Category Archives: General Practitioners

A curse on all their houses. Banal debates omit the really important questions. Entertainment has come before long term politics and unity..

For anyone who has watches the banal ITV debate (Boris v Jeremy)  and BBC question time leaders special I can only sympathise with the shallow nature of the questions, and the replies. They have omitted the really important questions. Entertainment has come before long term politics and unity. What a pity for those who gave their time to watch this display of denial. A curse on all their houses. They have all conspired to put patients and doctors lives at risk….

Here are some of the questions that NHSreality would like to have asked:

Brexit.

Do you feel that the Union of Great Britain and N Ireland is more or less likely to survive if we leave the EU?

Do you feel that continuing peace is more or less likely to continue if we leave the EU?

Do you feel that varied opportunities for work, particularly for younger people, are more or less likely if we leave the EU?

Do you believe the reports of the Economist, Governor of the Bank of England, World Bank, EU economists, all UK economists (bar one) and most politicians before the first referendum, when they indicate that prosperity and influence will diminish after leaving the EU?

Proportional Representation.

Please can you give your parties’ arguments against PR? Do these still apply?

If Proportional Representation is good enough for the devolved dispensations, why is it not good enough for the UK?

What form of PR would you advocate if we changed our system?

Do you think the vote should be extended to all those over 16, as in Scotland?

Identity

Since we have a virtual identity system with face recognition and other methods connected to central databases, and since we have a problem with identifying those eligible for state benefits, including health, would you support ID cards?

Could these ID cards lead to means related co-payments or taxes?

Tax

Would you support Land Rental Tax?

Do you think it could be at a level that allowed replacement of Estate Duty, Stamp Tax and reduction of Council Tax?

Health.

Do you feel that the 4 health services are sustainable under their present rules? Do you think that the pace of technological advance is faster than any government’s ability to pay? Given the demographics how would you change the rules?

If social care is means tested, then why not medical care? Or would you advocate the Scottish model of social care for England?

Is health care rationed covertly, so that nobody knows what is unavailable to them until they are denied it?

As far as health is concerned, has devolution worked in Wales and N Ireland?

Bearing in mind the excess of able applicants, for decades: Why are there so few doctors and nurses to meet the nations’ needs? Do you think this has anything to do with our political system and FPTP time horizons?

Usually when trying to fill the bath you put the plug in rather than turn the taps on more. We are now training more doctors, nurses and allied professionals than ever before. What are you going to do to change the culture  in the health service to stop the loss of the workforce soon after these individuals  qualify .

Bearing in mind that most purchases of equipment for the 4 health services are in dollars, and the costs have gone up 20% since the referendum, and this without trade barriers, do you believe leaving the EU will make our health as a nation better?

Education.

Bearing in mind job applications and competition for places at university, and interviews: Do you feel that all education is divisive? Is it more important to aim for excellence, or to reduce inequalities, when there is competition for resources and people? Do parents have the right to choose how to educate their children, and whether to spend their money on private tuition, sports activities, music etc?

Spin doctors – what the economist thinks about the conservatives health manifesto promises.

Northern Ireland health collapses. It would be kinder to bring in co-payments than to let more suffer.

Cloud cuckoo land….. The poor will remain slaves in a GIG economy.

Disgraceful leadership, and a longstanding culture of fear. Successive PMs of all colours are to blame. Spending money on bribing the electorate will bring only short term gains..

What the GP did best: used time as a diagnostic tool. The “failiing fiasco” of health care in the UK.

 

In the BMJs subsidiary magazine “Doctor” on 16th November the headline article is “On the cusp of collapse”. Overcrowding and Underfunding have left patients and doctors at risk……

New Registrations: More non-UK graduates than home grown clinicians…. in 2018

After failing to provide the 5000 extra GPs promised 4 years ago, the numbers have actually fallen by 1600, and of those remaining a far larger proportion are part time. The complete failure of forward planning is due to rationing of med school places, and the First Past the Post electoral system. It will happen again, and repeatedly. If the conservatives win an outright victory the money will dry up quickly. If Labour wins they wont be able to borrow, and they will have to print more money. Both outcomes are likely to lead to a fall in the value of the pound. We still have 11 applicants for every place. Increasing the numbers by a small % is not enough…. We now need locality based virtual training for medicine. It can be run by the local medical scghool, and exams and assessments can be centralised, but the training should be local, and graduate based. Traditional medical schools just dont have the capacity. …

Doctors‘ early retirement triples in a decade BMJ 21st June 2019

Rowena Mason reports in the Guardian 8th November 2019: Boris Johnson promises preferential immigration for NHS staff

The GP recruitment farce – Mr Hunt never said the 5000 would come from the UK!

PM proposes half-price visas and quick decisions for doctors and nurses as part of points-based system

Jonathan Paige reports in the Times 8th November 2019: Hospitals told to pay doctors cash over fears of winter crisis

Andrew Gregory in the Times 9th November 2019 reports: Will Tory promises help to clear your GP’s waiting room? 500 more GPs in training per annum promised……

The Conservatives today promised to create an extra 50m more GP appointments a year if they win the election.

In this early stage of the campaign, the NHS has dominated the agenda….

Adrian O’Dowd reports in the BMJ: More non-UK graduates than home grown clinicians joined medical register in past year (BMJ 2019;367:l6203 )

Where are the UK’s doctors from?

new registrations as an image

Of the 251 319 doctors on the UK medical register in 2019:

  • 164 525 trained in the UK (65.5% of the total, and a 2.2% rise from the number in 2018)

  • 22 280 trained in European Economic Area countries (8.8%, and a 2.2% rise from 2018)

  • 64 514 trained outside the EEA (25.6%, and an 8.3% rise from 2018)

There was an especially large increase in the number of medical graduates from Africa and the Middle East, but most non-EEA joiners still come from South Asia.

The trend of increasing numbers of doctors joining from Central and Eastern Europe and the Baltic countries continued in 2019. The number joining from northwest Europe remained the same in 2019, after a prolonged period of steady decline. Southern European doctors have joined in slightly greater numbers in 2019, a contrast to decreases since 2014.

Hands up – who want’s to be a GP today? Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

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

Some good news on new medical schools. Lets hope the politicians sieze the real opportunity for virtual medical schools living in local communities

 

Health Services might be designed wrongly: In praise of dissenters.. Currently there is little ability to speak out, “without fear of sanction”.

The Different health services in the UK are not open to the suggestion that they might be designed wrongly. They are failing more quickly than anyone imagined (other than those in the profession, and NHSreality). An interview with Helen Stokes-Lampard (RCGP chair) In “You and Yours” on Radio 4 17th October 2019 tells it straight: its going to take at least 12 years to remedy the failure in forward and manpower planning. (The interview is at the end of the recording) The culture of fear means that opportunities to learn constructively are being lost, educational standard are falling, and engagement with the politics of health is minimal. One route to honesty is the exit interview, and these collated together could give messages that lead to the changes needed. Meanwhile……  “Winter is coming”. We will all be hearing how they will listen (See Jill Patterson in Walesonline below), but NHSreality can tell you that even if they hear, they don’t have the human resources to act. 

In Bartleby in The Economist 12th October 2019 “In praise of dissenters – It pays companies to encourage a variety of opinions “

The ability to speak up within an organisation, without fear of sanction, is known as “psychological safety” and was described by Amy Edmondson of the Harvard Business School in a book on the issue. Mr Syed cites a study of teams at Google, which found that self-reported psychological safety was by far the most important factor behind successful teamwork at the technology giant. ….“In praise of dissenters

As many practices disintegrate, I give a link to a local practice in the news.

Eleanor Philpotts in Pulse 12th October 2019 reports on Ferryside practice.: Practice set to close after 3 years without a GP

In Walesonline Sandra Hembury on 14th October reports: The GP surgery that hasn’t had a GP for over 3 years..

A doctors’ surgery hasn’t had a GP working there for three years and is now being threatened with closure.

The Mariners Surgery in Ferryside has only had nurse sessions since 2016, because there were no GPs available to operate from it.

Now plans have been unveiled to close the surgery and relocate services to other practices, forcing patients to have to travel for miles to receive treatment.

A public drop-in session is being held to consult with patients at the Three Rivers Hotel in Ferryside between 2pm and 7pm tomorrow (Tuesday, October 15).

But there are fears those less mobile patients will struggle to get to the next nearest surgeries in the Meddygfa Minafon practice – in Kidwelly or Trimsaran.

Cllr Mair Stephens is ward councillor for St Ishmael and deputy leader of Carmarthenshire County Council.

She said the Carmarthen Road practice had been there for a number of years.

“There’s traditionally been a dispensing surgery, which is exactly what we do need,” she said.

“The majority of people who live in the area are older, and the surgery has been on the decline in recent years, but it still has such things as foot clinics and heart clinics.

“They are now going to close it, which is out of all proportion.”

She said the nearest surgery in the group was Minafon in Kidwelly, which was about four miles away. But it was difficult to get to if patients needed public transport. The nearest bus route to the Kidwelly surgery dropped passengers off at least 10 minutes away from the practice, which wasn’t suitable for the less mobile, she added.

She suggested the practice could set up a bus route taking passengers without suitable transport from the Ferryside surgery to Kidwelly.

Cllr Stephens added: “This is about moving services from their locality.

“What older people want to do is to see a GP. They don’t necessarily want to see a nurse.

“Once they have seen the doctor they are quite happy to meet a nurse or practitioner. That’s where the whole system seems to be falling down.”

She felt the consultation was not being spread out enough to the wider community, including nearby Llandyfaelog.

A petition has been set up to maintain the surgery in Ferryside.

Started by Ute Eden, it says: “We feel very strongly that it is essential to maintain a surgery in Ferryside.

“We need a doctor, a nurse and a dispensary to provide the vital services required by a village where most residents are over the age of 50.

“It is an integral part of Calon y Fferi Community Centre, which is very accessible.”

The petition, which has been signed by 44 people, said it would be a backward step to oblige all residents to leave the village for treatment.

Jill Paterson, director of primary care at Hywel Dda University Health Board, said: “As a health board we are committed to listening to and engaging with local populations around our proposals to relocate our primary care services from Mariners Surgery to neighbouring surgeries.

“We would therefore like to invite residents to come along and get involved in the conversation.

“Following a review of how services are used by patients at the surgery, it is becoming clear that these services are limited and not fully utilised and could be relocated to Minafon and Trimsaran Surgeries.”

The best and worst places to have your hip operation (In England. No global comparisons)

All hail the honesty of the Health Services Journal. Unfortunately they are not allowed to advocate rationing and freedom of speech is limited. But the stories they expose and the issues they address are relevant to  us all. There are many problems, which include poor staff hygiene, poor hospital cleaning, inadequate training, and above all, the failure to separate cold orthopaedics from “dirty” hospital cases where infected wounds and guts are operated on in the same building. The old fashioned DGH has served its time for hips and knees. But why are there no comparable figures for the Scottish, Welsh and Irish Hospitals? Because there is no “National” health service, I as a taxpaying citizen in Wales cannot find out how my service performs compared to England. Indeed, I would like to know comparisons with other countries, and with the private sector. Only with such data can patients be properly advised, and of course they also need to be “led” ask the right questions! Rationing by lack of choice, restriction to a local DGH, and long waiting lists, can only lead to more infections and complications (increased obesity and heart attacks from immobility). Should your GP air these issues when you choose to be referred? Of course he should even if it means telling the truth about your local services.

In the Times Monday 14th October a short report ( not in the on line edition) reads:

Repeat Offenders

The hospitals with the worst records for having to repeat knee and hip surgery on patients are revealed in a report in the Health Services Journal. The sick/ Six NHS hospitals are Southampton General, Milton Keynes, Chichester, Wansbeck, (Northumbria), Weston General, Somerset, and Ormskirk DGH Lancashire. Overweight patients, high infection levels and shortcomings in supervising trainees are blamed for poor performance.

In the Telegraph they report: “Revealed: the best and the worst places to have your hip operation”.

As it gets worse, YOU are going to have to wait longer and longer – or pay up. A “grim reality”..

The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

Orthopaedic waiting lists: time for more, and equal access to, non-urgent centres

South Wales NHS: Plan to centralise services on five sites

 

Ambulances use unproven scoring system to ration their service…

As a recent sufferer from sepsis, and having had much pain as a result, and from a hand operation (for which I am most grateful) I am interested in this new form of rationing. Since ambulances are “free” and since many calls are for relatively trivial issues, triage has to occur. However, when a GP rings, rather like when a doctor appears in A&E, lights should alert the telephonist that this needs to be taken seriously. A&E, and Emergency, and Urgent Care centres, have sepsis warnings all over their walls…  It made little difference to my care..

The ambulance service regards being in a GP practice as a place of safety, with medical care to hand, although GPs are being systematically deskilled in emergency care. This reduces their “points” score and the perverse action of the GP whose surgery has been “arrested” by this, is to send the patient outside and ask them to ring the ambulance!

Yes, the ambulance service is underfunded, especially if it remains free for all. The Air Ambulance is a charity, and like many others it too has to prioritise its service. Waiting times for ambulance calls are generally getting worse, and it wont be long before private contractors compete. But in West Wales it would be very expensive as the journey to a competent hospital is 1.25 hours at Swansea, or 2 hours to Cardiff.

Hiba Mohamadi reports for Pulse 27th September 2019: GPs requesting ambulance will have to provide a score for level of emergency.

In the BMJ Elizabeth Mahase reports: GPs warn against use of scoring system.  BMJ 2019;367:l5814

…..The system is based on six physiological measures: respiratory rate, temperature, oxygen saturation, systolic blood pressure, pulse rate, and level of consciousness. Despite not being validated for primary care, NHS England has “encouraged” its use. Last year its was made mandatory in ambulance trusts. NHS England said the score should be used “for all pre-hospital patients who are ill or at risk of deteriorating” and to “support colleagues to identify deterioration early and prioritise resources in times of surge.”…..

Dr Rachel Marsden RCGP Clinical Support Fellow for Sepsis, is on the RGP website: The updated National Early Warning Score and its use with suspected Sepsis

Image result for ambulance cartoon

Don’t believe we are rationing? Do you believe in transparency and honesty? Why not use the correct word?

Just in the last few days these news items reveal the truth. Despite this the “R” word can never be acknowledged by politicians. None since Enoch Powell has embraced the truth. (Described by Richard Smith, former BMJ editor as “the best book written on the NHS”. A new look at medicine and politics: 1975 and after. Pitman Medical 1976. 2nd edition. ) 

Link to his book published by the Socialist Health Association

Why do you think we had no PET scanners until 20 years late! Why are there waiting lists longer than any other G7 country (and the results to match)? Why have the two countries that emulated the original NHS reconsidered? (NZ and Scandinavia). Why are we only appointing 1 doctor for every 10 who apply and have been encouraged to do so by their careers officers? Why are botched operations so commonplace?  Why does the NHS Ombudsman produce reports which have no notice taken? Do the politicians read these reports?

If you believe in honesty and transparency why not use the correct word? We will never win the hearts and minds of the health service staff if politicians and media and public collude in the language of denial.

Henry Bodkin in the Telegraph 14th September 2019: NHS bosses tried to “gag” father of boy whose life was ruined in botched operation

In The Guardian 30th August 2019 Dennis Campbell: ‘Crumbling’ hospitals putting lives at risk, say NHS chiefs  –  Four in five NHS trust bosses in England fear Tory squeeze on capital funding poses safety threat

Why cannot Cheshire recruit enough GPs? Pulse reported by Lea Legraien 14th September

Why do we still get fraudulent managers promoted (The Independent 19th December 2018)

Why are half of the 4 health services’ trusts using out of date radiotherapy equipment? ( Andrew Gregory in The Sunday times 15th September 2019 )

This is particularly important for Pembrokeshire and West Wales as we have a long distance over difficult roads to travel to Swansea at present. Our planned new Hospital, wherever it is, needs Radiotherapy, Radio Isotope Investigations, and STENT treatment for Coronary Heart Disease if our options are to be the same as those in more favoured areas. I reproduce the article at the bottom of this post.

Adam Shaw for the Harrow Times reports 13th September 2019: North-West London CCGs dismiss claims of “rationing” services.

Kat Hopps September 13th in the Express reports: IVF: How NHS IVF treatment is unfair postcode lottery and keeps couples childless

A disgrace and a shame on politicians: “Surge in patients raising own cash for amputations”. Rationig by waiting and by incompetence.

Pembrokeshire Oncology cancer services in crisis

There is a “need to put doctors in charge and force them to take account of patients’ views. Cancer survival rates are (just) one of the prime examples of NHS mediocrity.”

Desperate NHS needs a desperate remedy – care is already rationed

The 3 myths of the NHS…..& …No learning from other countries – no co-payments, and more scandals..

Britain ranked last (out of 20 rich countries) by a wide margin in the number of CT and MRI scanners per head of population. Australia has six times as many CT scanners per head, and spends roughly the same as Britain on healthcare overall as a share of GDP.

Why are half of the 4 health services’ trusts using out of date radiotherapy equipment? ( Andrew Gregory in The Sunday times 15th September 2019 )

Almost half of NHS trusts are using outdated radiotherapy machines that are far less effective at killing cancer cells to treat patients.

The revelation comes days after the UK came bottom of an international league for cancer survival rates in The Lancet Oncology journal.

In 2016 the NHS said it was investing £130m in upgrading radiotherapy equipment but the figures, revealed via freedom of information requests, found 46% of trusts are still using outdated linear accelerator (Linac) machines beyond their recommended 10-year lifespan.

Dr Jeanette Dickson, president of the Royal College of Radiologists, said more advanced radiotherapy techniques enable “greater precision when targeting specific tumours and have been shown to be less harmful to surrounding tissue than older types of radiotherapy, depending on the complexities of the cancer being treated”.

Rose Gray, policy manager of Cancer Research UK, said it was “deeply concerning” to hear outdated radiotherapy machines were being used.

She said: “The NHS has grappled with the question of how best to replace outdated equipment for many years, and the government has repeatedly been urged to put a long-term plan in place.

“But . . . that still hasn’t happened. These investigation findings prove the urgent need for a solution to this persistent problem.”

In total, 57 of the 272 Linac machines used this year are 10 or more years old. One of them that is still in operation has been used for 17 years.

Dr Peter Kirkbride, the former chairman of the government’s radiotherapy clinical reference group and spokesman for the Radiotherapy4Life campaign, said: “That radiotherapy has been put on a lower footing than other cancer treatments — such as chemotherapy — by successive governments is an open secret within the NHS.”

The Liberal Democrat MP Tim Farron, chairman of the all-party parliamentary group on radiotherapy, described the figures as “shocking”.

He said they proved the investment in 2016 had been a “drop in the ocean” when compared with what is required to meet soaring demand.

Saffron Cordery, deputy chief executive of NHS Providers, which represents hospitals, added: “What we do know is that for year after year, money earmarked for capital investment has been siphoned off just to keep services running.”

An NHS spokeswoman said 80 radiotherapy machines had been upgraded since 2016 and patients were benefiting from “a range of improvements” to cancer services.

Enoch Powell 4 Supply and Demand – Rationing

 

Even London and the Home Counties are feeling the squeeze… as standards and staff numbers fall re revert to the pre-NHS divide.

Just some of the pain felt in the rural shires is now feeding into London and suburbia. Standards of staffing and clinical diagnosis and speed are all falling. The blame is long term political neglect and denial from an elected elite who always felt they had access to the best – in London. No longer… it is impossible to report on all GP surgery closures as there are so many. The reality is that private services for ambulance, GP, A&E etc will follow… Bevan wanted the same high standards for the miners as the bankers – instead the standards are falling, but as before we had a health service, the bankers can afford the private option.

Owen Sheppard for MyLondon reports 7th September 2019: West London overspends by £112m!!

GP surgeries across Surrey are facing an uncertain future, with two confirmed closures and a third possibly following suit, which are set to put pressure on those nearby.

Patients say they are worried about the pressures on neighbouring services following the announcement of closures of surgeries in Staines and Guildford.

In Burpham, a petition has been launched to save the Burpham New Inn surgery which is also facing closure.

So why are surgeries closing?

The Guildford and Waverley Clinical Commissioning Group (CCG) has cited problems with leases and premises, which have led to the closures of two practices in the area.

In Staines, the Staines Thameside Medical Practice shut on Saturday (August 31) following a decision by the doctors to end their contract with the NHS to provide GP services. This was reportedly due to personal reasons.

Patients will lose the St Nicolas branch surgery in Bury Fields, Guildford, which will close at the end of October following issues with the premises and its lease.

Guildford and Waverley CCG has confirmed the surgery will close on October 24. All services will instead be provided by the main surgery at Guildford Rivers Practice in Hurst Farm, Milford.

One St Nicolas patient, who did not wish to be named, said: “I am very upset about the closure of St Nicolas Surgery, it came as a shock.

“[I believe] this was pre-planned since last year but without telling patients previously. I have not received a letter as yet about the closure.

“I think it’s been about a year that all the telephone calls to St Nicolas Surgery have been re-directed to the general practice in Milford.

“The closure of St Nicolas Surgery will put extra pressure on other GP surgeries in Guildford as patients who are ill, disabled, elderly or who don’t drive won’t be able to get to Milford.”

The CCG has said it will work with the practice to ensure that despite the changes, patients will continue to receive high quality care.

A spokesman said: “The CCG received an application from Guildford Rivers Practice that proposed the closure of its branch surgery, St Nicolas Surgery, due to issues with the premises and the lease which was proposed to have had a negative impact on the service offered to patients.

“Following a period of engagement with patients and neighbouring GP practices, the application to close the branch has now been approved by Guildford and Waverley’s Primary Care Commissioning Committee (PCCC).”

The spokesman added: “Registered patients of Guildford Rivers Practice will remain so, following the branch closure, with GPs from St Nicholas Surgery transferring to the main site and continuing to offer appointments to patients.

“Any patients who require home visits will continue to receive these in the usual way.

“The practice is committed to providing the best service for patients by operating solely from the Guildford Rivers Practice main site and the CCG will work with the practice to ensure patients continue to receive safe and high quality care moving forward.”

The news comes as patients await the decision on the future of Burpham’s New Inn surgery. A decision was set to be made on August 28 but this has been delayed.

A spokesman for Guildford and Waverley CCG said: “The PCCC has been re-arranged to ensure every option put to the CCG is fully explored, before a final decision is made.

“The committee has been rescheduled for September 13.”

In a letter to patients sent on July 31, the CCG said it was likely the New Inn Surgery in London Road would have to close later in 2019 due to problems securing a long-term home.

The letter said the surgery’s lease was expiring and no other suitable alternative sites have been found.

Patients launched a petition to save the surgery, which has been signed by 282 people to date.

Staines

Around 4,500 patients have had to re-register with another GP surgery after Staines Thameside Medical Practice closed its doors on Saturday (August 31).

Other GP surgeries in the area are accepting new patients despite some having recently had their lists capped.

Two Staines councillors are concerned about the additional pressure on those surgeries.

Councillor Jan Doerfel, Green Party member for Staines, said: “Expecting other GP practices to absorb the additional 4,500 patients is likely to result in longer waiting times for all those affected and additional travel for those that had to enrol with those practices. This is not acceptable.”

Councillor Veena Siva, Labour member for the ward, said: “Yet another GP surgery closes. Smaller practices are closing due to underfunding and insufficient GPs which means they can no longer be run safely and sustainably.”

She added: “As it stands, it is unfortunately no surprise that there was no interest from GPs to take over the surgery when in doing so all they would face is under-resourcing, enormous pressure and stress.”

NHS North West Surrey Clinical Commissioning Group (CCG) was responsible for supporting patients as they switched to a different GP service.

St David’s Family Practice Doctor Jagit Rai works at one of the surgeries receiving patients from Staines Thameside and is a governing body member at NHS North West CCG.

Doctor Rai said: “The closure of this practice does not relate to funding or staff shortages. The CCG was disappointed to receive notification from GPs at Staines Thameside of their decision to end their contract with the NHS to run the surgery.

“They made this decision due to a change in personal circumstances that could not have been predicted or planned for. The CCG asked neighbouring practices about the option to take over the running of Staines Thameside and reviewed their capacity to take on new patients.

“The surgeries decided the best way to care for Staines Thameside patients is at their practices where they can benefit from an established team and range of services.”

It’s slightly brighter news for the residents in Chiddingfold, where a new surgery is being built after the former building was destroyed by a fire.

Chiddingfold Surgery in Ridgley Road was gutted on January 7, 2019.

Plans were submitted in March to Waverley Borough Council for the complete rebuild.

The surgery has relocated to Cedar ward at Milford Hospital, where full doctor and nurse surgeries are in place. Expanded opening hours are available for patients at Dunsfold surgery.

Update : Diane Taylor in the Guardian 8th September 2019: London GPs told to restrict specialist referrals under new NHSThe New “Rationing Plan”. Plans for new cuts sent same day Boris Johnson reinforced NHS spending commitments..