Mr Hunt unites the profession: BMA membership surges amid dispute over contracts

The Guardian 6th October reports: BMA membership surges amid dispute over contracts

About 80% of 5,000 new members who signed up between 26 September and 5 October are junior doctors, says union

There has been a huge surge in the number of junior doctors joining the British Medical Association (BMA) in the wake of the row over contracts, according to the union.

Between 26 September and 5 October, a total of 5,451 doctors joined the BMA, bringing the total membership to just less than 160,000. About 80% of the new members are junior doctors.

The rise in membership comes after the BMA said it would ballot its members over possible strike action. Negotiations – including a meeting with the health secretary, Jeremy Hunt – have broken down over conflict regarding working hours and pay.

The government has said it plans to impose the new contract on doctors, up to consultant level, next year.

The contract will reclassify doctors’ normal working week to include Saturdays and up to 10pm every night of the week except Sunday.

Medics argue they will lose out financially as evenings and Saturdays will be paid at the standard rate rather than a higher rate. They say this amounts to pay cuts of up to 30%.

Dr Mark Porter, chair of the BMA council, said of the rise in membership: “These new membership figures are an indication of the anger felt by not just junior doctors, but the profession as a whole…

… “Then there was no talk of 90-hour weeks, no talk of large numbers of junior doctors having their pay cut.

“There was instead a recognition by the Department of Health that now appears to have been lost: that better pay and work-life balance incentives were needed to ensure doctors were attracted to A&E and other gruelling specialities.”

Hunt, speaking at a fringe event at the Conservative party conference in Manchester, said: “In politics you do get quite a lot of angry ex-minsters who opine with their views but, I have to say, in office Dan and I never disagreed on this issue, and we both recognised that we needed to find a way to make it easier for hospitals to roster to protect patients who are admitted at weekends.”

 

GPs in Scotland to be freed from QOF

BBC News reported 1st October 2015: ‘Outdated’ QOF GP payment system scrapped in Scotland

GP payment system which gave surgeries money for achieving a list of outcomes is to be scrapped in Scotland.

Health Secretary Shona Robison made the announcement at a conference in Glasgow attended by about 2000 doctors.

The Qualifty and Outcomes Framework (QOF) makes payments based on an itemised list of services but has been criticised as too bureaucratic.

The doctors organisation BMA Scotland welcomed the move, saying it could reinvigorate general practice.

In her speech, Ms Robison said officials would work with the BMA to dismantle the QOF system by 2016, before a new GP contract begins the following year.

She also promised that the Scottish government would not cut junior doctors’ pay.

She told the Royal College of General Practitioners annual conference: “I have always said I want to work with GPs in addressing the problems faced by the profession.

“Today I have announced that we will begin discussions to remove the outdated QOF system of payments for GPs, which I know many in the profession find bureaucratic and time-consuming.

“I have also given the conference a cast iron guarantee that we will not be following the UK Government’s plans to cut junior doctors’ pay. I know that the RCGP are particularly concerned the proposals and the growing confusion and alarm that this is causing trainees.”

Dr Alan McDevitt, chairman of the BMA’s Scottish GP committee, said the announcement was a “significant” step forward.

“This bold move by the cabinet secretary is part of the re-invigoration of general practice in Scotland,” he said.

“It will have a positive effect on practices, by reducing workload and bureaucracy, allowing GPs to focus on the complex care needs of their patients.

“We believe that moving to a professionally driven, peer referenced system of quality will ensure that general practice and the NHS in Scotland continues to deliver a high standard of care to its patients.”

UK end-of-life care ‘best in world’

Nick Triggle is fortunate to have this good news item to report 6th October 2015 for BBC News:

UK end-of-life care ‘best in world’

End-of-life care in the UK has been ranked as the best in the world with a study praising the quality and availability of services.

The study of 80 countries said thanks to the NHS and hospice movement the care provided was “second to none”.

Rich nations tended to perform the best – with Australia and New Zealand ranked second and third respectively.

But the report by the Economist Intelligence Unit praised progress made in some of the poorest countries.

For example Mongolia – ranked 28th – has invested in hospice facilities, while Uganda – 35th – has managed to improve access to pain control through a public-private partnership.

End-of-life care: The best and the worst
Top 10	Score out of 100	Bottom 10	Score out of 100
UK	93.9	Iraq	12.5
Australia	91.6	Bangladesh	14.1
New Zealand	87.6	Philippines	15.3
Ireland	85.8	Nigeria	16.9
Belgium	84.5	Myanmar	17.1
Taiwan	83.1	Dominic Republic	17.2
Germany	82	Guatemala	20.9
Netherlands	80.9	Iran	21.2
US	80.8	Botswana	22.8
France	79.4	China	23.3

The rankings were worked out following assessments for the quality of the hospitals and hospice environments, staffing numbers and skills, affordability of care and quality of care.

Just 34 out of 80 countries provided what could be classed as good end-of-life care – and these accounted for just 15% of the adult population.

The report said the quality of end-of-life care was becoming increasingly important with the ageing population, meaning people were increasingly facing “drawn-out” deaths.

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Tulip Mazumdar, Global Health Correspondent

It’s no major surprise that richer countries, with stronger health systems, provide some of the world’s best palliative care. But a few poorer nations are bucking the trend, and it’s often down to the efforts of individuals campaigning for everyone to be allowed a dignified and pain-free death. Panama, Chile, Mongolia and Uganda are singled out for praise, whereas the situation in India and China is described as “worrying”.

India ranked 67th in the index, and China was in the bottom 10 at 71. Both have huge populations and have experienced rapid economic growth, but care for people at the end of their lives has not kept up. The report warns further improvements are needed across all countries to cope with the future demands of an aging population, increasingly facing drawn-out illnesses such as cancer, heart disease and dementia.

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The UK received top marks for affordability – as would be expected for a service that is provided free at the point of need – but also got a perfect score for quality of care.

Overall it was given 93.9 out of 100, but the report still said there was room for improvement – as there was with all the top-performing nations.

Services in England have recently been criticised by the Parliamentary and Health Service Ombudsman.

‘World class’

Report author Annie Pannelay said: “The UK is an acknowledged leader in palliative care. That reflects its comprehensive strategy towards the issue as well as the improvements that are being made.

“But there is more that the UK could do to stay at the forefront of palliative care standards, such as ironing out occasional problems with communication or symptom control.”

Claire Henry, chief executive of the National Council for Palliative Care, said: “At its best how the UK cares for people who are dying is absolutely world class with hospice care leading the way, but there can be no room for complacency, especially as the demand for palliative care is increasing.”

The UK also came top the last time this report was produced in 2010. Also in the top 10 this time were the Irish Republic, France, Germany and the US.

Iraq and Bangladesh finished bottom of the ranking, while China was in the worst 10.

Dr Stephen Connor, of the the Worldwide Hospice Palliative Care Alliance, said: “The biggest problem that persists is that our healthcare systems are designed to provide acute care when what we need is chronic care. That’s still the case almost everywhere in the world.”

The secret will “Out”. NHS finances: Why we are being kept in the dark… The word “rationing” will continue to be banned from the political lexicon.

In a short while Nick Triggle predicts that the secret will out, and Health Service finances will be evidently BUST. There will however be no engagement and NHSreality predicts more denial from the politicians. The word “rationing” will continue to be banned from the political lexicon.

 30th September for BBC News “NHS finances: Why we are being kept in the dark”

It’s coming up to six months since the start of the financial year. A year that many believe – financially at least – will make or break the NHS.

Yet we still don’t know how hospital, mental health, ambulance and community services are shaping up.

Yes there have been predictions and forecasts. But – as yet – no concrete figures.

There are two economic regulators for the sector: Monitor, which keeps an eye on the books of foundation trusts (the leading trusts), and the Trust Development Authority, which looks after those that have not attained the status

Neither has released the figures for the first quarter of April to June. Finance directors on the ground have submitted data, but the figures need more work apparently. Hence, we approach the half-year mark in the dark.

So when will we get an idea of what is happening? I have heard whispers that the two regulators are planning a joint publication after the party conferences.

But this – it seems – is only likely to delay the bad news. Last year was the first that foundation trusts finished the whole year in deficit, recording a £249m loss.

When the non-foundation trusts were included, the deficit topped £800m. And trusts only broke even after an extra £250m cash injection from the Treasury and by raiding the capital budget, which is meant to be spent on buildings.

‘Challenging year’

This year, the budget has been increased by 1.6% above inflation, bringing it to just over £116bn. But even that looks like it will not be enough.

While the accounts are being kept under wraps, a survey of 100 finance directors by the King’s Fund think tank over the summer found two-thirds were predicting deficits.

The outlook was particularly bleak in the hospital sector, where nine in 10 thought they would finish the year in the red.

It has also been suggested that the business plans, submitted by trusts at the start of the year but not published en masse, forecast a £2bn deficit.

It’s no wonder then that King’s Fund chief economist Prof John Appleby has called 2015-16 “the most challenging year this century”.

This is not the first time that the NHS has had problems with its finances though. A decade ago, it was struggling to make the sums add up.

But the difference then was that the health service was enjoying record rises in its budget and was able to find the reserves and savings to cover the overspend.

But Chris Hopson, chief executive of NHS Providers, which represents trusts, says such slack is simply not in the system this time round.

“Trusts are doing everything they can – but a lot of the easier savings have been done, so it is going to be difficult to do any better than a £2bn deficit,” he said.

It raises the prospect of NHS bosses having to curb spending in the coming months or the Department of Health going cap in hand to Chancellor George Osborne to ask for more money while much of the rest of the public sector is being squeezed. Neither seems palatable.

So is a tough year about to get tougher? When the figures do finally come out, we should have the answer to that.

Short journeys become longer: 40% of maternity units are inadequately staffed (and some are so old they need replacing).

Although we do not ration health care officially, we in reality give full funding to birth and only partial funding to hospice care and death. (luckily, a short journey for most of us) The shortage of midwives has been predicted for years, and concentration into centres of excellence seems pragmatic when so many births are to first time and elderly mums, (and therefore high risk short journeys). Closure or downgrading of some units is inevitable, especially now that so many are threatening to leave their health service.. There is little choice when there is a shortage of both midwives and obstetricians, and when the litigation is increasing…    Compounding the problem is the threat of increasing Nurse and Midwifery debt.. 40% of maternity units are inadequately staffed (and some are so old they need replacing), so longer journeys will be necessary in rural areas.

Sarah Kate-Templeton in the Sunday Times 4th October reports: Four in 10 maternity units risk poor care

FOUR in 10 maternity units recently visited by inspectors were found to be at risk of providing poor care.

The chief inspector of hospitals this weekend criticised an “unacceptable” variation in the quality of NHS maternity services after regulators reported concerns about care given to mothers and babies in 33 of the 83 units they visited.

Maternity units have been troubled for years by staff shortages and questions about safety, but the 83 inspections conducted since April 2014 suggest a widespread need for urgent changes.

Professor Sir Mike Richards, chief inspector of hospitals, said: “A significant number of units are providing or are at risk of providing elements of poor care. Almost a third are rated as ‘requires improvement’ . . . and about 5% are inadequate where we have the most serious concerns. This wide variation in the quality of maternity and gynaecology care in England is unacceptable.

“A lack of staffing, poor learning from incidents and poor culture and leadership have all contributed to ratings of requires improvement or inadequate.”

At East Sussex Healthcare NHS Trust, the Care Quality Commission (CQC) found staffing on the labour ward often fell below planned levels, women in labour did not have one-to-one care and mistakes continued to occur in monitoring the baby’s heart rate. It also found management at the trust seemed to be in denial, despite an earlier investigation highlighting the concerns.

The CQC report, published last month, said: “There was a lack of acceptance of the serious nature of the concerns we identified by the leadership of the maternity services . . . There was not a learning culture and incidents were not reviewed in sufficient depth to enable lessons to be learned and disseminated.”

East Sussex trust said it had put many improvements in place since the inspection but “acknowledges that there is still more to do and is committed to working hard . . . to make the necessary improvements”.

Another CQC report last month into maternity services at Cambridge University Hospitals NHS Foundation Trust found “serious concerns regarding the safety arrangements”, problems with foetal heart rate monitoring and an “unsafe” environment in the birthing unit.

The maternity unit was closed 37 times in 2013-15, mainly due to a shortage of midwives. Cambridge University Hospitals Trust said: “Despite the CQC findings we provide safe and high quality maternity services.”

A third report published by the CQC last month into West Hertfordshire Hospitals NHS Trust said mothers and babies were at risk from frequent staff shortages. The trust said it had improved staffing levels and safety since the inspection.

Last week a coroner called for a national review of staffing at high risk deliveries after finding that a baby might have survived if a more senior doctor had been present. Dr Peter Dean, the coroner for Suffolk, is writing to Dame Sally Davies, the chief medical officer, to ask whether consultants should attend high-risk deliveries.

In January Bonnie Strachan died half an hour after her birth at Ipswich Hospital. She was delivered in the breech position, meaning her legs came out first. After a delay in delivering her head, she emerged in poor condition and could not be resuscitated.

The doctor undertaking the delivery had experienced only two breech deliveries independently and the on-call consultant was not asked to attend.

Bonnie’s mother, Emma Strachan, 29, from near Framlingham, Suffolk, said: “Our baby girl was taken from us and Percy’s little sister was taken from him. The whole situation has affected us all physically, emotionally and socially.”

Guy Forster, the Strachans’ lawyer and a partner at law firm Irwin Mitchell, said Bonnie’s parents had opted for a natural birth in the belief that an experienced obstetrician would be there. “Bonnie was such a big baby that, according to national guidelines, a breech delivery was never advisable.”

Nick Hulme, chief executive of the Ipswich Hospital NHS Trust, where maternity services were rated as good by the CQC, said: “We are extremely sorry baby Bonnie died and . . . have made changes to our practices.”

Nicola Merrifield in The Nursing Times 22nd September 2015: Nurse and midwife shortages factor in ‘elite’ FT entering NHS failure regime

Laura Donnelly in the Telegraph 2nd October 2015: Nurses could be forced to pay tuition fees under new Treasury proposals

The Nursing Times 4th October 2015: Treasury ‘looking’ at replacing student nurse bursaries with loans

Wrexham.com reports 2nd October 2015: 10,000 Sign Petition Opposing Downgrading of Maternity Services

Andrew Gregory in The Mirror 29th September reports: NHS faces massive staff exodus with two-thirds of workers planning to quit

NHS denies Englishmen low-cost cancer drug

Sarah Kate-Templeton points out the post-code rationing between different  regions in the UK, reinforces the case for having a home in Scotland as well as England, and is a denial of a National Health Service. The Sunday Times article “NHS denies Englishmen low-cost cancer drug” is honest. Is it reasonable to have periods of time when one region is completely different to another, and within that region the assertive and informed get better care?

MEN in England with prostate cancer are being denied an inexpensive drug that could give them an additional two years of life — while Scottish patients receive the treatment.

In Scotland, the drug, docetaxel, is given as soon as prostate cancer starts to spread. In England it is given at a later stage, denying patients 22 months of life on average.

To adopt the Scottish approach would cost the National Health Service nothing, but bureaucrats say they will not act until a trial is published in a peer-reviewed journal. The results of the trial have been described as “staggering” by Prostate Cancer UK.

The extra 22 months of life emerged in a major trial carried out in UK universities and NHS hospitals. Up to 5,000 men could benefit from the treatment every year.

The trial, called Stampede, was funded by Cancer Research UK and the Medical Research Council (MRC) and presented at cancer conferences in Europe and America.

NHS England says it cannot approve use of the drug at an earlier stage in the disease until the study has been published.

Professor Nicholas James, a cancer consultant at the Queen Elizabeth Hospital in Birmingham and chief investigator on the trial, said: “This is classic NHS bureaucracy and jobsworth behaviour.”

Scottish patients are given six courses of the chemotherapy drug, alongside hormone treatment, as soon as they are diagnosed with prostate cancer that has spread.

In England men are given 10 courses of the chemotherapy, but only after they have suffered a relapse while just receiving hormone therapy.

Doctors at Queen Elizabeth Hospital, run by University Hospitals Birmingham NHS Trust, are giving patients the chemotherapy as soon as the cancer spreads with the support of trust managers to do so. All Scottish NHS trusts are also giving the chemotherapy at the earlier stage.

Elsewhere in England, however, patients are being denied the chemotherapy when it has been shown to be of benefit to them.

James said: “What you would want to happen when, having shown that you can make people live two years longer with less treatment than you were giving before, is that you would want the NHS to adopt it pretty quickly.”

Iain Frame, director of research for Prostate Cancer UK, wrote in a blog: “The findings were staggering. These researchers showed a 22-month survival benefit from giving men newly diagnosed with metastatic prostate cancer docetaxel chemotherapy at the same time as hormone therapy . . . [Even though] docetaxel is an off-patent, inexpensive drug, we know that men are still being denied earlier access to this treatment. What’s more, we lack any sense of how long it will take for this to become standard practice.”

NHS England said: “Decisions such as these have to be made based on good-quality clinical evidence. We’ve committed to developing a policy once that evidence becomes available, which at this stage means waiting for the publication of the trial.”

Tony Doherty, 75, a retired engineer from Leicestershire, heard of the treatment through the charity Prostaid. He was surprised to be told by his NHS consultant in Leicester that he did not qualify until his cancer had relapsed. He sought a second opinion from James in Birmingham and is starting chemotherapy with docetaxel on the NHS there.

Doherty is concerned that other men, who are not as well informed or as “pushy” as he, may be denied the treatment.

“It makes me very happy that I am getting something rather than just being left to wait until my PSA [prostate specific antigen] goes up and that is the end of it,” he said.

“If I can get the chemotherapy then I maybe stand to get another couple of years out of it.”

 

NHS cancer bonuses ‘are abhorrent, risky and misguided’ – altruism lost

Laura Donnelly, and Victoria Ward in the Telegraph 2nd October 2015 report: NHS cancer bonuses ‘are abhorrent, risky and misguided’   NHS reality agrees.. altruism lost somewhere in this argument..

Leading doctors speak out amid a growing backlash against new schemes offering doctors payments to cut referrals

Ministers have been urged to ban schemes which pay GPs financial bonuses for reducing referrals to hospital – including cases of suspected cancer.

The calls come amid growing criticism of the NHS initiatives, which doctors have described as “abhorrent, risky and misguided.”

Labour’s new shadow health secretary Heidi Alexander last night called on ministers to “review the impact and extent” of these schemes “as a matter of urgency”.

She said: “Patients must be confident that their GP will always act in their best interests. Financial rewards for denying patients access to care are wrong and risk damaging that trust between doctor and patient.“

Ministers have been urged to ban schemes which pay GPs financial bonuses for reducing referrals to hospital – including cases of suspected cancer.

The calls come amid growing criticism of the NHS initiatives, which doctors have described as “abhorrent, risky and misguided.”

Labour’s new shadow health secretary Heidi Alexander last night called on ministers to “review the impact and extent” of these schemes “as a matter of urgency”.

She said: “Patients must be confident that their GP will always act in their best interests. Financial rewards for denying patients access to care are wrong and risk damaging that trust between doctor and patient.“

An investigation yesterday revealed that practices are being paid up to £11,000 under schemes to reduce referrals to hospitals, some of which involve cutting referrals for suspected cancer.

Dr Chand Nagpaul, chairman of the British Medical Association’s GP committee, said such schemes were “short-sighted and misguided,” and would leave patients questioning their doctors’ motives.

“We believe it is far more appropriate for CCGs to introduce clinical pathways that ensure patients are referred appropriately rather than these crude, salesman-like bonuses which pay GPs simply to make reduction to referrals in numerical terms,” he said..

Dr Louise Irvine, a south London GP, said she found the idea “abhorrent”. “Incentivising reduced cancer referrals is highly risky and contradicts the evidence that GPs should be referring more people earlier for cancer tests,” said Dr Irvine, a spokesman for the National Health Action Party.

The UK has the worst survival rates for cancers in Western Europe, largely due to late diagnosis.

The schemes appear to fly in the face of a recently announced NHS Cancer Strategy, which promised an 80 per cent increase in tests for cancers, in a bid to improve survival Research by Pulse magazine has revealed nine parts of the country offering such schemes.

They include NHS North-East Lincolnshire CCG, which is offering the average practice the equivalent of more than £6,000 to reduce outpatient referrals – including urgent cancer referrals – to the same level as the 25 per cent of practices with the lowest referral rates in 2014/15.

A spokeswoman insisted that the figures quoted were the absolute maximum a practice could earn, and that in order to show significant improvements, they would have to completely overhaul how patients were managed.

Dame Barbara Hakin, national director for commissioning operations at NHS England, said: “The number of patients referred to hospital for urgent cancer checks is up by over 600,000 over the past five years, and we now want it to go up even more, so as to diagnose suspected cancers earlier.

“NICE has set out evidence based guidelines for when patients should be referred, and no CCG incentive scheme should in anyway cut across that. We are in touch with each of the CCGs mentioned to ensure that this is very clearly communicated to all practices.”

Lincolnshire NHS group offered £6,000 to reduce numbers sent for outpatient appointments

Cost over care? GP doctors given cash to cut hospital referrals

Our NHS is in serious danger – we should be scandalised – GPs are being paid not to refer cancer patients to hospital and free hearing aids are being axed. All the politicians are cowards.. This is a healthcare system under strain, but where is the debate?

They all know it must change, and yet all the politicians are cowards. So it’s failure gets worse, and the solutions get harder and harder. (Nigel Hawkes in the BMJ – NHS truths that dare not speak their name) and on NHSreality

Owen Jones in The Guardian opines 3rd September 2015: Our NHS is in serious danger – we should be scandalised  – GPs are being paid not to refer cancer patients to hospital and free hearing aids are being axed. This is a healthcare system under strain, but where is the debate?

Wanted: somebody who can explain why this story is not being reported as a national scandal. There are English GP practices being paid money not to refer patients to hospital, including cancer referrals, in order to cut costs. One clinical commissioning group reportedly offered more than £11,000 to slash everything from follow-ups and emergency admissions; another more than £6,000 to GP surgeries to bring their referrals down to practices at the bottom of the league for referral rates.

This is playing with people’s lives. Britain is already languishing up to two decades behind the survival rates of other European countries. The NHS should be encouraging more referrals, not incentivising fewer. The inevitable risk, of course, is that early symptoms of cancer will be missed, leading to even more unnecessary deaths.

If you want to look for other evidence of a healthcare system increasingly under strain, it won’t take you long. Hearing aids break the solitude of those who are hard of hearing, giving them independence and the ability to carry on life as normal. But North Staffordshire’s clinical commissioning group is to stop giving free hearing aids to its predominantly older patients. Again, here is an attempt to save costs in a way that undermines the NHS’s central mission of defending the wellbeing and health of the British people.

Difficult though some will find it to listen to advice from the Liberal Democrats, the ex-health minister Norman Lamb should be listened to when he warns the NHS could face a crash without an emergency injection of billions of pounds. It is worth considering what the NHS is going through. It has experienced the most protracted squeeze in funding since its foundation in 1948. Cuts to local care services are piling on extra pressure. It suffers from the combined legacy of private finance initiative (PFI) and the chaos of the Tories’ current marketisation drive, effectively stripping the “National” out of National Health Service.

Despite the Tories’ gimmicky and vague election promises of extra money, our healthcare system is in great danger. But where is the debate or the scrutiny? It will be health and lives imperilled without an NHS that is properly integrated and resourced. It would be naive to believe that incentives not to refer cancer patients and the scrapping of free hearing aids is the end of it. The direction of travel is clear, and it should scandalise us.

 

Time to stop the indemnity circus

Nigel Praities, editor of Pulse magazine, opines on 30th September 2015: Time to stop the indemnity circus . The only way out is no fault compensation…. Or a salaried service with corporate indemnity. The problems for practices in meltdown, where there are too few remaining doctors and no applicants, is that they have grasped the nettle of “nurse practitioner” to diagnose. And guess what, nurses are not trained to make a diagnosis…. The only circus like character is the minister – a clown?

 

Paying indemnity fees is a necessary evil for GPs, and I have never known a time when they’ve been popular. But the situation has become a circus.

Many GPs tell me they are giving up working in out-of-hours and other settings because the premiums are so high. And who can blame them? A recent survey by the Family Doctor Association revealed that GP indemnity costs have increased by 25% in just one year. Pulse recently reported that one out-of-hours GP was quoted annual premiums of up to £30,000 by a medical defence organisation (MDO).

This isn’t an isolated case. This year’s LMCs Conference heard the cost of out-of-hours cover for some is £35 per hour. And it is not just GPs. One practice recently saw fees for its advanced nurse practitioner rise from £900 to £8,000 in 12 months, despite the nurse facing no complaints during the year.

Premiums will only rise further as practices struggle to recruit GPs and employ staff such as pharmacists and physician associates. The NHS is desperate for practices to take on more specialist care to save cash, but that will mean more hikes in premiums.

And don’t get me started on plans for seven-day working (which are already leading to increases in indemnity costs) and the use of technology, such as Skype consultations, to manage demand.

This problem will not go away. But there is a big transparency problem with the MDOs. In the past, the big three have been able to give Pulse at least a ballpark figure of their annual rise for the average GP. Now, though, they provide no figures at all, merely saying they are based on an individual’s risk.

Pulse asked recently how much it would cost a practice to indemnify a physician associate but got no clear answer from the MDU, MPS or MDDUS. I have some sympathy for them as we live in an increasingly litigious culture, but in what other industry would this lack of transparency be tolerated? I can think of a certain meerkat that would be appalled at how these firms are behaving.

The truth is the system is bust. State intervention is needed to enable GPs to work across different settings and take on greater risk, at a price they can afford. If the health service wants GPs to work more flexibly it will have to find an affordable mechanism to enable them to do so.

In this respect, Wales is leading the way. It has included all GPs in its NHS ‘risk pool’ for out-of-hours. This has significantly cut fees and while there are things it does not cover – disciplinary hearings and criminal proceedings, for example – at least it is a model that has been shown to work.

LMC leaders recently voted to look at whether a crown indemnity scheme for all practices could work in England, and I understand NHS England is considering what it can do nationally. Whether managers can be trusted to choose a scheme that is effective, rather than cheap, is another matter. But I urge them to think imaginatively and quickly.

Any crown scheme needs to be comprehensive enough to make a real difference to indemnity costs. Other mechanisms, such as reimbursing fees for non-routine activity by GPs should also be considered, and confusion over how to indemnify new grades of practice staff needs to be cleared up.

The curtain needs to come down on the indemnity circus, and soon.

Litigation – The rising tsunami is swamping us all.. NHSreality lists all the posts on litigation in the two years of existence. NFC (No fault compensation) is essential.

Perverse behaviours – and perverse incentives. This is partly what drives doctors away…

The nature of the behaviours and the incentives in the English Health Service in particular is becoming more perverse. GP locums do get large salaries, but they are working in a market created and controlled by government. Successive Governments have ignored the longer term, and the result is what is in the news today. Perhaps this doctors never refers! (BBC News 2nd October – GPs being paid to cut patient referrals). He certainly does not want to rescue one of the increasing number of failing and closing practices. Perhaps he has signed Pulse’ petition (Stop Practice Closures). The perverse activity comes from administrators wriggling on the hooks of financial constraints and quality control… There is no answer except rationing overtly, and the covert incentives to restrict referrals is immoral.. Even the United Nations and the Kings Fund agree.. Such behaviours and schemes reduce a doctor’s self worth, and can drive them abroad.

Chris Smyth in The Times 2nd October reports: Doctor paid £500,000 as costs soar for the NHS

Britain’s best-paid locum doctor is to earn nearly half a million pounds from the NHS this year, The Times can reveal.

The earnings, which are the highest known for a hospital doctor working shifts to plug shortages in the health service, emerged as figures showed that the NHS bill for temporary staff had soared to £1 billion.

Patient leaders said it was unacceptable that at least eight locums were paid more than £250,000 last year. Growing numbers of doctors were tempted to become “permanent temporary” staff because they could earn so much more than in full-time jobs, they warned….

…This summer Jeremy Hunt, the health secretary, announced plans to set maximum hourly rates and limit the amount each hospital could spend on agency staff, saying that “taxpayers are being taken for a ride”.

However, Mark Porter, the chairman of the British Medical Association’s governing council, said last night: “With the NHS relying on locums more and more, the government’s policy is unlikely to have any real impact. In fact, clamping down on the market runs the risk of leaving hospitals with further shortages, putting patient care at risk.”

He said that stress and gruelling workloads were deterring staff from joining the front line, warning: “In some specialities, especially emergency medicine, this has contributed to a recruitment and retention crisis and the increasing need for locums.”

Earlier this year, The Times reported how hospitals were routinely paying stand-in A&E doctors almost £2,000 a day because staff refused permanent jobs in “war zone” departments. Some staff have been paid £3,500 a shift.

The Department of Health said: “Having the right number of staff is vital so we have prioritised and invested in the front line by employing 20,600 extra clinical staff since 2010 and committing to 5,000 more doctors in primary care by 2020. We are also supporting the NHS to employ the staff it needs at a fair price by introducing cost-control measures to clamp down on extortionate agency rates.”