the PM is ,however, if you could say 'enough is enough' on these terror attacks , why wouldn't you admit 'enough is also enough' for the attacks of the government on public services funding?

    Last ,but not necessarily the least , the so called power surge in British Airways IT system leading to thousands of passengers stranded in airports ,opened up the question of whether it was down to their services outsourced to cheaper providers abroad . That was blatantly denied by their charismatic CEO(reminds me of Agent Hunt) . More importantly, BA belongs to a larger airline group , IAG, as this is the social norm of ' huge is better than big ;big is better than small' these days after globalisation . Again , sounds familiar to us ?
    Truth is private sectors always copy the behaviour of how a government treats the public sectors. If cheap is to be better , Cheap is Better. Anybody recalls the name Capita?
    Ironically , these passengers are still under protection because of EU legislations before we reach the deadline of Brexit. If I remember correctly , Mr Davis said the task of simply transferring the EU laws into British legislations would be straightforward.

    ..................................
    If your heart believes it will work , as difficult as removing a mountain to create a land in the sea, there will be an eventual day of success.
    If your heart does not believe it will work , as easy as snapping a twig from a tree , there will not be a time of completion.
    Sun Yat-Sen

    So , what do we believe so far about this general election? What do our political leaders believe ?
    There are some 'facts':
    (1)All polls suggested Tories to win although the lead was slashed down to four to five points in some polls.Then the possibility of hung parliament was mentioned in a Yogov poll last week and it suggested Tories to fall 18 seats short of majority. Other polls insisted the lead was still around 10 points.
    (2) What about bookies(depends on which one):
    Auntie May as PM stands at around 1/5 Uncle C as PM at 11/2 or 7/2
    Tories majority of seats around 1/5
    No overall majority at 11/2 or 5/1
    Labour majority at 25/1
    (3) Niel Kinnock , alongside other anti-Uncle C Labour MPs,told The New Statesman: "There is no honest measure of success and failure other than success equals Labour gains, Tory losses and at least a tight finish with possibility of a minority government. Failure equals Labour losses, Tory gains and an increased Tory majority."
    (http://www.newstatesman.com/politics/june2017/2017/06/neil-kinnock-success-labour-more-seats-and-possibility-governing) .
    (4) The front page heading of latest edition of The Economist was
    'Britain's missing middle' (3/6 -9/6 2017). This reinforced my belief that general practice in U.K. should always be driven by centre ground politics and this explained the predicament we have been forced into by this government. Interestingly , the editorial had declared the magazine will vote for Liberal Democrats.
    (5) One conservative candidate standing for re-election in South Thanet has been officially charged by CPS for overspending in 2015 election. Auntie provided her 'nurturing' and said ''The Conservative party continues to believe that these allegations are unfounded. Craig Mackinlay is innocent until proven guilty and he remains our candidate.” But Uncle C reminded us the independence of our judicial system and no comment should be made in an ongoing court proceedings.

    .................................
    Who and what are you going to believe?
    Ultimately, it is about people having a normal and happier lives . I yet to see any party's manifesto fulfilling this goal. Pulse was spot on to call them 'zombie manifestos'. As I said before , it is no longer about who and what you trust the most , it is about who and what you trust the least in modern politics.
    Perhaps ,William Beveridge's five giant evils had never gone away but simply transformed itself into a 21st century version . That is ,in addition to a war of terror(WWIII under the cover)........

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