Monthly Archives: January 2016

Breaking down monopolies in the medical profession

An article from the IEA( Institute for Economic Affairs ) think tank on the problems of too few doctors in the NHS( see article below) this links to a previous posting by NHSreality on a similar theme

https://nhsreality.wordpress.com/2014/06/23/economic-rent-and-competition-in-healthcare-a-uk-perspective/

justice-unblinded-crushing-anarchy-but-sparing-monopoly-cartoon-of-DD619Y

Breaking down monopolies in the medical profession

‘The monopolists, by keeping the market constantly under-stocked, by never fully supplying the effectual demand, sell their commodities much above the natural price, and raise their emoluments, whether they consist in wages or profit, greatly above their natural rate.’ So wrote Adam Smith in 1776, and he had corporations and statutes of apprenticeships such as that of the Royal College of Physicians in mind.

True to form, the Royal Colleges have never fully supplied the effectual demand for their services, their policy being to keep the numbers of Fellows as small as possible. They excluded the apothecaries, and later the general practitioners and specialists from the voluntary hospitals in the eighteenth and nineteenth centuries, and when the NHS began after the war, consultants made up a meagre 15 per cent of the medical profession in England, when at least 40 per cent were needed.

When Labour nationalised the hospitals in 1948 it added monopolies of its own. Socialists are ideologically opposed to private practice. They resent the way that consultants move between the NHS and the private sector. Thus Labour governments distorted the proportions of NHS consultants, general practitioners and junior doctors to minimise the number of private consultants. Constrict the proportion of NHS consultants, the strategy goes, and private practice cannot expand much, even if the NHS has far too few consultants as well.

The mechanism by which governments manipulate proportions of doctors is obscure.  It is done by expanding the proportion of hospital doctors who cannot be consultants. So, although ‘non-consultants’ made up 30 per cent of the medical profession in 1948, they were increased until in 2012 they had a monopoly of 43 per cent of NHS posts, an expansion that should have rung alarm bells decades ago. But if the health service was brought in line with better foreign systems, the number of consultants would increase by over 55 per cent and the number of general practitioners by over 50 per cent.

Waiting times

Governments thus have monopoly control over key parts of the health sector, public as well as private, and the consequences of state planning have been disastrous. Take waiting times for instance. The NHS has so few consultants that there have always been long waiting times, and there always will until we overcome the monopolies

For example, NHS patients who are referred to consultant outpatient clinics can wait for weeks or months for their first appointment. Time spent in waiting would be approximately halved, and certainly much reduced, if the number of consultants were to be doubled.

The same applies to patients who are referred to private consulting rooms. They too can wait, although waiting times are very much shorter than in the NHS. The reason is the same – there are far too few consultants. It’s a rough approximation, but outpatient waiting lists are inversely proportional to the number of consultants, and the number of consultants is inversely related to the number of junior doctors. This leads to a general conclusion that waiting times for first consultations are related to the number of junior doctors: they would be shorter if there were more consultants and fewer juniors.

This flatly contradicts the entire staffing policy of the Ministry of Health since 1948. The small number of NHS consultants is a bottleneck. It leads to a second conclusion, that private and NHS outpatient waiting times could both be sharply reduced.

However, having more consultants and fewer juniors would involve other doctors doing the service work that the juniors currently do. NHS statistics show that general practitioners admitted an average of one surgical patient every five days and two to three medical patients a week in 2012, and with a 50 per cent increase in their numbers, as described above, they could do many of the admissions themselves as general practitioners often do abroad.

The appointment of consultants at an earlier age, common abroad, would not however reduce surgical waiting lists greatly, because junior surgeons already do so many of the operations for them (although the increase in their number by over 50 per cent would help.)

Productivity

Nevertheless, it is not widely known that nationalised medicine is based on the repetition of hospital work: that a general practitioner usually makes the initial diagnosis, a house officer repeats it, a registrar confirms it, and when the consultant finally arrives the worst of the problems are usually over. And when the consultant is there the house officer and registrar present each patient to him, so they have to go over everything a second time. Of course there are illnesses in which large amounts of work take place in the weeks following the initial evaluation, but again, junior doctors take the initial crucial decisions and critical steps in treatment. There are variations between the branches of medicine and surgery, but overall the repetition of work in the NHS is enormous.

Furthermore, the European Working Time Directive rules that after eight hours the first ‘team’ must hand over to a second team, with yet more doctors and more repetition. One result is that junior doctors see NHS patients as a series of short term ‘cases’ who they will never see again.

But if the whole population were to be treated as private patients within an upgraded health service, only one or two doctors would be involved in each medical and surgical case, and productivity (output per doctor) could be approximately doubled, or in some cases even quadrupled.

Over-manning

Furthermore, consultants would not have teams of junior doctors if there were not over-manning, because over-manning is a familiar post-war problem for all nationalised industries. Over-manning shows that the NHS has lots of spare capacity and that productivity could be several times higher than it is, i.e. by raising the output of work of individual doctors.

When general practitioners abroad manage their own patients in district hospitals the productivity of the medical profession is increased to levels unheard of in Britain. The culture of the NHS would be utterly transformed if the monopolies within the medical profession were brought to an end, and if general practitioners were able to work independently alongside consultants in district hospitals. This is legal, though it needs a Trust’s permission.

Medical emigration

The National Health Service has so few consultants that over the last 65 years tens of thousands of potential consultants, fully trained and desperate for senior posts, have been rejected and flung as by a lunatic centrifuge to the rim of the English-speaking world, especially to America, Canada, Australia and New Zealand.

This is partly the result of a further monopoly. Immigrants make up approximately 13 per cent of the UK population, but foreign doctors have a monopoly of 34 per cent of the consultant posts in England, 22 per cent of those in general practice, 72 per cent of the Senior House Officers, and 71 per cent of the sub-consultants posts where, as Assistant Specialists and Specialty Doctors they are unable to have private patients. Indeed, the quota for foreign doctors is so large that it has crowded out UK-born applicants for consultant posts, leading many doctors to conclude that they can only obtain the level of responsibility which they seek if they emigrate.

State planning in general practice

A further set of problems is evident in general practice. Firstly, there is the ability of a group of general practitioners to monopolise health services over an area of 100-200 square miles. Within this area they can outvote competitors and block useful change. For example, the doctors in a health centre can influence the decision whether or not a new practice is needed in the area, and veto it if they feel threatened. They can block the introduction of new technology if they haven’t been taught how to use it, and they can, for instance, monopolise anaesthetics in community hospitals to keep contacts with consultant surgeons to themselves. And they can veto the facilities needed for hands-on maternity to prevent their lack of obstetric skills from being revealed.

Group practices and health centres have monopoly power that greatly reduces the potential range and output of work of general practice. Moreover, some groups of general practitioners under-perform all their lives, yet they still have large incomes and job security because monopoly of their practice area makes it impossible for new doctors to enter the scene, no matter how uncompetitive the incumbents are.

A second issue is the planning of out-of-hours provision. In 1948 a single-handed practitioner could manage his patients out of hours without referring many people to hospital. Twenty years later, as I saw in 1968 when health centres and group practices were increasing in size, a doctor in a group of three could be rushed off his feet at nights and weekends. A further twenty years on in 1988, groups of five doctors were so overworked that the quality of the work they provided was sometimes, through no fault of their own, little more than referral to hospitals. By 1998 the Department of Health’s obsession with larger and larger groups had continued until doctors in many parts of the country felt they had to join together out of hours so that, while one or two of them worked themselves into the ground, the majority could rest. And finally, by 2008 general practitioners felt they had to band together in massive cooperatives of 100 doctors, or more.

This did not, of course, in any way increase their access to the equipment and the hospital beds they needed to treat people themselves, nor did it increase the time they had for individual patients. What it did do was to increase the number of patients they had to send to junior hospital doctors out of hours, especially to Accident and Emergency Departments, where in 2014 large numbers of seriously ill patients make their own way to safety, some to wait and even die because the queues are so long. So much for state planning.

Finally, there is the controversial problem of part-time doctors. Women currently have a monopoly of 47 per cent of all the general practitioner posts in England, and the Department of Health plans to increase the percentage until women have a quota of over 50 per cent. But many women doctors choose part-time work, specifically so that they can spend time during the week with their families.

In competitive healthcare systems abroad patients appear to value continuity of care more than choice of gender. They prefer full-time general practitioners who will always be available to them, full-timers who will not pass them over to other doctors and back again. There is a different, superior culture in industry where jobs are won by the best applicants, but this cannot happen in the NHS as long as part-time doctors are allotted by the state. The best solution would be choice and competition, but that is only available in private practice.

The monopoly of state finance

Perhaps the worst monopoly of all is state funding. NHS doctors are salaried. There are no financial incentives for them to do much more than the minimum for each individual patient, no incentives to be more productive, to develop new, faster and better services. The ‘dead hand of the state’ is everywhere, and productivity is poor compared to the competitive fee-for-service health services found abroad, where competition between doctors produces much better results

In summary, six decades of state monopoly have produced far too few consultants and too few general practitioners, too many junior hospital doctors, worse clinical outcomes than those of other countries, the need for huge numbers of foreign medical graduates, recurrent crises in specialist training such as the rebellion of junior doctors in 1966 and the crisis in graduate education in 2007, the problems of the European Working Time Directive, decades of wasteful medical emigration, the dumping of large numbers of patients onto Accident and Emergency Departments by general practitioners, and last and certainly not least – long waiting lists.

David Joselin is the author of The Crisis in British Medicine.

https://nhsreality.wordpress.com/2015/07/16/7-day-working-in-england-can-the-other-regions-afford-it-are-there-enough-doctors-to-go-round-competition-for-recruitment-could-mean-doctors-all-move-to-england-wales-might-need-to-rebuild-offas/

https://nhsreality.wordpress.com/2015/03/07/its-the-competition-silly-just-as-the-health-service-is-a-market-for-services-the-world-is-for-doctors-more-and-more-doctors-considering-emigration-and-a-snowball-effect-is-possible/

https://nhsreality.wordpress.com/2014/11/07/private-members-bill-aims-to-repeal-competition-rules-in-nhs/

Which speciality is suffering most in medicine ? The US has some information

Medscape a US medical information and CPD site has just published this article on Physician burnout …. I wonder how the UK would compare .

 

Link below to a presentation on Physician burnout in the US by speciality

burnoutd

 

http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview?src=mkm_ret_160128_160131_mscpmrk_life_int&uac=82256EV&impID=974237&faf=1

Waiting times matter -especially in Wales – to see your GP, for investigation, and diagnosis as well as treatment.

Not everyone is able to assess the seriousness or the emergency nature of their symptoms. Stoics present later than neurotics, but a doctor who knows his patients will take this into account when he sees them. Waiting times matter – to see your GP, for investigation, and diagnosis as well as treatment. When interviewed on BBC News Vaughan Gething, deputy minister for health excused the difference by saying that Wales wanted to “focus on outcomes”. Since Wales deliberately chooses different outcome measures to England (and excludes England’s) there is no comparison possible for these outcomes, until the WHO reports it’s gross figures on mortality, perinatal deaths and maternal mortality in a couple of years time. Access to GPs is so poor that you can wait hours on the phone to get an appointment weeks ahead. When you see that Dr he may well not know you and your history on the stoic-neurotic index. If you despair and attend A&E or Out of Hours you will be competing with drunks on a weekend, and possibly wait 8 hours or more. After all, if you have broken the waiting target you might as well break it properly. Where access to investigations for important diagnosis exclusion is slow, or when the next stage, an appointment with the specialist is delayed, or when waiting lists for operations are long, outcomes will be worse. It looks as if there’s a long trail (and trial) ahead…

Owain Clarke and Nick Servini for BBC Wales reports 28th Jan 2016: NHS Wales: Waiting times worse than in England. (see graphics through the link)

NHS patients in Wales wait longer for treatment and diagnosis than patients in England for most of the main categories, BBC Wales can reveal.

Hip operations showed the biggest difference of four months, with an average wait in England of 75 days compared to 197 in Wales in 2014/15.

Diagnosis of heart disease takes on average 10 days longer in Wales.

Deputy Health Minister Vaughan Gething called for a focus on the results of treatment, not just waiting times.

Waiting times for hip surgery have deteriorated significantly in Wales over the past four years. Since 2011/12, the average wait has risen by a fifth for the nearly 6,000 people who had hip operations in 2014/15. 

Waiting times in Wales for the treatment of cataracts, hernias and some heart operations are around two months longer than in England.

Diagnosis of pneumonia takes two weeks longer in Wales and waits for stomach operations 12 days longer.

There were minimal differences in waits for heart procedures, diagnosis of cancer and head injuries, while waits for kidney operations were less in Wales than in England.

The figures are drawn from the headline figures measured in the Hospital Episode Statistics from the English NHS and the Patient Episode Database for Wales.

The difference in waiting times since 2011/12 and 2014/15 has narrowed significantly for heart operations but has grown for hip and cataract operations, and the diagnosis of hernias.

 

More than 40,000 routine orthopaedic operations take place in Wales every year.

But the numbers waiting more than six months for treatment has been increasing since 2012, and in 2015 a national plan for improving orthopaedic care was launched by the deputy health minister.

The NHS in Wales has also been tackling the backlog of cardiac patients on the waiting list.

Mr Gething said he did not accept there had been failings in the Welsh NHS, but added: “I know we have more to do.

 

“We want to have a system that properly runs on waiting for treatment that is acceptable, but importantly the focus has to be on outcomes.

“How do we run a service in a different way because we know we have lots more demand coming into the system with an older population?

“What we need to do in Wales is to have a real focus on outcomes and not just on treatment times.”

The Welsh NHS Confederation, which represents local health boards and trusts, said waiting times “capture only one part of what the NHS does”.

“Much of the work carried out by the NHS is helping people to manage long-term conditions, often in primary care and the community, and avoid the need for hospital admission,” a spokesman said.

“While waiting times will always be a priority, our members will continue to work hard to improve the quality of care, and people’s health and well-being in the future.”

Welsh Liberal Democrat leader Kirsty Williams said: “Time after time Labour ministers have ducked and dived, claiming statistics aren’t comparable.

“Yet these figures are stark, and make it explicitly clear that waiting lists are much longer in Wales than in England.

“After 17 years, Labour’s legacy on the NHS is one of failure. They should be ashamed of these figures and, quite frankly, the people of Wales deserve an apology.

“The Welsh Liberal Democrats will deliver an NHS that puts patients first.”

Plaid Cymru health spokeswoman Elin Jones said: “Month on month, the Labour Welsh government fails to achieve its targets for routine matters such as cancer treatment waiting times, referral to treatment waiting times and waiting times for crucial diagnostic tests.

“Labour’s inability to plan the workforce properly, tackle blockages in the system and meet its targets is putting NHS workers under incredible daily pressure.

“Plaid Cymru plans to drive down waiting times by increasing capacity in the health service through training and recruiting 1,000 extra doctors in Wales, by establishing three dedicated diagnostic centres across Wales, and by fully integrating health and social care services to improve patient flow from admission and beyond.”

General Practice ” in a state of emergency” declares GPC chair

Update 21st March s016. Alex Matthews-King in February in Pulse: Practices’ redundancy and premises costs could be covered in CCG’s merger drive

Chaand Nagpaul’s speech to the LMC special conference in full courtesy of Pulse online magazine

The explains covert rationing by deliberately being unsafe in systems, capacity and skills (editor). Nobody is to blame except our political masters and the first past the post system. Long term capacity planning is beyond them. The Doctor is powerless.. The system is in meltdown and just a few GPs remain on the last ice..

Slide1

The mere fact that an extraordinary conference has been convened, bringing GP representatives from all corners of the UK to London on a Saturday, speaks volumes about the state and crisis facing general practice today. We should of course not need to meet at all, since today’s reality was both entirely predictable and preventable.

Using Simon Stevens own words last summer ’we’ve systematically underinvested in general practice for at least 10 years’. This progressive resource starvation and thoughtless workforce planning has resulted in the proportion of NHS doctors who are GPs reducing from 36% to 25% in two decades and with fewer GPs per head today than 2010.

Yet we’re now seeing a record 370m patients annually in general practice- that’s 150,000 more patients daily compared to 7 years ago. This gross mismatch between demand and capacity is untenable, with both GPs and patients suffering the dire consequences.

This conference demands an end to the pretence that all is well on the road to recovery. It’s not.

Patients are being short-changed on a daily basis, with nine in 10 GPs stating that workload pressures are damaging quality care to patients.

This is a disgrace in a system in which the government promotes quality and safety as central to the NHS.

It’s not safe nor sustainable for GPs to see patients with complex multiple morbidity in 10 minutes, many of whom will be on over 10 different medications, and with heightened risk of medical error.

It’s not safe for GPs to have up to 70 patient contacts daily conveyor belt style, and on top of that plough through 100s of clinic letters, pathology results and reams of repeat prescriptions.

It’s not safe to discharge patients out of hospital and expect GPs to manage complications beyond their competence. It’s not safe for investigations to be requested by other doctors, and ask GPs to chase them up and blindly interpret them.

It’s not safe for GPs to be told to prescribe specialist drugs outside their expertise and worse without even seeing the patient.

It’s not safe for GPs to be examining patients while simultaneously having to take urgent calls from hospitals, district nurses and social workers, and also be called for an emergency home visit at the same time. It is not safe for practices struggling with unfilled vacancies to be forced to carry on registering patients when they haven’t the doctors or nurses.

And it’s not safe to fuel the political hyperbole of routine seven days services, taking GP away from ill elderly housebound patients in greater need.

To put it simply, it is not safe to carry on the way we are, and which is why this conference is highlighting that general practice is quite literally in a state of emergency

And we must put an end to the adulteration of the word “safety” by an inspection regime in England that measures safety in terms of curtain cleaning schedules, scrutinising minutes of meetings and expecting an encyclopaedia of polices as an end in itself.

And this is why GPC has totally rejected CQC’s proposals to hike its inspection fees seven fold, since we’re challenging root and branch a process that is disproportionate, nit-picking, crude and flawed.

There are more motions on CQC than any other part of the agenda today highlighting the damaging impact this regime is having, and why over 1900 practices responded to GPC’s current CQC survey in less than 2 weeks.

Nine out of 10 GPs believe that CQC’s ratings are flawed or misleading, and less than 3 in 10 practices rated ’good’ felt their inspection was an accurate measure of quality, and so it is not about an axe to grind. Nearly 8 in 10 practices say they reduced care for patients while spending days per month in preparatory paperwork, and thousands of appointments nationally are cancelled on the days of inspections, denying patients access to GPs and nurses.

Of course we need to regulate for safety, and we’re not talking about turning a blind eye to poor care.

But what we don’t need is a bloated behemoth charging £40m to identify 4% of practices deemed inadequate, while the true cost to the NHS is far higher with practices spending millions more on GP locums, overtime and backfill in preparing for and enduring inspections. This could instead pay for up to 1000 more GPs to provide frontline care for patients

Further it’s tragic that GPs and practices live in a climate of fear, in which CQC takes no account of your circumstances, and blames, names and shames you even if you’re running on empty with skeleton staff, or locked into inadequate premises not of your own choosing.

Eight out of 10 practices said preparing for CQC inspections was ’very stressful’ at a time of already rock bottom morale, and 80 % of GPs stated they’re more likely to want to leave the profession as a result

Our survey also showed CQC refusing to reschedule inspections even in extenuating circumstances when the lead partner or practice manager was off sick, adding further stress and tarring practices with a public label based on visiting them on the wrong day.

Yet CQC has the double standard of unilaterally cancelling inspections at a moment’s notice. We received several hundreds of heart-breaking comments from practices in our survey, but I’ll give just one example: ’We are fearful. I feel bitter because the workload and pressure in preparing was that high that decisions were made such as not visiting some terminally ill patients. The extra mile of caring we do was devoid in the weeks to the lead up to the CQC visit.’

Shameful.

What’s tragic is that 1 in 4 practices state they are less likely to raise concerns about practice pressures because of fear of CQC reprisals, and it’s a travesty that a regime designed to regulate for safety is itself perversely undermining safety.

The government clearly appears not to have read a single word of Don Berwick’s post Francis safety report commissioned by the Prime Minster himself in which Berwick calls for an end to a blame culture in the NHS and highlights that safety is in the hands of systems not individuals – I quote: ’NHS staff are not to blame – in the vast majority of cases it’s systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.’

Conference it’s therefore outrageous and unacceptable that we have a law compelling practices to pay for a regulatory system they believe to be flawed, one that does not measure quality fairly and in fact undermines it, and worse a system that’s compromising safety with collateral damage to the majority of hard working practices.

So no Conference, we have absolutely not failed as a profession, rather a costly unfit for purpose regulatory regime has failed English general practice and patients alike.

And it’s this very regulator that is inadequate and needs to be put into special measures, so that GP surgeries can be given the support, resources and time to improve quality, assure safety and be there caring for our patients.

I’ve already put to government a simpler, cost effective and proportionate alternative based on targeted support to ensure safety, with quality improvement being a facilitative peer review process.

Let’s now talk about being ashamed. You know what I’m ashamed of? I’m ashamed of successive governments that have callously disregarded the needs of patients by defunding general practice from 11% to less than 8% of the NHS budget, to the extent that GPs are forced to process patients akin to an assembly line, in which GPs aren’t even afforded the health and safety limits provided to other workers.

I’m ashamed there’s been a rocketing of GP practice closures in the last year, displacing over 200,000 patients forced to re-register. I’m bitterly ashamed that the Commonwealth Fund recently reported that the UK – the birthplace of holistic general practice – now has the most stressed GPs who spend the least time with patients out of 11 western nations studied

I’m ashamed that the government considers it a crisis if an arbitrary 94% rather than 95% of patients are seen in less than four hours in A&E, while totally ignoring the far greater crisis that 1 million patients daily are denied the quality of care GPs would like to provide.

I’m ashamed that politicians recognise the term ’deficit’ in all sectors of the NHS except in general practice where the word ’bailout’ doesn’t exist either. And while I’m immensely proud to be a GP, I’m ashamed that I’m working in a system that prevents me from doing my job properly caring for patients.

Conference, while we must keep shouting from the rooftops about the crisis affecting general practice, ultimately we have come together today to discuss solutions – about how to resuscitate general practice, how to ease the pain and exhaustion amongst a demoralised workforce, and how to build a sustainable future for a job that means so much to me, to you and of course to our patients.

The first priority must be to stabilise the current brittle landscape and support practices at risk of imploding from harsh funding cuts, or practices at a tipping point unable to recruit. I’ve said before that only a 6% reduction in general practice capacity would double the number of patients attending A&E if they went there instead.

The government therefore cannot afford for a single practice to close unnecessarily since this costs hugely more in hospital costs and the expense of picking up the pieces. It isn’t a case of the government not having money, but about responsibly saving money by saving practices.

And it’s a scandal that area teams say they don’t have tens of thousands of pounds to stop a practice closing, but can in the same breath spend over a million pounds on challenge fund schemes to pay GPs to sit in empty surgeries on Sundays. This is plainly morally wrong.

So in England the government has made £10 million available to support ’struggling practices’.

This totally misses the point that all GP practices are struggling, even those branded outstanding in CQC inspections tell us they are fighting for survival and are equally vulnerable to closing. And the idea of providing a crumb of resources on a one-off basis to a few won’t solve the problem.

Conference, general practice does not need a disaster relief fund – it needs proper recurrent and sustained resources for all practices to have the infrastructure and capacity to meet relentless escalating demands.

We also require proactive support. We’re all vulnerable – even the most apparently secure practice today could be a victim tomorrow, with one partner retiring early, another falling sick, a nurse going on maternity leave and if there aren’t the applicants to fill vacancies it will suddenly find itself on a cliff edge.

We hear of such examples daily. Sadly countless practices have needlessly folded and destabilised patient services, and which clearly could have been avoided by pre-emptive plans.

We need a system in which practices worried about their ability to cope can hold their hands up in advance in a nonthreatening climate, with resources to support them to get back on their feet, and protect patient services – not wait for them to keel over to be labelled a struggling practice.

GPC has already put specific proposals to NHS England to resource local resilience teams, with GPs, nurses and managers able to be parachuted to any practice at short notice. GP federations for example could be funded to do so, and it is incumbent on government to safeguard patient care by implementing this forthwith.

We also need immediate workload limits. Inappropriate, unfunded, and excessive workload has to stop in the name of patient safety, and our BMA survey showed this is the greatest reason driving GPs out of the profession.

We cannot continue to allow GPs to work inhuman hours in a day with a punishing intolerable intensity.

GPC produced our Quality First workload management document a year ago- and it’s crucial to restate that our contractual professional duty to patients is to provide them with essential services.

No patient should suffer from a GP not being there for them because the GP is diverted doing work outside their contract.

No indemnity organisation or the GMC will come to our rescue and consider exhaustion or overwork as mitigating factors if safety is compromised. We therefore need a shift in mind-set where we must cut our cloth according to the resources we’re given to safeguard our own and our patients’ health, and openly challenge and whistleblow any national and local system that undermines this.

Put another way we must learn to say ’no’ to that which takes us away from doing our core job, in order to say ‘yes’ to providing safe quality care for our patients.

NHS England’s own commissioned research ’Making time for general practice’ published in September staggeringly revealed that 27% of GP appointments were avoidable. Hardly surprising when the suffix to any unfinished work is ’see your GP’. We cannot continue playing pass the workload parcel where the music always stops at the door of general practice.

As a result GPC is working with NHS England to run a series of roadshows with LMC involvement starting next month specifically with the aim of reducing inappropriate workload, bureaucracy and releasing capacity.

The government has accepted our call for an end to automatic GP re-referral of patients missing hospital appointments, and GPC will be seeking an end to GPs chasing up hospital test results and follow up appointments, as well as enabling appropriate internal secondary care referrals with patients having direct access to hospitals for problems post discharge.

This needs coordinated work on the ground by LMCs, practices, hospitals and commissioners to collectively put in place local systems of workload management.

And a non-negotiable principle is that resources must follow where care is delivered. More out of hospital care means more out of hospital resources period

But we must also manage demand. Given the government a year ago launched its ’say no to A&E’ campaign to use emergency services appropriately, it’s shameful that in the same breath we’ve seen the stoking up of demand on GPs in the face of dwindling resources.

GPC calls upon government to similarly put out an unequivocal public facing message that general practice too is crippling under strain, that it needs to be used wisely, and to signpost patients to use other services where appropriate.

The government must also back a national self-care campaign to empower patients to manage their own health for both minor and chronic conditions, avoiding having to unnecessarily sit in GP waiting rooms full of ill people

Turning to workforce, the pronouncements of 5000 extra GPs by 2020 is an irrelevance given the government’s total oblivion to the elephant in the room – which is retention.

The government’s own commissioned GP worklife survey from the University of Manchester published just three months ago shows 38% of GPs intend to quit in the next five years, even higher than our own BMA statistics; That represents a loss of over 10,000 GPs that will wipe out any increase in recruitment.

This is compounded by increasing numbers working part time due to workload pressures, resulting in net reductions in GP capacity below crude headcounts.

So what can be done? Well you aren’t going to improve retention nor recruitment by just talking up the job with promotional videos, flying in the face of the reality of an overstretched exhausted workforce. The job has to sell itself in actuality, and that means putting in place a manageable and rewarding workload, so that medical students and foundation doctors when they experience general practice want to be GPs and existing GPs want to remain in a job they enjoy.

Therefore while we’re thousands of GPs short today, and given we simply can’t magic up GPs tomorrow, we need immediate skill mix support from other healthcare professionals who can see some of our patients, do much of our clinical administration and ease our workload burden. And that needs resources- not pilots of short-term funding to a few, but sustainable resources and follow the lead in Northern Ireland where every practice will be supported by a fully funded pharmacist.

And we need primary care teams working across the walls of GP surgeries, with integrated community nurses and health professionals visiting and caring for vulnerable housebound patients putting an end to the GP always being the first port of call regardless of whether they are the best person to deal with the problem.

Conference, we are here today as representative leaders and we also need a fighting spirit to do what we can ourselves to protect our discipline, and to restate our status as GPs and independent contractors in which we do have some control over the way we work and organise ourselves.

That’s why a key proposal from GPC’s vision document is to create networks of GPs and practices supporting each other to facilitate collaboration, share resources, staff and provide cross cover with the strong protecting the weak.

A spirit of collectivism where we see ourselves as one GP profession, working with and for each other in local communities with common identity and synergy between sessional GPs and partners, rather than working in parallel to each other.

And that’s where LMCs come in as brokers, leaders and change agents to create this community of collaborative GP resilience. Networks that cater for the increasingly diverse career aspirations of GPs, including those who wish employed status and portfolio working but with career progression and inclusivity rather than the current sessional arrangements in which many feel disenfranchised.

And this is why we have told NHS England to give us the organisational funds to create such networks. And for the avoidance of any doubt this is not about diminishing individual practice units, but strengthening and protecting practices both small and big, so that they are sustainable. Because the practice unit is the kernel of personalised continuity of care that defines the absolute success of UK general practice.

I want to talk now about our patients. They are our allies and we exist because of them, and I’d like to thank them for seeing through the media smears and mud that’s slung at us, and for continuing to have faith in us with recent figures showing 92% of patients trust their GP, higher than any other profession, contrasting with 16% who trust politicians. And an extraordinary 85% of patients are satisfied with their GP service in the recent National GP survey in spite of the fact we are working against all impossible odds.

We must never take this support for granted, and why whatever measures need to be taken to deliver a safe and sustainable service, they must be taken with our patients understanding our plight, with them on side, and in partnership with them.

Our patients must be told that the reason they’re waiting longer to see a GP, the reason we don’t have enough time for them is not of our making, but a direct result of government neglect where we’re at least 10,000 GPs short to meet demand. And we will argue the case for general practice from the moral high ground that our earnest aim is to be given the tools and space to do our jobs and what’s best for patients, and unlike politicians it has nothing to do with the vested interest of electoral timeframes or winning votes.

I want to scotch the oft quoted myth that all we do is complain without solutions, since I’ve today described a wealth of ways in which general practice can be turned around from a vicious cycle of negativity into a virtuous cycle of positivity. GPC produced a comprehensive solutions document last year, and we will spell out more in launching our imminent campaign an Urgent Prescription for General practice.

Conference, we’ve heard lots of platitudes from the centre over the past year. We heard about the New Deal that never was. The Five-Year Forward view is explicit about the need to rebalance funding in favour of primary care. And most recently Jeremy Hunt stated he will announce a support package for general practice in February.

We are sick of hearing just words, but now need to throw them back to government to demand real delivery. We don’t want to hear about last year’s money rebadged as a new resource. We don’t want to be to be told about what may or not happen in 2020. What we need to know is what the government is going to now do to enable 1 million patients daily to receive a safe and sustainable GP service today

I’m constantly told by ministers that the greatest battle is getting money out of treasury.

My message to the chancellor is to use his financial nouse- stop penny-pinching and be pound wise, grab yourself a bargain while there are GPs out there because once they’re gone they’re gone – since it costs £136 for all-in unlimited care and home visits per patient per year which is less than the price of walking through a single outpatient clinic door once

So, Conference, today marks the great fightback of UK general practice. I urge government to do the right thing for patients and equally the right thing for a GP workforce whose goodwill continues to be shamefully exploited. And to protect and nurture a discipline that’s not just the jewel in the NHS’s crown but a beacon of personalised continuity of care internationally. And to make 2016 the year in which we begin the revival of UK general practice so that we have a future generation of GPs to look after a future generation of patients

Low doctor count makes NHS “mediocre”

From Doctors.org.uk

Low doctor count makes NHS “mediocre” – study 1026/01/2016

The UK has one of the lowest proportions of doctors in Europe – helping to explain overall failings in health care, according to a study published today.

Out of 35 European countries studied, the UK came 28th for the number of doctors for every 100,000 people.

Overall the study ranks the NHS as the 14th best service in Europe, matching countries such as Slovenia, Croatia and Estonia.

The Euro Health Consumer Index is produced by Swedish analysts Health Consumer Powerhouse.

It ranks the Netherlands first, Switzerland second and Norway third.

The report marks the UK poorly for GP and A&E waiting times and for its ability to offer scans within a week for potentially serious illnesses together with access to cancer drugs.

It says there have been some successes in the UK, leading to improvements in heart and stroke care and reductions in traffic accident deaths.

Partnership chair Prof Arne Björnberg said NHS performance had been “mediocre” since the start of the surveys ten years ago.

He said: “Problems are: autocratic management of a very skilled profession, resulting in waiting times, mediocre treatment results.”

https://www.politicshome.com/health-and-care/articles/story/nhs-mediocre-due-lack-resources-report

http://www.primarycaretoday.co.uk/news/uk-healthcare-system-%E2%80%9Cmediocre%E2%80%9D

The sick parade – of GP closures. This list heralds the end of the health service as we knew it.

There is an increasing sick parade of GP practices throughout the country. It may be worst in the North East and Wales, but it is endemic and generalised. It is probably too late to save the old GP model now, as there are so many GPs needed, and with retirement, leavers, part timers and locums, the numbers cannot be made up in time. Suffolk needs 300 more and Wales 400 more and that’s just 7% of the UK. The combination of entries listed below heralds the end of the health service as we knew it. As Chris Smyth reports in The Times 27th Jan 2016: GP shortage hits thousands of patients (see text at end of this post)

The West Briton 26th Jan 2016 – Cardrew Health Centre closure “devastating news” for Redruth

Tavistock Times Gazette 23rd Jan 2016 – Tensions run high at Okement Surgery public meeting

Nottingham Post 22nd Jan – Planned closure of GP surgery labelled ‘appalling

The Sussex Argus 22nd Jan 2016 – Funding row led to health group withdrawing running from five Brighton surgeries

Noth Ormesby Gazette 22nd Jan 2016 – Patients ‘very worried’ about potential closure of North Ormesby and Eston Grange walk-in centres

The Express and Star Jan 21st 2016 – Public meetings on future of Dudley GP surgeries

The Daily Update 18th Jan 2016 – Surgeries in parts of Suffolk need 33% increase in GP numbers to cope with patient demand

The Coventry Telegraph 16th Jan 2016 – Thousands of patients forced to find new GP after Coventry surgery announces closure

The Bradford Telegraph and Argus 15th Jan 2016 – Closure of Bradford doctorssurgery would be ‘disaster’ for thousands of patients in deprived area ..

The Epping Gazette 14th Jan 2016 – Angry patients have worst fears confirmed after surgery is “closed by stealth”

The Cambridgeshire News 8th Jan 2016 – Closure of surgeries to new patients show Cambridgeshire GPs are ‘facing a real crisishttp://www.bedfordshire-news.co.uk/Lansdowne-Road-8203-GP-closure-doctors-ordered/story-28391499-detail/story.htmlhttp://www.bedfordshire-news.co.uk/Lansdowne-Road-8203-GP-closure-doctors-ordered/story-28391499-detail/story.html

Nursing in Practice 6th Jan 2016 – Practice list closure applications rise by 100

The Echo 20th December 2015 – GP surgery threatened with closure if it fails to improve within six months and Third Denbighshire GP surgery to close after doctor resigns from Betsi Cadwaladr contract

Bedforshire on Sunday 19th December 2015 reports – Major Bedford GP practice ‘unable to replace doctors’ terminates NHS contract

The Daily News 18th December 2016 – Reigate MP concerned over possible South Park Medical Practice closure

BBC News 10th December 2015 – Donegal surgeryclosed for months’ after flooding

East Anglian Daily Times 18th October 2015 – Inquiries into closure of two Lowestoft GP surgeries

Northumberland Gazette 16th October 2015 – Harbuttle Surgery to reopen but some question marks still remain

Norfolk EDP 15th October 2015 – Two GP surgeries are closed by court order ‘with immediate effect’ for first time in East Anglia

News North Wales 13th October 2015 – Plans drawn up for Prestatyn after closure of two GP practices

East London and West Essex Guardian 13th October 2016 – Surgery’s walk-in service facing closure

Daily Post 9th October 2015 – Blueprint for Prestatyn GP surgery cover being drawn up after two practices announced plans to shut

The Huffington Post 3rd July 2015 – 43 GP Practices Close After Funding Reform Prompting Fears Of A ‘Quiet Crisis’ In The NHS

In BBC News 17th April 2015 – Two GP surgeries close in Rugby, Warwickshire

Essex County Standard 13th March 2015 – Villagers left in limbo over closing GP surgery and Thurrock Labour slam loss of Tilbury GP surgery

The Sheffield Star 16th March 2016 – Thausands sign petition against Sheffield surgery funding changes

The Lincolnite 11th March 2015 – Burton Road GP surgery saved after closure threat

Joanna Hunt in the Worthing Herald 6th March 2015 reports – Patients are outraged at the “atrocious” way NHS England has handled the short notice closure of two GP surgeries.

Patients are outraged at the “atrocious” way NHS England has handled the short notice closure of two GP surgeries.

Albert Street Medical Centre in Rugby and Brownsover Medical Practice, in Bow Fell, Brownsover, will close on April 17 when the NHS contracts comes to an end.

The Independent 3rd March 2015 – 500% increase in GP practises seeking advice on closure

169 GP surgeries contacted NHS England between April and December last year for advice on closing

Pulse 25th February 2015 – GPs offered £25 per patient they register after practice closure leaves thousands without a GP

The Kidwelly Star reports 19th Jan 2015 – Hywel Dda University Health Board takes on new GPs at Kidwelly surgery, as the practice keeps going under “special measures”.

Pulse reports 16th April 2014 – GP practice sets ‘red button’ closure date after losing MPIG funding

 

Chris Smyth reports in The Times 27th Jan 2016: GP shortage hits thousands of patients 

Two hundred thousand patients were forced to move GP surgery last year, a four-fold increase since 2013.

Dozens of surgeries have closed as family doctors either gave up or merged with other practices to cope with a shortage of GPs, official figures show.

Doctors warned that elderly or vulnerable patients were being left without care as surgeries shut. Maureen Baker, chairwoman of the Royal College of GPs, warned of a “genuine danger to patient safety” as a result of overstretched GPs.

In 2013, 11 GP practices closed and a further nine closed after mergers, forcing 43,649 patients to find a new doctor or travel further to keep their existing one.

Those figures surged over the next two years. Last year 31 practices closed entirely and 41 shut surgeries as part of mergers, displacing 206,269 patients, according to NHS England figures given to Pulse magazine.

Roger Goss, of Patient Concern, said that closures “can be very disruptive because the majority of patients are older and less mobile”.

Jeremy Hunt, the health secretary, has promised to recruit thousands more doctors and pump £2 billion into the GP system over the next five years.

However, Richard Vautrey, deputy chairman of the British Medical Association’s GP committee, said that there was a crisis now. “It’s becoming increasingly difficult for small practices to cope with rising levels of bureaucracy and manage their workload,” he added.

 

 

 

 

 

 

A microcosm of the whole – Cardigan GP practice disintegrating slowly…

The GPs working in Cardigan Health Centre are long suffering. Their premises are not up to standard and they have been awaiting new ones for years. Finally they are being built but recently the GPs  handed in their notice to terminate their contract from April 1st. A last minute reprieve occurred when one of the partners agreed to remain part time for a year rather than retire. What this will mean for patients remains to be seen, but NHSreality has predicted that primary care might degenerate like dental care. Various media sources are listed below… There will be 8000 patients for two doctors when the part timer stops work. The result of prolonged undercapacity rationing of professional training.. It takes 10 years to train a GP. Wales takes in 200 per annum, and retirement is at a greater rate as GPs disintegrate themselves.. Where will the extra 400 come from, and when?

17th May1985 – Hospital plan is unveiled, Cardigan Tivyside

20th June 2006: – Doctors raise concerns over hospital future

21st Jan 2014 – GP: “We’ve been misled and patronised” (Teifiside advertiser)

1st March 2014 – Cardigan health centre work ‘to start in 2015’ – BBC News

14 Dec 2014 – Plans unveiled for new care resource centre for patients in Carmarthenshire, Ceredigion and Pembrokeshire

23rd June 2015 – Plans for £20m care centre in Cardigan given approval

18th March 2015 – Another delay for new Cardigan health centre

16th Nov 2015 – ‘Make your future part of our future here in Wales’ Health Minister Mark Drakeford urges junior doctors to train, work and live in Wales

18 Nov 2015 400 more GPs are needed in Wales to avert a ‘deepening crisis’, says Royal College

20th Jan 2016 – Work on health facility could begin soon

23 Jan 2016 – Health watchdog warning over temporary hospital boundary changes

1st December 2015 – Pembrokeshire has most empty GP posts in Wales (Western Telegraph)

 

The health divide increases. Doctors deny patients the right to choice..

Choice and diversity are the issues which West Wales is trying to attract workers with.

Unfortunately choice in the Welsh Health service has long gone. Now it appears that the reality of lack of choice is apparent to the English Health service. Chris Smyth reports 25th Jan 2016 in The Times: Doctors refusing patients the right to choose hospital. Choice is only important to the population when there is overcapacity. We have undercapacity, therefore choice is unimportant within the state health services. This means choice becomes a “private” option, either by direct payment or insurance. This increases the health divide (see previous posts below). We have a choice – ration covertly as now, or overtly as advocated by NHSreality. The Guardian leader refers to the National Sickness Industry, and advocates choice for consumers. It fails however to advocated duty rather than rights, and overt rather than covert rationing. (a recent example of the latter is exclusion of docatexel for prostate cancer – now changed – in England)

Health is closely correlated to Wealth – If you are poor you get no choice (Wales), and live a shorter life, but if you are rich, or born abroad, you live longer and you do get choice! So much for equity…

The Election. Health v Wealth? Or a more balanced approach…

Health is Wealth: How parts of Britain are now poorer than POLAND with families in Wales and Cornwall among Europe’s worst off

Stop the NHS runaway train before it’s too late. The health service is consuming all our wealth ..

The times article reads:

Fewer patients are being given a choice over where they are treated by the NHS, prompting warnings that their care is suffering.

Forty per cent of patients were offered a choice of hospital and clinic by their GP, down from 50 per cent in 2010, according to official surveys.

Advocates of choice say that family doctors are neglecting patients’ rights as they revert to “default” local hospitals, and that they are getting away with it because choice has slipped down the agenda while health chiefs deal with a financial crisis.

Howard Freeman, the medical director of the NHS Partners Network, said: “It’s how GPs are programmed to work — we keep coming back to the default position of the local hospital. Choice is something that has to be programmed into them — and it was in the 2000s.”

Giving patients the right to choose where they are treated on the NHS was one of the main health policies of the Labour government. The proportion of patients who remembered being offered a choice of hospital or clinic increased from 30 per cent in 2006 to 49 per cent four years later.

Despite significant reforms that were criticised by doctors for broadening the scope of markets within the NHS, Conservative ministers have made little fuss about the importance of patient choice.

The latest survey found that only 40 per cent of patients were offered a choice over where they were treated, and that only 47 per cent were aware that they had the right to choose where they were treated.

Dr Freeman said that GPs ought to be confronted with data showing how many patients they had referred to places other than the local hospital, so that they could compare themselves with their colleagues.

“We do need to focus on it again,” he said. “The drug industry gets people to go round reminding prescribers about their products. What we need to be doing is reminding people about this product.”

He added: “It is better for patients, that’s one thing I’m absolutely clear about. Many patients [think] that a hospital is a hospital and they’re all the same. As a clinical professional, I know that’s not correct.”

Richard Vautrey, the deputy chairman of the British Medical Association’s general practitioners’ committee, played down the importance of choice, saying: “It’s never been a significant priority for patients. They are more interested in having a good local hospital than travelling.”

He added that while choice was fine for big cities, it did not mean much in rural areas and was deservedly taking a back seat. “It’s become less of a political priority. The focus is very much on the integration of services and bringing local health bodies to work together rather than on competing. I don’t think there’s very much evidence that choice is driving [improvement]. It leads to a more fragmented service.”

 

Why don’t doctors come to rural Wales?

Not enough doctors trained, lack of aspiration, falling educational standards. Sian Griffiths reported in The Sunday Times 24th Jan 2016: Welsh pupils ‘risk being left behind’ and prospective medics for Wales might consider The Sunday Times Schools Guide where The UK’s top 2,000 schools revealed (England only) so they can find comparators – and they cannot for Wales. Welsh education has been in decline compared to the rest of Europe for some time. Nicola Woodcock reports on the increasing competition to live in aspiring areas Number of pupils at grammar schools is highest for 35 years – these are the areas with most competition to be a doctor. How close are the rural shires to civil unrest can be assessed in the BBC “Any Questions” in Pembroke Dock this week. Readers may now feel more able to answer the question, but there are other factors such as ignorance of how sociable we are, and how beautiful the country is. Bringing back grammar schools might help, as then more students might obtain places in UK medical schools. Changing the politics might help.. It looks as if education as well as health has suffered under devolution. Wales needs to empower it’s youth to aspire and achieve. Even the Economist in “Young, gifted and held back” agrees.  They say that, contrary to the Liberal promise, smaller class sizes are not necessary. This is however what parents want.. West Wales wants to attract GPs. This video may help, but it does not address the educational deficit.

Update 30th Jan 2016: Melanie Phillips in The Times (School class warriors only hurt the poor ) opines…”The real issue is social mobility. Class war has been the battle cry of the left for decades. But they have merely widened the divisions. Obsessed by equality and redistribution, they set about replacing the notion of a meritocracy, with its winners and losers, by the supposedly level playing field of the comprehensive school.

Social mobility has gone backwards ever since. A study by Oxford University published last year reported that, over the past four decades, it had become more difficult to rise up the social ladder; young people were even sliding downwards.

Back in 1997, Andrew (now Lord) Adonis and Stephen Pollard wrote in their book A Class Act: “The comprehensive revolution has not removed the link between education and class but strengthened it.”

ITV News 25th Jan 2016: Concerns about ‘variability’ in the quality of education in Wales

South Wales Argus 26th Jan 2016: Education chief: ‘Schools must take a fresh look at teaching …

The Sunday Times article. PUPILS in Wales are at risk of being left behind in the global competition for jobs and university places, the chief inspector of schools for England has warned.

In a controversial interview ahead of a television documentary about the Welsh education system, Sir Michael Wilshaw said: “I am of the view that the English education system is moving ahead quickly . . . It now really is up to the Welsh government to look at its own performance to ensure it matches the performance of England.”

Wilshaw’s intervention comes a few months before elections to the Welsh assembly in May. Control of education is devolved to the assembly.

About half (48%) of state school pupils in England went to university in 2013. By contrast, it was 36% in Wales.

Wales also ranked bottom of the UK countries for maths, science and reading in the 2012 Programme for International Student Assessment (Pisa), a study of 68 countries by the Organisation for Economic Co-operation and Development.

Andreas Schleicher, the director of Pisa who will also appear in It’s an Education, a BBC1 Wales documentary to be broadcast on Tuesday at 10.40pm, warned that the teenage children of Chinese builders performed better than the offspring of the wealthiest professional families in Wales.

“Poverty is a challenge but poverty is not destiny,” he said. “You can see, for example, that the 10% of the poorest children in Shanghai come from backgrounds where their parents have no education, where they work as construction workers in the large cities.

“Those children outperform the 10% of the most privileged children in Wales.”

Wilshaw suggests the decision by the Welsh government to scrap performance measures — such as school league tables based on exam results and the national testing of 11 year olds in maths and English — may also have contributed to a decline.

“If you take away those accountability measures it drives down standards rather than drives them up. My view is that that’s what probably happened so they might want to reconsider those policies,” he said.

He also suggested that the Welsh government should consider copying England by allowing schools to become academies, which are free from local council control. “Bureaucracies do not improve schools. People sitting behind desks in the town hall do not improve schools,” he said.

Huw Lewis, the Welsh education minister who recently announced he would step down from the assembly after the elections in May, rejected Wilshaw’s criticisms.

While he accepted that the 2012 Pisa results had been “a wake up call”, Lewis said steps had been taken since then to improve education in Wales.

Lewis insisted that reforms in Welsh education since 2012 were working and said he was confident that Wales’s scores would have improved when Pisa’s next rankings are published in December.

Update: The parlous State of NHS Wales and its aspirations does not help doctor recruitment.

The Welsh Government (Assembly) is a parasite. It is sucking the life out of Health and Education

Education Education Education!!! Our politicians have failed us all.

Poverty in Wales

Recruiting and retaining Profesionals into poorer regions of the UK.

Deprivation differences…. especially across the UK – revisited

Devolution of health to Wales was a mistake?

Gender bias. The one sex change on the NHS that nobody has been talking about

We need more doctors. The gender bias for female applicants at 18 can be levelled off at 21 years old. Graduate entry to Medical Schools should become the norm. More and more women are outperforming men. (Where are the men? Gender gap hits record at universities The Times 4th Feb 2016) and (Head teachers have clashed over the benefits of single-sex schooling – Sunday Times 31st Jan 2016), but it is from these schools that many doctors come from.

Top results for girls

Dominic Lawson in the Sunday Times 17th Jan 2016 reports: The one sex change on the NHS that nobody has been talking about

Every now and then, a conflict arises that splits apart not just the country but even individual families — the dispatch of British troops to the Suez Canal in 1956 and to Iraq almost half a century later, for example. Contentious military invasions have that consequence. Yet now a mere industrial dispute — that between the British Medical Association (BMA) and the Department of Health over a new contract for junior doctors — is having a similar effect.

This was seen with excruciating clarity in the letters pages of one national newspaper last week. On Tuesday Dr Russell Hopkins introduced himself: “In 1998 I was elected a fellow of the BMA in recognition of outstanding service.” He then went on to damn the present-day doctors’ union for its withdrawal of labour in protest at what it claims to be a contract enforcing excessive antisocial working hours as “pressing the financial needs of the profession, giving little thought to patient care, ethical practice or the need for out-of-hours care . . . This is not the same organisation I was once proud to serve.” (the shape of the job?)

Two days later a reply appeared from Dr Claire Hopkins: “I read the letter from my father, Russell Hopkins, with some dismay. He has been out of clinical practice for so long that he is disconnected from the problems facing the profession today . . . My father and his generation enjoyed a career where they had respect and autonomy, were lavished with hospitality by drug companies and then retired on final-salary NHS pensions. They would not recognise the job today. As a consultant surgeon I — along with most of my colleagues — support the junior doctors in their decision to strike.” You don’t have to know either Dr Hopkins to wince at such a cruelly personal exposure of intergenerational dispute.

Those two doctors are divided not just by age but also by sex. The latter is, though not mentioned during last week’s strike, a significant factor in the row over “antisocial hours”. The profession has become one in which new graduates are more likely to be women than men. This would have been almost inconceivable two generations ago. Not much observed by the public, a debate has raged for years in the pages of the British Medical Journal about what its disputants refer to as “the feminisation of medicine”.

In 2008 one of its contributors, Brian McKinstry, then a senior research fellow at Edinburgh University, warned: “Increasing numbers of female graduates will create a major shortfall in primary care provision . . . Fewer women than men choose to work out of hours, and the increase in women doctors may have partly influenced the recent abandonment of out-of-hours work by general practitioners in the UK.” That was a reasonable supposition; the consequence has been an increasing pile-up in the accident and emergency wards of our hospitals.

It’s not just a matter of wanting to avoid “antisocial hours” that interfere with family life — an institution to which men tend to pay homage but that women are actually more likely to put ahead of their career. Last year Dr Max Pemberton wrote: “We are facing a crisis in the NHS . . . It’s a crisis caused by having too many female doctors . . . Quite simply, the average male medical graduate will work full-time, while the average female won’t. In fact, a study of doctors 15 years after graduation showed that . . . after career breaks and part-time working are taken into account, women work 25% less than their male counterparts.”

When you consider that it costs roughly £500,000 to bring each medical student up to the status of a fully trained professional, it becomes obvious why governments have been reluctant, especially at a time of vast public sector deficits, to increase the number of medical degrees to fill staffing shortfalls created by the swelling number of “part-time” female doctors.

Or as Dr Chris Heath, a 40-year NHS veteran, wrote to me: “Women doctors don’t like weekend rotas . . . This is one of the reasons why paediatric units are failing: 70% of their junior staff being women and therefore frequently off on maternity leave.” I wonder what Dr Heath would make of Sarah el-Sheikha, who complained in The Guardian that the government’s proposed change will “particularly damage specialities such as anaesthetics, a department that has striven to make itself family friendly”. What about being friendly to the families who need to use the service?

There is a statistical counter-argument to those put by Drs Pemberton and Heath: that opening up the profession to women as equal participants will tend to increase the quality of those graduating — the bigger the talent pool, the better the doctors that emerge. That, however, is no consolation to the patient who can’t get a GP appointment or has to wait longer in A&E during “antisocial hours”.

The societal split emphasised by the doctors’ dispute is not just along grounds of generation and sex. There is also that between private and public sector. While I suspect the overwhelming number of other public sector employees will be supporting the junior doctors in their industrial action, those in the private sector, who do not get time and a half for working on Saturdays, see things differently. So I have received quite a few perplexed letters from airline pilots — who also, in a different way, hold our lives in their hands — pointing out that they don’t get paid different rates for flights at weekends to compensate them for the disruption to their family life. But then how many female airline pilots have you ever met?

Those of us on the profit-making, tax-generating side of the private/public schism are much more fortunate in one respect. While businesses — at least those that prosper — have abandoned the corporate monolith mentality and become much better at encouraging employees to come up with their own ideas, the NHS has moved in the opposite direction.

Its doctors are no longer allowed to be the rather free-wheeling, occasionally eccentric, day-and-night, autonomous professional elite that I recall from my youth — long before anyone had heard of the EU’s working time directive and its average 48-hour week limit. Now, they are monitored incessantly by swollen ranks of administrators, who seem to think the medics should share their bureaucratic fascination with the filling-out of forms. The target-driven agenda of the Blair-Brown years had a rational motivation, as far as the politicians were concerned, but it made doctors feel as though they were wage slaves, being paid for pure hours worked and, yes, forms filled.

In this context, the decision of the BMA to take industrial action (leading to the cancellation of many thousands of operations) becomes less surprising. If you are no longer treated as a professional elite, you will not behave like one.

Funnily enough, some feminist writers have a theory that ties this all together: that when women become accepted into an elite, it ceases to be treated with the same respect as previously.

Perhaps. Though, whether it’s male or female doctors waving placards and chanting slogans outside their hospitals, neither exudes the sense of quiet authority traditionally associated with their position.

I’d better say no more, however, or my daughter might write a letter to this newspaper, shooting me down in flames.

Correspondence from a week later 24th Jan 2016: Misdiagnosing female junior doctors as the cause of A&E problems (And all the NHS ills..?)

‘More doctors than ever’ coming to UK from Europe

Medical Student debt – time for government to change policy on doctor recruitment

Women (& medical students) “.. from poor homes storm the best universities and Medical Schools

First UK private medical school opens with £36,000 fees. A regressive development, which could increase inequalities further.

Medical Schools: your chances – applications-to-acceptance ratio was 11.2.

Medical Student debt – time for government to change policy on doctor recruitment

It was the best job in the world – for me 1979-2012 – but now there are not enough of us to cover the country

Unreal manpower planning. It’s too late for a decade. GP services face ‘retirement crisis’. It’s the shape of the job silly.