Monday, December 22, 2008


Lots of fuss this morning about this.

Apparently all us GPs are to receive training to recognise dementia much, much earlier. Once we've diagnosed it we will send people with it to memory clinics for treatment.


Well, I've been diagnosing dementia for years.

I've been referring for years.

Support services for people with early disease are rudimentary. Most people with early disease are able to live completely independently.

The disease is characterised by an inevitable and inorexable decline. There is no treatment that works and even the treatments which are said to slow the progression of the disease have recently been said by the government to be too expensive. Just talking about the possibility of having it scares most people rigid. The vast majority of those with it die of something else well before the dementia itself gets severe enough to carry them off.

Which rather leaves me wondering what the point of this announcement is.

Oh wait: Parliament is in recess and Christmas is coming up...

Wednesday, November 12, 2008

Oh dearie dearie me

The saga continues.

Other blogs have covered this in much more detail.

I would expect the investigation to be robust, but we will see.

Thursday, October 30, 2008

Bless her.

6 years old, known her since birth (the joys of GP).

Flare up of eczema since the heating went on. Not too bad, but obviously irritating.

I say to Mum "Increase the frequency of the diprobase to three times a day."

Little one pipes up, very loudly: "Oh Doctor Brown, I HATE diprobase!"

"Why's that then?"

She of course goes bright red and looks at her feet.

"S'itchy on my back mumblemumblemumble"

"Want to try a different cream?"

"Sss, plsss..."

"Ok, lets try something else than diprobase then."

Cue big grin and another satisfied patient.

Her first steps into an independent relationship with her health.

Great job this, innit?

Monday, October 13, 2008

Sick notes

Specifically with reference to getting them from hospital doctors. The guidance is available here.

This is NOT a rant against my colleagues in secondary care. Hopefully some of my readers are secondary care docs. Some of them may learn something from this post. Or they may not. (grandmothers, eggs, natch...)

There are 2 main types of sick note patients will come across. The Med3 and, less frequently, the Med5.

The Med3 is the white certificate you might obtain from your GP if you need more than seven consecutive days off work. Its duration can be open (specified typically as "two weeks" for example) or closed (when a specific return to work date is recorded). It cannot be backdated. The patient must be physically seen, in the flesh. Telephone consultations, although they seem to be ignored by the DWP, actually fall outwith the regulations governing these certificates

A Med5 has two possible functions. One is for a doctor to backdate a certificate, but only if he or she has seen you in the recent past and for upto only a month from the date of signing. The other is to provide a certificate (without necessarily seeing a patient) on the basis of a recently received (within a month) letter from another doctor. In this instance, the certificate cannot be backdated (again the DWP seems to ignore breaches when this inevitably happens).

As a GP I do a lot of these.

Not infrequently, patients come to see me after operations or hospital stays to get one because they have not been furbished with one at the time of discharge or they have been given one for a shorter period of time than will obviously be necesary (for example 1-2 weeks after a hysterectomy rather than the 6 weeks virtually everybody needs).

This irritates me. Greatly.

I would imagine it occurs mostly because of ignorance of the regulations by hospital junior doctors. I would hope that it isn't just laziness.

Because you see the guidance is quite clear:

The duty to provide a statement rests with the doctor who has clinical responsibility for the patient at the time. Hospitals are required to provide all certificates for social security and Statutory Sick Pay purposes and doctors' statements for both in-patients and outpatients who are incapable of work. The Med 3 should be issued on discharge from hospital where a hospital doctor advises a patient to refrain from work, and the doctor was attending and had clinical responsibility for the patient at the time this advice was given. In such cases the Med 3 should be issued for an appropriate forward period. Responsibility for issuing further certificates rests with the doctor who assumes clinical responsibility for treating the incapacitating condition. In cases where the GP has not taken over responsibility for the incapacitating condition, responsibility for issuing further certificates will rest with the treating clinician.

I am sure that, at times, junior doctors are advised by others (perhaps administrators or nursing staff on the wards) that sick notes are not available, or that "we haven't got any". It certainly happened to me when I was training.

I have written twice this year to senior colleagues at my local hospital advising of these regulations. The second time I offered to go and do a session at their twice-yearly inductions for the junior doctors. I didn't receive a reply to my second letter, but there you are, some people are just rude. Such is life.

However, given all the problems around the accountability of the GMC (as well as to it) together with increasingly draconian messages regarding probity coming from it, I suspect that in future, I will be regretfully apologising to patients as I do now. But the focus will shift from an apology that my secondary colleagues have somehow abrogated themselves of responsibility for the sick note and provide it whilst steaming quietly in my chair, to apologising that I may not provide a note for them and directing them back to the hospital consultant. I will show them a copy of that paragraph, and will give them a copy to show the consultant.

Hopefully the message will sink in, bit by bit. I will repeat my offer to educate if the opportunity arises (which sadly, I suspect it will). Letters will be written, patients will be inconvenienced.

Does that make me stroppy? I don't think so.

Monday, August 11, 2008

Doctors and freedom of speech

Story here.

This has been covered by other medical bloggers. I don't blog as much as I used to because I often feel generally pissed off with the way the NHS and the Medical Profession generally seem to be heading.

But I am really very cross about the way that the events leading to the Pulse story have been dealt with. Go on, click on the first link in this post if you haven't already read it. Professor Paice's comments about free speech are quite enlightening.

The Jobbing Doctor has also posted that various out-spoken bloggers have gone quiet. That worried me. But I'm not anonymous, never have been.

So we can say what we like, as long as we mind how we say it, or by implication, who we say it about?

Well, as an alternative, how about I say what I like and you put up with it?

This isn't Stalinist Russia. It isn't even the USA. If you don't like it, I do believe you can bloody well put up with it.

Despite the fact I am a professional, I am also a citizen of this country and am entitled to express my opinions to whomsoever I choose in whatever way I see fit within the bounds of the law.

Not the bounds of others sensibilities.

I haven't really said much about MMC/MTAS and the utterly ridiculous and reprehensible way in which our junior colleagues have been dealt with, and I specifically include the young surgeon in Scotland in that comment.

Someone should be held to account.

It will be interesting to see the GMC's attitude to the reporting of Donaldson to them by RemedyUK.

And I don't think its any coincidence that is out now. I would very much like to see a definite statement about it from both the Department of Health and the GMC, specifically with regards to their level of involvement in the project.

But I won't hold my breath that anything of any substance will occur.

Wednesday, July 23, 2008


I've just realised that I haven't updated my blog-roll for ages.

I tend to use Google Reader to keep up to date with those I read. Many of my favorite blogs are not listed on my roll.

If that's you, sorry.

I will try and update the roll soon...

News today

Several front page-type news stories today.

The main one is the release of a report by the Chief Medical Officer, Sir Liam Donaldson, on revlaidation of doctors. In principle, I think is a "good thing". But I am a little worried about the details, because that is where the Devil is. And, in my (not so) humble opinion, Donaldson has failed the profession several times in recent years, the most reprehensible episode involving his lack of accountability for the MTAS/MMC debacle.

What I would support is an annual exercise to check that we are keeping up to date that is more robust than the current system.

What I would have difficulty supporting is anything which involves excessive paper chasing. We GPs are already "answerable" to a couple of dozen different organisations and quangoes, from the PCT, to the Health Care Commission to the GMC, never mind the fact that people can also take us to Court, separately and additionally to all the other ways they can have a go at us.

And I'm not even going to mention the abomination that is Iwantgreatcare... (bugger, I did, didn't I?)

The next story is about GPs prescribing antibiotics: again, I'm in two minds about this one.

I don't prescribe antibiotics at the drop of a hat, and guidance will add to the credibility of my already rather paternalistic and uncomrpomising argument when a patient is insistent that they need "something or I'll get pneumonia" ("You'll need them when you have pneumonia, at the moment you don't.")

On the other hand, the premise that GP prescribing is part of the problem with the rise and rise of the so-called superbugs such as MRSA doesn't have a lot going for it. Dr Grumble and the Jobbing Doctor have already blogged about this failry recently, so I won't bore you further (though I do commend their blogs to you, go and have a read). Suffice to say that the Government should be looking elsewhere for solutions, rather than looking for scapegoats.

Finally, this story: I (and my colleagues) am (are) missing the diagnosis in patients presenting with HIV. Apparently there should be more widespread testing (well, I can't argue with that). But I should also be considering it in anyone presenting with a flu-like illness.

Do these people have any idea whatsoever how many people I see with just that story every week? Even in a good week its half a dozen or more. In a bad week it'll be in the fifties or sixties.

There are 7000 new case of HIV diagnosed every year. That compares to almost 114,000 deaths form heart disease, over 33,000 deaths from lung cancer and a prevalence of diagnosed diabetes of almost 4% of the population (not counting those patients who we don't know about yet).

This suggestion by the National Aids Trust, while laudable, is another example of Ivory Tower speak: they may be experts in their field, but they are patently not experts in mine. It would make much more sense to me to be dishing out free condoms and promoting safe sexual practices.

Finally, I am grateful to the Jobbing Doctor (good grief, 2 mentions in one post. I'm not stalking you, JD, don't panic...) for bringing to my attention something that isn't my fault.

Wednesday, July 16, 2008

Access and Choioce survey 2007/8

Results are out for this survey, available here .

You can search for your own surgery by post-code or street name.

Here's a brief summary of our results (bear in mind that this survey predates the start of extended hours and also predates us setting our website + services up, total respondents 269 out of 5950 patients, so 4.5% of our list):

  1. Happy with phone access 96.6% (last year 92, PCT average 90.4, number happy/number not happy 255/less than 10)
  2. same day or within 48 hour access 98.1% (94 and 92.5, 157/ <10)
  3. Advanced booking more than 48 hours away 58% (29 and 70.7, 47/34)
  4. Book with specific GP even if means waiting longer 89% (84, 88, 105/13)
  5. SAtisfaction with opening hours 90.6% (87, 83.4, 241/25) (although thats 9.4% of sample, that's less than half on one percent of list)
The questions with smaller numerators were usually asked after a different question, so eg my number 3 was after this question: "In the last 6 months, have you wanted to book ahead for an appointment with a doctor?" and only those people who had wanted to, had had to answer the book ahead question.

I'm really pleased, especially with the pre-booking figures. Thats a big improvement, just from telling people as they come in to the surgery. That should improve even more over the next few months; for example, since we launched the website in March, almost 200 people have signed up for the EMIS Access services we offer. We should be at or beyond PCT average by the time of the next survey.

And 5 simply justifies our stance of not doing extended hours, in my opinion.

Of course, the redoubtable Mr Bradshaw thinks otherwise:

"The survey results are a real measure of success for those GPs and their staff who have listened to what their patients think and who have responded with even better access to GP appointments. I congratulate those practices.

"I also want to thank the two million patients who took the time to respond to the survey as these results show the difference patients' feedback can make to the services they receive.

"The NHS now needs to respond to what this latest data is telling us. It is clear patients increasingly need access to primary care at more convenient times. Since the survey took place over a quarter of GP practices have begun to offer extended opening hours and from 2009 the 152 new GP-led health centres around the country will continue to improve provision."

I'm not entirely sure how one can suggest that "it is clear patients increasingly need access to primary care at more convenient times" when obviously so many people are ALREADY VERY HAPPY!

But then, that's why people trust me and not you Ben. You are a politician, whereas I am (now, what was it you said? Oh yes...) mendacious and misleading.

Tuesday, July 15, 2008

Having a laugh

I've just seen Doug. Doug is 79 and has COPD. But that isn't why he came in today.

Doug has had non-specific back pain for some time. No worrying features, other than the fact it isn't resolving. He tends to manage it with simple analgesics.

He has seen a chiropracter recently. The chiropracter thinks Doug may have osteoporosis, based (I assume) on the X-rays that he took. So I'm arranging a DEXA scan to see if he does. He doesn't have any risk factors, but its possible.

The chiropracter also found what he thinks is an abdominal aortic aneurysm. I hadn't had reason to examine Doug's belly before, so I did so today. Sure enough he has a small pulsatile mass just below the belly button.

The trouble is, Doug is tall and skinny, So I'm not sure that this mass is of any significance. S I've requested an abdominal ultrasound scan. I explained what I'd found and why I think we should scan it. I also advised him that I might want to refer him to our excellent local vascular surgery clinic if the result shows it is larger than 5cm.. If not, I will just keep an eye on it myself. For the time being anyway.

Then Doug said something which surprised me a little: "Well, that's a relief."

I asked him what he meant. I thought perhaps that I'd explained something badly. But I needn't have worried.

"I thought you were going to tell me I was pregnant!"

We shared a snigger. He left happy.

Thursday, July 03, 2008

GPs to blame - again

Ben Bradhsaw has accused me and my colleagues of operating a gentleman's agreement to stop patient's having the choice of practice.

Of course he doesn't actually offer up any particular evidence of this.

But he's a Minister, so it must be true.

Quite why he hasn't advised the Competition Commission of the facts that he obviously has to hand I don't know. Agreements of that nature would be a serious breach of the law. Indeed our current contract regulates us such that, assuming we have an open list, we must register anyone within our practice area who wants to register. If our list is closed, we can't take on new patients. That's it, nothing complicated.

Unfortunately the BMA response has been less than robust, describing his comments as "nonsense", rather than "libellous" which is probably what I would have said.

Its all part of the "choice" agenda that they are pushing so hard. If patient's have choice, all will be well with the world. I keep saying it, but patients are less concerned with choice and more concerned with good, local services.

But that doesn't fit in with the current agenda to get private companies involved in health care, particularly Primary Care (for which read General Practice).

And as for the practice in the South of England with only 2 patients.

Really, Ben?

Where is it then?


Put up : evidence in public of these agreements, evidence that GPs are restricting choice, give it to us, make it public.

Or shut up.

Monday, June 30, 2008

BMA position statement

Downloadable pdf.

Also the text of aletter from the BMA's patient involvment group:

Letter from Juliet Dunmur re. Privatisation of GP practices:

Dear Hamish

Privatisation of GP Practices

After comprehensive discussion by the members of the BMA PLG, I am writing to you about our fears as patients, and on behalf of patients, about the changes being implemented in the way General Practice in England is organised, funded and run.

Our concerns are based on the change from self-employed GPs and partner-led practices to market-controlled, profit-driven clinics; on the issues the DH has chosen to prioritise when commissioning and remunerating General Practice services, and in the way it has chosen to address these issues. We are apprehensive that these changes and the new focus of Government will lead to a decline in the quality of patient care for all patients in England.

The PLG has identified a number of major concerns, many of which we believe you will share, and also makes some proposals on what the BMA might do to address them. Our main concerns are:

The voices of older, less able, more ill and less vocal patients and carers are not being heard.

The current Government focus on longer opening hours masks and ignores the needs of many patients who, ironically, are the people who are more likely to be ill, make more use of NHS services and more likely to cost the NHS more if their needs are not addressed early on.

Opening hours is an easy goal to measure, cheap to provide and amenable to private providers. However, this focus gives the appearance that patients’ needs are being addressed while ignoring patients’ other needs and preferences. Evidence from the Picker Institute shows that continuity of care and confidence that your GP will act as your advocate are vital for patients, particularly those with long-term conditions, and elderly and disabled people. We are concerned that government is selectively focusing on objectives that serve their political goals and are pushing forward service redesign based on this, rather than on what patients want and need.

Our proposal is that the BMA should challenge the government to develop policies for providing general practice services that meet the needs of the all patients, using evidence from the Picker Institute.

The unilateral imposition of change, instead of flexibility according to needs in a particular area.

We are concerned that government is increasingly imposing a ‘one-size-fits-all’ pattern of service delivery instead of allowing local variation according to local need. The BMA often quotes the figure that 84% patients are content with practice opening hours. However, this overlooks the needs of some sections of the population for whom current opening hours are inappropriate, and who do not use General Practice as a result, giving the potential for ill health through late diagnosis and intervention. Similarly, the policy to compel every PCT to set up a polyclinic, regardless of what services currently exist in the area and their acceptability by and convenience for the local population, shows a blatant disregard for patients’ needs, and the needs of the general community served by general practices.

Our proposal is that more evidence of how GP practices are already being flexible, meeting the needs of local communities and engaging with their patients should be made more public. We feel there should be more public acceptance of variability of service provision in general practice by the BMA: promote the good practice and be open about the areas where it is not so good.

The new GP arrangements are a step backwards for community health and participation and a psycho-social approach to care.

The consolidation of GPs into large, anonymous clinics, and the move towards private companies running GP services is likely to lead to a significant reduction in the development of initiatives to involve local communities in improving their health. As Sam Everington has demonstrated, GPs who see themselves as much a part of the community as their patients and the other residents are more likely to make a commitment to that community and develop innovative means of improving public health. Those patients less likely to use conventional services, who are also of lower socioeconomic status, non-English speaking and who have long-term conditions are likely to suffer as a result of reduced community commitment from profit-led provider companies.

Moreover, care focused on fulfilling the minimum requirements of a low-cost tender and subsequent contract will almost inevitably lead to a more biomedical model of care rather than a rounded, medico-psycho-social approach that is accepted as necessary to improve health and encourage people to participate fully in their health care, their families, jobs and communities. The issue of increasing health inequalities needs to be made forcefully.

Our proposal is that the BMA should engage with patient and consumer organisations also concerned with health inequalities, offer your support to their efforts to make such needs known and campaign with their support. The voice of the powerful doctors’ organisation along with them would make a real impact.

GPs will lose even more clinical autonomy

We fear that GPs operating in new profit-driven and cost-sensitive private companies that are commissioned to run clinics and practices will have less autonomy to utilise their clinical training and judgement when offering care to their patients. Referrals to secondary and tertiary providers are likely to be even more curtailed than they are now through PCTs.

We also worry that these new healthcare corporations will not want their employees (GPs) to prescribe expensive drugs or treatments, even if the GP feels that it is the best decision in her/his clinical judgement. This scenario is likely to lead to a more widespread postcode lottery when it comes to referrals and treatments, and the gradual decline of clinical freedom as more ‘expensive’, clinically-led GP practices are replaced by profit-driven and cost-dependent corporate medical employees.

Travel and access to general practice

One reason why patients like a local GP surgery is that travel to them is short and easy, a particular concern for people with long-term conditions, older people and people with young families. The proposal for universal polyclinics is likely to take away this neighbourhood access and continuity of care. The RCGP’s recent briefing by their PLG sets this out clearly.

Our proposal is to join forces with the RCGP and their PLG on this. The RCGP has sent out some excellent factsheets on Lord Darzi’s review of the NHS which give an overview of the benefits of GP surgeries from both the doctors’ and the patients’ points of view.

In conclusion

We believe that services can be improved by building on the strengths of general practice: on personalised care; healthcare close to home in the heart of the community; co-ordination of care; GP practice teams able to deal with multiple conditions and integrate different types of care; aftercare for patients after discharge from hospital; lifelong care; prevention of illness.

At present patients have free access to their GPs under the NHS. We have seen what happened to NHS dentistry: when top-down measures were imposed on dentists, many abandoned NHS service completely and chose to work privately in order to provide the level of service they valued. This resulted in half a million people losing access to NHS dentistry since the government introduced reforms in April 2006, figures from the Information Centre suggest. Only 50% of all adults in England were seen by an NHS dentist last year; the rest either having to pay for their care, or going without any care. This has resulted not only in a two (three)-tier system but in a consequent build-up of health problems for those denied access to dental services, leading to the development of more serious conditions, and therefore extra distress for the patient and potential extra expense for the NHS. We do not wish to see this happen to access to general practice but fear the potential outcomes highlighted in this letter may leave few other options. This would be a tragedy for the NHS, especially as we celebrate its 60th anniversary.

We look forward to hearing from you, and are happy for you to circulate this letter or to quote from it as seems appropriate to you.

With best wishes,

Juliet Dunmur,
Chair BMA Patient Liaison Group

Darzi links

Not had time to read them yet (obviously, being a full time GP) but here are some links to the various documents.

The Report.

The Proposed Constitution.

A High Quality Workforce.

Friday, June 06, 2008

Louise Boden

An email has come to my attention. It is from Louise Boden, the Chief Nurse at UCLH, and so she is no longer a clinician at all of course, but a manager, paid for out of tax payers money.

The email is full of hyperbole and half-truths, insults and implications about GPs in general. It is really very insulting about GPs. She obviously is very jealous of us.

Here is the text:

-----Original Message-----
From: Boden,Louise=20=20
Sent: 06 June 2008 07:54
To: Divisional & Senior Nurses; Nurse/Midwife Consultants; Clinical Nurse
Cc: Heads of Nursing
Subject:Don't be fooled: this doctors' protest is all about profits, not patients

GPs are fighting the new polyclinics for the same reason they refused to join the NHS 60 years ago: to protect their businessThe British Medical Association has declared war on the government. Nothing new there, as the doctors' trade union sends out several press releases a day crying wolf about anything the government does. Next week is polyclinic protest week, with posters and leaflets in every GP practice encouraging patients to sign a petition doctors are taking to Downing Street.

The ideas of surgeon-turned-minister Lord Darzi mutated through various models - but finally emerged as 152 new clinics (London) or health centres of flexible size (everywhere else), which each primary care trust designs to suit its most needy area. But the BMA says they will "fragment care and destabilise existing services. Some surgeries may have to reduce services for patients while others could be forced to close." Scary warnings abound tha
t the era of the GP is over, bureaucracy will rule and your beloved local surgery will go the way of the post office. The BMA told PR Week it is digging into its war chest for a national poster campaign. The Conservatives have jumped on the Save Your GP campaign - something they may regret. So what's the problem the new clinics seek to solve? Although the nation's 8,500 GP practices do 90% of NHS work, hospitals take 80% of the cash. For decades
Labour and Tory governments have striven to get resources out of hospitals and back into the community, with more early prevention and less emergency repair. The other reason is to get a grip on bad GPs, which is difficult as they are private businesses. Most are good, but up to 15% are seriously inadequate - often single-handed practices in shabby premises in the neediest areas, in stark contrast with some of the most hard-working and idealistic GPs.

Polyclinics are only destined for London: elsewhere there will be health centres grouping several GP practices with new facilities. Lord Darzi's London model will be a hub around which are grouped existing local GP practices, often in the same premises - or new ones that fill in gaps. The hub will offer diagnostics and specialist clinics of all kinds; patients can walk in and see a GP, or be referred by their own GP. These clinics come with new
money from the centre and just two universal rules: they must be open from 8am to 8pm, and must see any patient who walks in. Does this sound like a threat or a promise? That may depend on whether you are a patient or a GP. It's hard to see a downside for patients. They will have access to a host of services nearby instead of in a distant hospital - and, joy of joys, at any time from 8am to 8pm. Where new health centres have opened recently - I
saw a beautiful one in Crewe - there has been a stampede of patients to join.

In one of their few firm policy commitments, the Conservatives seem to be making a bad error. They say they will stop the polyclinic and health centre programme - and, even more surprising, they won't make GPs open their doors outside office hours. Andrew Lansley, the shadow health spokesman, told Pulse magazine they would restore GPs' control over what hours they open, which oddly puts the Tories on the side of the union against patients' interests.However, the BMA draws its power from the trust people put in doctors but not in politicians, which may be why Cameron reckons he should hang on to their coat-tails as they march on Downing Street, pretending that "patient care will be damaged" whenever anything threatens their own terms of service. Cameron should ask Kenneth Clarke for his unfond memories of BMA tactics. Many decent doctors blench at the crude and dishonest shroud-waving
carried out in their name. The BMA fought tooth and nail against opening GPs' doors at hours to suit working people: the government won only a meagre three extra hours one evening a week, and no weekends. This is despite a 58% increase in pay when their brilliant negotiators pulled the wool over the eyes of John Reid and Alan Milburn - whose 2004 contract let GPs off all weekend and evening work for a puny =A36,000. (BMA negotiators could hardly believe it: they were expecting to lose =A315,000). The contract paid them if they hit 75% of their targets: they pretended that was tough but when they easily reached 92% they hit the jackpot. The National Audit Office said it cost =A31.78bn. Unsurprisingly, GPs have had no pay rise in the four years since, and that's part of the grumbling grievance behind this current campaign.

The BMA's petition to Downing Street will be shaped as a giant birthday card for the 60th anniversary of the NHS, so let's remember what happened back then. Aneurin Bevan failed to get GPs to the join the NHS, so they remain to this day private businesses. They have life-long contracts that can't be removed, with a guaranteed income, and large increments for doing things that should be part of their job. They own their businesses - and usually
their premises - and sell them on when they retire. As a result the NHS hasn't been able to ensure GP practices are spread to where they are needed most. The fact GPs are not direct NHS employees has always worsened inequalities in health provision as they congregate in richer, leafier spots. This BMA protest has nothing to do with patient care - and everything to do with jealously protecting what they see as a threat to their business model. So
it's hard to keep a straight face when the BMA scaremongers about "the threat to your surgery" from "commercial providers" who "will be more interested in their shareholders than patients". The BMA expresses indignation that more GPs might become directly employed by the NHS - but forgets to mention that a growing 35% of GPs are now directly employed by other GPs who meanly refuse to make them full partners in their businesses. Some contracts may
go to private providers - but the first has gone to a group of local GPs, and that is expected to be the model, except in rare cases. The new clinics will be built with various financial partnerships between the NHS, private funds and GPs' own investments. In the London borough of Camden and Derby, whole GP services have been contracted out to a private health company, causing consternation about creeping NHS privatisation - but these will remain the exception. In Camden the practices were already being run by the loca
l primary care trust and now open long hours, attracting more patients. But anti-privatisation campaigners are right to be wary: it is typical Gordon Brown triangulation that a mention of using the private sector has to be injected into everything to show he's a Blairite reformer at heart - as with this week's announcement that, as a last resort, failing hospitals could bring in private managers - though few expect it to happen: it was tried at Birmingham's Good Hope - and failed.

Of course polyclinics could go wrong. They could be underfunded and badly run. PCTs are not always good commissioners and could choose the wrong models in the wrong places. Clinics attracting patients may destabilise other practices - but frankly, that's the point. GPs who can't be bothered to join something offering new services for their patients are the very ones who may need a bit of destabilising. For all the fuss, London's 152 new clinics
will cover only 3% of GP services. But if they are half as good as promised, they may blaze a trail so that soon every patient will want one.

I will be passing this to the BMA as I suspect that a robust defence will be forthcoming (who am I kidding?!). There are many statements in this email which I suspect are not evidence based, for example that 15% of GP surgeries are seriously inadequate.

With colleagues like these, eh?

  • I have just discovered that this is a cut and paste job from Polly "I love Labour" Toynbee in today's Guardian.

Friday, May 30, 2008

Fuel poverty plan being unveiled

This issue is perhaps more social than medical, but it impacts on me every year.

BBC NEWS | Business | Fuel poverty plan being unveiled

Lets get people out of fuel poverty. Good idea!

Lets collect and share data with the power companies so they can identify who to help. Then they can offer to insulate their lofts, make sure they are on the cheapest tarrifs, check the draft excluders on the windows.

Not so sure on that. You want to collect data identifying people who are at risk of fuel poverty. How would you do that? I can only imagine the Government would make use of data derived from pensions somehow.

Or (now wait a moment!) could this just be another way to try and persuade us of the merits of national ID cards?

I've just heard a minister on the Today programme, Malcolm Wicks I think it was. He was explaining why the Government thought this was a good idea. He began with the data sharing idea, which made me feel uneasy. I'm on record as to how I feel about ID cards. Given recent episodes of data insecurity I have no faith whatsoever that the Government would keep my data secure. But then he compounded the problem by stating that changing the Pensions Bill, the Government could give itself more "powers".

Government seeking more "powers".

Seeking yet more control over our lives.

Once again they forget that they are our servants, not our masters.

But there is no point in me being critical without suggesting alternatives. Of course, I speak from a position of relative ignorance, in that I am neither an expert in fuel poverty nor a Government minister (who are of course by definition infallible, like the Pope, until they decide to spend more time with their familes).

So how about this as a relatively easy, cheap to administer idea: anyone over 65 on income support gets sent a voucher to give to their energy company. No data sharing, its up to the individual to decide whether to engage with the scheme or not as they see fit. Consequently there is no need to change the Pensions Bill, with a commensurate saving of both Parliamentary time and tax-payers money (no changes/revisions means less working hours spent on it). I can't see that it would cost more than the suggested increase in executive powers. I can see that it doesn't make the Government any more top heavy. More legislation does.

But they won't listen. They never listen. They consult. They decide what they are going to do, decide on a timetable, go through a public consultation exercise (which is to inform, not seek views from, the public) then do what they decided to do. Then they pass laws designed to do what they want without thinking about the difficulties that those laws might cause. This Government is forever having to deal with the Law of unintended consequences. They usually seem to do this by retrospectively changing what they set out to do and saying that it had been their intention to do that all along.

By all means help the poor, Mr Brown. But you don't need "powers" to do that. You just need common sense.

Friday, May 23, 2008

Save Your Surgery

The NHS is 60 this year.

That means that my predecessors and I have been looking after your family from cradle to grave, personally and with knowledge about your health and illnesses built from the familiarity that comes with a relationship that may well span decades.

Gordon Brown wants to change that.

He doesn't want you to see the same doctor each time you need some help. He has bigger plans. He wants to introduce commercial companies to the sector.

"So what?" I hear you say. "You GPs are private, you just work for the NHS."

Perhaps. But who am I accountable to (exclusding for the moment the couple of dozen Quangos which can also make my life busier than it needs to be)? My patients. I have a GMS (General Medical Services) contract. It is a long term arrangement to provide care.

What about a commercial company? They have a responsibility to their shareholders, first and foremost. They will likely have something called an APMS (Alternative Personal Medical Services) contract. APMS contracts will likely be for 3-5 years maximum. so what happens when the contract runs out? Will you lose that service as well? Perhaps. But don't worry, some other company will be providing the service if the first one isn't. It really doesn't matter who you see.

Does it?

What about polyclinics, walk in centres and the like? The Government have said there will be up to 250 large new health centres. Great! More services! Sounds super! And what's that? It'll be up to local PCTs to decide if they need one? Wonderful! (Oh no it won't, they've all been told that this is a political "must do", whether they need it or not.)

Except the money that is being spent on those (around £1 million per centre I would guess) could be spent investing in the current service being provided by people like me, for people like you. That money has to come from somewhere. I am not reassured at all by Ministerial reassurances that they have no plans to disinvest in GPs. They think we are superfluous and that what we do could be done more cheaply by nurses, paramedics and pharmacists.

These polyclinics will have many more doctors than the current style of GP surgery, maybe as many as 25 doctors. Great! Easy access! It doesn't matter if you don't see the same person twice.

Does it?

If this concerns you as much as it does me (and I'm concerned equally as a patient of the system as I am as a GP) then please go to the website and sign the petition. Or visit your local surgery and sign.

Write to your MP and the local papers, the Nationals even. Espeically write to your local council, address it to their Overview and Scrutiny Committee.

But please do something.

When we're gone, it will be too late.

Musings of a Dinosaur: Why Breastfeeding is a Bad Idea

Musings of a Dinosaur: Why Breastfeeding is a Bad Idea

Please, go and read this.

It made me snort coffee on my keyboard.

Crewe and Nantwich

Schadenfreude - Wikipedia, the free encyclopedia: "Schadenfreude (IPA: [ˈʃaːdənˌfʁɔʏ̯də] Audio (German) (help·info)) is enjoyment taken from the misfortune of someone else. The word has been borrowed from German by the English language[1] and is sometimes also used as a loanword by other languages. German philosopher and sociologist Theodor Adorno defined it as 'the largely unanticipated delight in the suffering of another which is cognized as trivial and/or appropriate'.[2]"

Friday, May 09, 2008

Time to start a campaign?

(With thanks to Prit Buttar and colleagues on the BMA Communications team)

This one is mostly for my GP readers, but here is a transcript of an email I've just sent to my LMC mailing list.

I listened to Darzi on Radio 4 this morning. If anyone missed it, use
the BBC website 'listen again' thingie, it was at about 0712.

He was explicitly asked whether PCTs would be able to choose NOT to
have a polyclinic if that was what the locality decided. He said that
they would be allowed to make such a decision.

Annual budget for one of these places is going to be somewhere in the
region of £800k-1m per year.

Using PBR tariffs and the BNF, I estimate that this could be used to buy:

1,139 cataract operations
154 hip replacements
113 courses of Herceptin
or 36 full-time district nurses

Perhaps we should therefore be undertaking a survey of our patients to
find out if they want a centre of some of the above. We should then
pressurise the PCT boards to accept our findings. especially as Darzi
specifically said that PCTs should take into account local

This could be run along side the BMA campaign (see Laurence's email of
yesterday or press release on BMA website).

Window of opportunity here I think.

Any other GPs reading this: Get up and start making noise. Now is not the time to knuckle down and get on with it, or the rug will be pulled from under you. Talk to your patients. Read the bumph from the BMA which will arrive next week.

If not us, then who? If not now, then when?

Friday, May 02, 2008

I don't believe it

Last year I posted this.

She's back.

I have just had the SELF-SAME CONVERSATION with her!

Thank goodness its Friday.

Hendrick's, Fever-tree tonic and cucumber await...

Tuesday, April 29, 2008

George Monbiot tells it as it is.

An excellent article has been written by Mr Monbiot, a Guardian journo who is unhappy with the political direction the NHS is taking.

His article is well written and contains much insight into the current threats to YOUR health service.

Required reading, especially with local elections coming up.

Monday, April 28, 2008


I have just been described as "a lovely bit of stuff" by a female patient*. To my face.

So how should one deal with this sort of thing? Complaints are dealt with in a structured way, utilising our Practice's complaints procedure as a first step. The huge majority are dealt with in this way, insofar as no further action is taken by the complainant. Presumably most are satisfied by the resolution of the problem. Sometimes the complaints are trivial, other times more serious. Some are patently vexatious, though they are few and far between thank goodness. All complaints are dealt with as significant events in our practice, which effectively means we try and learn from them. That sounds rather "cardy" (by which I mean "cardy-wearing, leather elbow patches, touchy-feely") but generally there is something which we could change. At the very least we discuss it (partners, practice manager and if appropriate other staff). All the details are recorded and kept.

I sometimes think, though, that we don't deal with compliments as robustly as we might. I receive compliments fairly often in the form of thanks (for doing my job!). Sometimes, especially around Christmas I receive small gifts, often of the imbibing variety. Soemtimes, I receive letters or cards. I keep the cards. A few years ago I put them in my appraisal folder as I thought they might help show that my relationships with patients contributed to the evidence that the GMC should continue to register me. I no longer do that. I now keep them in a different folder, for my own benefit. I don't look at them often but I know they are there. Perhaps we should be logging all of these episodes as we do with complaints. That seems a little excessive but I suppose it would allow a veriafiable balance against the complaints.

But there is a part of me that feels that doing so might cheapen the intentions behind the gestures.

As for the ribald comment I have just been both the subject and recipient of, well, I take it as its intended and wink.

*Ok, she's 74 and partially sighted...

Friday, April 25, 2008

Tax cuts

Losing the 10p tax band has hurt my staff. not badly, but all of them.

They have each lost about £15-25 a month (they are all part-time). Those paying pension contributions have seen those drop by about £10 a month as well. None of them will be able to recoup this money as their husbands/partners are all in work as well, so no tax credits.

Thanks Gordon.

Thursday, April 24, 2008

Extended hours - some random thoughts

Still no sign of the specification of the DES to provide this apparently vital service. There has been some interim guidance published (here)by the Department of Health to allow the development of LES's by PCTs and LMCs. I noticed that our illustrious Health Secretary, Postman Pat, is now talking about "Family Doctor Services" rather than "General Practice" and that Laurence Buckman is being described as an Arthur Scargill figure (good for you Laurence). I was also disgusted to hear AJ say that he was pleased that 92% of GPs accepted their proposals, but not surprised. Firstly, 92% didn't, it was 92% of those that voted. I bloody well didn't. And the 92% had little choice, did they Alan? What was the alternative?

Anyway, back to extended hours. I can't see why anyone would want to commit to a system which has yet to be agreed, or at least published, which will result in more work for less money, for minimal benefit for a minimal number of patients.

Some GPs will it seems do anything for money. I fear a lot of GPs will just keep their heads down and get on with it anyway, even if it ends up costing them money. Some I'm sure would argue they can't take the financial hit of not doing it. Although quite how you get your practice finances in to such a state that the loss of £6000 per partner (approximately, maximally and gross) can be so catastrophic is something I struggle with.

But it isn't about the money as far as I'm concerned. Its about the hours. I have a contract. Well, I call it a contract, it can be changed at will by the Government at 3 months notice.

Some extra background about me. I'm a full timer. I work 4 and a half days a week. My half day not infrequently ends up being a "finishing a couple of hours early" day instead. I recently worked out my hours of work for my appraisal. 47 hours a week, in 4.5 days. More than most I suspect. I don't mind my hours. I'm a GP, its what I do. I'm also a married, family man.

The government reckons that 6.5 million people want us to open longer hours, an analysis of a survey which even the most ignorant of people must realise is a bogus extrapolation. For my practice of just under 6000 patients, only 42 people who were surveyed (out of 330, so 13% of those surveyed but only 0.72% (that is, not quite three quarters of one percent) of our entire list) were unhappy with our current hours. 3 felt we didn't open early enough in the mornings. 2 were unhappy that we weren't open long enough at lunchtime, although we don't actually close during the day, unlike many other surgeries. 9 felt we needed to open longer in the evenings. 15 wanted us to open on Saturdays. 4 had what is described as "other reasons", undelineated.

If we were to open for 1.5 hours in an evening and 1.5 hours on a Saturday, that would provide 12 extra appointments in the week. Bear in mind that this would be for routine, pre-booked appointments. Home visits would not be on offer. Emergency care would not be on offer (although quite how we could morally turn away someone who turns up acutely unwell is unclear to me, apparently it is not a major problem from the politicians' point of view). I would be very surprised if that service was utilised fully for some time. Indeed, the people who would eventually make use of the service on the whole are very likely to be the very people who come during the day at the moment. So the people who might "need" (for which read "want") the appointments in the extended hours would be unlikely to be able to access them because they would get filled by other people.

And we are back to square one.

And I don't wish to repeat my divorce experience, thank you very much.

Of more concern to us, in actual fact, was the perception by those surveyed that patients could not prebook appointments. Only 29% of those surveyed thought they could. In actual fact people have been able to prebook for several years. We did have a period of time where we adopted so-called Advanced Access, in other words, day only booking, to reach a target. When it became clear (within a few months) that it wasn't suiting some of our patients we started to allow a limited amount of prebooking. We are trying very hard to advertise the fact that people can. Part of that work is that we have set up our practice website. Registered patients can make appointments and request repeat prescriptions through the website.

We are actually quite pleased. The system has only been up and running for about 4-5 weeks. We already have 71 patients registered to use it. 10 patients have made appointments. We are starting to get repeat script requests through.

So things are improving. I think.

But we have no wish to open longer hours. We don't think that there is actually any demand for it.


The NUT has my support, for what it is worth.

Think about it: a 3 year pay deal which is below inflation (as per RPI, rather than the completely useless CPI) and depends on Government plans for the economy coming to fruition.

The BBC annoyed me this morning (for a change) by comparing the "average teacher's salary" of about £34k with nurses' and police constables' starting salaries, figures which they acquired form that font of all accuracy, the Government. So of course the figures are not comparable. Idiots (and Voltaire had a thing or two to say about idiots...).

The fact that the NUT and its members felt that a strike was needed speaks volumes to me. The first national strike for over 20 years by a teaching union.

(Apologies for the lack of links. Lazy perhaps, but I'm in the middle of surgery. This post is what Neighbour would describe as "housekeeping", to aid in the maintenance of my (in)sanity.)

Tuesday, April 22, 2008

Bad news

Sometimes a patient comes along who reminds me why I'm here.

Ettie is a lady of 82 years. She's been widowed for almost a quarter of a century. Apart from high blood pressure and quiescent ischaemic heart disease she is relatively fit and healthy. I've been her GP since I joined the practice in 1999. She only sees other GPs rarely, usually if I am on leave.

But Ettie wasn't well recently. She had what appeared to be a chest infection with some pleurisy. I treated her with antibiotics. She felt better in herself, but the pleurisy didn't settle so she came back to see me a month later. Although her chest was clear I arranged a chest x-ray.

The x-ray showed a shadow in the top of her right lung. It also showed some destruction of two of her ribs, just where she was still getting discomfort. Ettie probably has lung cancer, almost certainly in fact. It would also seem to have spread beyond her chest to her ribs. This is bad news.

I have seen Ettie this morning. I have spoken to her at length about what is going on, what the likely problem is, what will happen next. I have referred her to our excellent local lung cancer rapid assessment clinic.

Ettie is devastated. She is scared. She is sure that this means the end for her. It may well do. But I will be there whatever happens. I will treat whatever symptoms she develops to the best of my ability and will enlist the help of our local palliative care team if I need to (or if Ettie needs me to).

I would prefer not to have to, but I will coordinate her care, to what will hopefully not be the bitter end, but a dignified, peaceful death.

Who better than me, who has known her for so long, who she has a relationship with, who she trusts?

I am her GP.

Enough said.

Tuesday, March 04, 2008

New practice website

Apologies for the lack of posts.

I've been rather busy trying to make some headway against the destruction of General Practice.

Sadly I think that we (the public) will lose our Primary Care service. Even more sadly, many people won't realise that the replacement is less good than the current system until it is too late to go back.

I suspect that within 5 years the current model of partnerships providing continuity of care for patients will be largely defunct, replaced most likely by Polyclinics with some shift-working salaried doctors but mostly with non-medically trained staff such as nurse practitioners and nurses.

On the up-side, we have spangly new practice website at

Have a look if you like.

And to the 50-60 or so people (according to site monitor) who view this website a week despite the lack of posts, thanks for keeping an eye out for so long.