Category Archives: General Practitioners

Too fast, too furious, too many…… The 10 minute consultation needs to be challenged.. Interview rape is commonplace.. There are not enough people with enough time to care.

Chris Smyth reports in the Times 18th Jan 2018 that the average “GPs see more than 40 patients a day”, and some see 50, twice as many as recommended. This is in addition to the administration. (results, letters in and out, telephone calls) as well as visits, meetings and keeping up to date in one of the fastest moving sciences. No wonder medical indemnity costs are rising, and more mistakes are being made. Perhaps the profession is partly responsible, setting an exam for GPs based on 10 minute consultations…. Whilst the UK’s 4 health services metaphorically abuse their staff, Interview rape is commonplace. There are not enough people with enough time to care. Replace ANC by NHS in this cartoon..

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The average GP is seeing 41 patients a day, which puts safety at risk, a survey suggests.

One in five family doctors does more than 50 consultations a day, twice the number recommended under European safety guidance, the poll found.

Patients’ appointments are too short for proper care and the rush to see so many people could lead to mistakes by exhausted doctors, professional leaders have warned.

Jeremy Hunt, the health secretary, has acknowledged that GP appointments are a “hamster wheel” that do not work for patients with several illnesses, but a pledge to recruit 5,000 more family doctors by 2020 is in trouble as numbers continue to fall.

A survey of 900 doctors by the GP magazine Pulse found they faced an average of 41 appointments a day, either face-to-face or over the phone and internet. A handful of doctors reported doing more than 100 consultations a day, despite advice that they should not be doing more than 25 a day.

The average GP is seeing 41 patients a day, which puts safety at risk, a survey suggests.

One in five family doctors does more than 50 consultations a day, twice the number recommended under European safety guidance, the poll found.

Patients’ appointments are too short for proper care and the rush to see so many people could lead to mistakes by exhausted doctors, professional leaders have warned.

Jeremy Hunt, the health secretary, has acknowledged that GP appointments are a “hamster wheel” that do not work for patients with several illnesses, but a pledge to recruit 5,000 more family doctors by 2020 is in trouble as numbers continue to fall.

A survey of 900 doctors by the GP magazine Pulse found they faced an average of 41 appointments a day, either face-to-face or over the phone and internet. A handful of doctors reported doing more than 100 consultations a day, despite advice that they should not be doing more than 25 a day.

AOL Travel: GP workload above safe levels, says leading doctor 17th Jan 2018

BMA (Scotland) BMA approves new GP contract 19th Jan 2018

Family doctors working ‘beyond safe levels’, says GPs’ leader
The Guardian17 Jan 2018

GPs dealing with ‘unsafe’ work load
PharmaTimes18 Jan 2018

Most practices in England do not want to provide online consultationsGP online15 Jan 2018


Yet another surgery closes. St Clements in Neyland …. How to make a population angry…

Yet another surgery closes.. NHSreality has been told of scores of surgeries closing since the last post on this subject. Neyland has two surgeries, and so one will have to do. Some closures lead to large travelling needs, great inconvenience, and sometimes expense. The idea that “access” should be free and easy is being challenged by a thinning primary care workforce – why? There are just not enough doctors, and this is only the beginning of a ten year decline. A&E departments, particularly in Wales, (Owain Clarke for BBC Wales: A&E safety risks ‘unacceptable’, first minister warned) are imploding, and as NHSreality has pointed out in the past, there may come a day when ambulances ask the patient to choose between state A&E and Private A&E departments. Do the people of Neyland, who have another practice they can attend, prefer a surgery manned by paramedics and nurses, untrained in differential diagnosis or living with uncertainty? Fortunately, Pembrokeshire is benefitting from increasing numbers of Trainee applicants for General Practice, mainly due to financial inducements, and will be relatively better off in 5 years time than other regions. In the last 6  months 50,000 patients have lost their surgery.….. over 2 years about 4 million. This becomes a sizeable, angry, voting population….

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The Western Telegraph reports 17th Jan 2018: Public meeting announced to fight plans to close St Clements Surgery in Neyland.

Neyland looks set to lose one of its two doctor’s surgeries.

Argyle Medical Group is planning to close the St Clement’s Surgery, it announced on Wednesday.

It means Neyland patients will have to pay £1.50 a time to cross the Cleddau Bridge to attend appointments in Pembroke Dock’s Argyle Street surgery.

Argyle Street itself is already under major pressure with photographs over recent months showing patients in large queues trying to get appointments.

In a statement posted on Facebook on Wednesday evening, Argyle Medical Group, said: “Argyle Medical Group has submitted an application to Hywel Dda Local Health Board to close the Branch Surgery at St. Clements Neyland.

“The reason for this application is to consolidate & maintain patient care services at a time of reduced GP numbers at the practice.

“Despite concerted attempts at GP recruitment over recent years the practice has been unsuccessful. The practice has been successful in recruiting a further Nurse & Pharmacy practitioner & is continuing to try to recruit further such practitioners.

“The practice plans to increase its capacity to deal with urgent medical problems by offering increased clinical practitioner appointments. These practitioners will be backed up by a GP to provide immediate advice as needed. It is planned this service will be provided from Argyle Surgery, Pembroke Dock alone.

“Argyle Medical Group will continue to provide the full range General Medical Services to its registered patients in Neyland & the surrounding area. In order to facilitate the enhanced same-day service at Argyle Surgery it is proposed that appointments at St. Oswalds Surgery, Pembroke will change from a same day to a pre-booked appointment system.

“The practice consider this action to be the only option to enable a safe level of clinical care to be offered to all its registered patients at a time when recruitment & retention of clinical staff is extremely challenging.”

The move has sparked anger in the town with patients blasting the decision as ‘absolutely disgraceful.’

Neyland county councillor Simon Hancock said the move cannot be allowed to happen.

He has organised a meeting for Neyland residents.

Cllr Hancock said: “A public meeting will be held at Neyland Athletic Club next Thursday 25 January at 7pm to protest against the proposed closure of St. Clement’s Surgery. It cannot be allowed to happen.

“A campaign committee will be formed. Please come along to show your support for a matter of enormous importance for every person and family registered there.”

Cllr Hancock, who is mayor of Neyland, added: “The proposed closure of the surgery is completely unacceptable and will put patients in Neyland and the surrounding villages at risk.

“A town of the size of Neyland needs good quality medical facilities and the Argylr Medical Group will be breaching their responsibilities in seeking to close their Neyland base.

“People without transport will be disadvantaged, people will have to pay travel costs and the consequences when the Cleddau Bridge is closed to all traffic are  too shocking to contemplate.

“I hope we have an excellent and representative turnout  to the public meeting to fight the proposed closure. Simply this is a battle Neyland cannot afford to lose.”

Fellow Neyland county councillor Paul Miller, said: “‘While I understand recruitment of GP’s is difficult this proposed move is a serious betrayal, by the Argyle Medical Group, of its patients in Neyland.

“I’ll be standing side by side with the people of the town in opposition to what would be a serious backward step in the provision of vital medical care.

“The Health Board must block this request and engage with us in an urgent conversation about providing a sustainable GP service for Neyland.”

Preseli Pembrokeshire MO Stephen Crabb said: “This is hugely disappointing news that St Clements Surgery feel the need to close due to a failure to recruit.

“Pembrokeshire is a fantastic place to live and work and more should have been done by the Hywel Dda University Health Board and the Welsh Government, who hold power over the NHS in Wales, to ensure that St Clements Surgery had staff in place to remain open.

“The Welsh Labour Government have known about recruitment problems in rural practices for a long time and have failed to come up with a strategy.

The decline of General Practice.. Bribes may be too late…

Jeremy Hunt to unveil state-backed GP indemnity deal. Bribery is an admission of perverse recruitment and education processes..

A humanitarian crisis – and the goodwill of staff has disappeared. When will the public ask for private A&E?

Patient died in care of unqualified paramedics

Its more than a thin front line, as half timers take over from deserters…

2,000 foreign GPs needed to tackle growing shortage. How about an apology to 20 years of rejected applicants to medical school?

Jan 27th 2016 – almost 2 years ago: The sick parade – of GP closures. This list heralds the end of the health service as we knew it.

Nick Bostock in GPonline 18th Jan 2018 Practice mergers or closures affect 50000 patients in 6 months.

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Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts..

Brexiy buyers remorse may be increasing, as the message in health is clear. There is going to be less rather than more. The Guardian on 13th October published “Labour flags up Brexit poll suggesting public regrets decision”, and no wonder when rather than saving £350m we are losing more than twice than much, annually in the devaluation of the £ and the cost of imports.

Just like Brexit, health is a complex and long term problem. Decisions on both should be taken only by experts.. As the health services collapse, mainly due to lack of long term planning, and a political and media collusion of denial, some of the predictions in NHSreality are becoming true. The only thing that is National is the opportunity to buy better, faster private care…. We need more youngsters to man our service industry country, and if we don’t stay in the EU we may need to take the example of a town in Japan. (The Economist Jan 9th: A small town in Japan doubles its fertility rate).

The first part of the safety net is the GPs, and the second is the Hospitals and all their staff. 80% of health contacts are seen by GPs, but lives are saved mainly in the second net.. Rationing needs to happen at all levels and the letter from Dr Burt (below) should be read with care. NHSreality has asked for GPs to work alongside Oncologists and this alone would save millions.

Subsidising parenthood appears to work wonders

An unofficial two tier National system. (Where moneyed people go privately)

Covert and post code rationing.

A disengaged medical workforce.

A management wriggling on the inability hook: to make the books balance.

An English language which obfuscates the truth.

A collusion of denial between politicians and the media.

A system where even those fearful conditions, such as cancer, are not properly and fairly covered by the state safety net.  (Bring back fear instead of “In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear“)

Carolyn Wickware in Pulse reports 30th October 2017: GP leaders prepare for explosive vote on practices leaving the NHS

Sarah Marsh in the Guardian 11th Jan 2018: NHS winter crisis: hospital ‘felt like something out of a war zone’ – Husband of a patient and locum doctor share moving experiences of severe pressures on national health service

Kat Lay has reported on Cancer services, especially in Oxford, in the Times recently. Jan 11th: Hospice loses beds in NHS staff crisis and in the letters 12th Jan:

Cuts to cancer care owing to staff shortages

Sir, For the past three years we have been urging the government to tackle cancer workforce shortages in the NHS. It is totally unacceptable that these shortages could now lead to delays in patients getting treatment. This latest episode at the Churchill Hospital in Oxford (report, Jan 10), where chemotherapy may be delayed owing to a lack of specialist nursing staff, adds to a growing list, which includes cases where lung cancers were left undiagnosed because of a lack of radiologists. Immediate action needs to be taken by the government to deal with this, otherwise problems like the one at Oxford will become more widespread and more severe.

An additional 150,000 people are expected to have cancer diagnosed annually by 2035. We need more staff, with the right training and support, in the NHS to deal with the increasing number of cancer patients who need to be diagnosed and treated. We estimate that the projected 2022 consultant oncology workforce could be roughly half the size that it may need to be to deliver the best care, with a shortage of between 1,281 and 2,067 staff. Health Education England recently published its first-ever plan to deal with the staff shortages in cancer care, but this relies heavily on stretched local areas taking action and making difficult spending decisions, and will not change the situation overnight.

We have a national ambition to achieve world-class cancer outcomes for all patients. We will not get close to achieving this — and to offering patients the best chance of long-term survival — without tackling crippling workforce shortages.
Sir Harpal Kumar

CEO, Cancer Research UK

Sir, Oncologists need to take a long hard look at what they are trying to achieve. Response rates in second and third-line chemotherapy are very poor and inevitably interfere with quality of life. There is an obsession with including patients in clinical trials, which are costly and are often used for career progression rather than cancer progression. The hardest thing for an oncologist to learn is not how to treat patients but when to treat them. Many need to learn that no treatment is often the best treatment. It takes guts to tell a cancer patient that no further active anti-cancer treatment is now right for them. The best oncologists do that.

Oncology can surely not moan about staff shortages when literally dozens of consultants and senior nurses sit down for hours on end to discuss routine cancer cases, the management usually being obvious. Multidisciplinary team-working (or medicine by committee) is the biggest waste of NHS resources bar none.
Dr Paul Burt

Retired clinical oncologist, Stockport

Sir, Cancer care at the Churchill Hospital is likely to be compromised as a result of the shortage of trained oncology nurses. The reasons are multifactorial; one that is quoted by the management of the hospital is the high cost of housing in Oxford. Training more specialist nurses takes five years, whereas the introduction of an Oxford weighting to nurses’ salaries on a par with the existing London weighting could be introduced immediately. London is not the only city with housing costs well above the national average. No doubt new money would have to be found to do this but it would go some way to help nurse recruitment in high-cost areas.
Griffith Fellows

Retired urologist, Churchill Hospital, Oxford

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

Bringing back fear, and suffering. A return to 19th century inequalities.. How quickly politicians destroyed what was the best safety net in the world?





Its more than a thin front line, as half timers take over from deserters…

With apologies to the Economist, NHSreality feels this article is an honest summary of the situation and state of General Practice today. Where possible I have linked to previous postings in support. But even if the manpower planning had been better, and if politicians had avoided the repetitive short termism, we still  need a joined up system, and the unified electronic record is where we should start. Cash is not enough — the NHS must be forced to unify: the only cure is a properly joined-up health service (Camilla Cavendish in the Sunday Times 7th Jan 2018) Its more than a thin front line, as half timers take over from deserters… To add fuel to the fire, GP premises development has not been facilitated, even though moving care out of hospitals is policy.

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The Economist: A thinning front line The NHS’s latest problem: a shortage of GPs – As hospitals struggle with a winter crisis, a longer-term problem is brewing in primary care

IN PLOIESTI, just north of Bucharest, Daniela Margaritescu had a grand house, a big car and her own surgery. But when she set eyes on the Beechfield Medical Centre in Spalding, Lincolnshire, it was “love at first sight”. The 46-year-old Romanian was hired last year as part of a pilot scheme to recruit more foreign doctors to fill chronic vacancies in primary care. For Dr Margaritescu it is a “perfect” deal. She learns new skills, her three children attend good schools and her pay has roughly doubled. For their part, the people of Lincolnshire—who voted heavily to leave the European Union in the referendum of 2016—are happy to have new doctors at last.

As people return spluttering from their Christmas holidays, the National Health Service is entering its busiest time of the year. On January 3rd Jeremy Hunt, the health secretary, apologised to patients after non-essential operations were suspended until the end of the month to ease the pressure on hospitals. Senior doctors took to Twitter to lament the “third-world” conditions on wards. But although the scenes in hospitals, where patients have been left waiting on trolleys in corridors for hours, are dramatic, a less-noticed crisis is under way on the front lines of the NHS. General practitioners (GPs), patients’ first port of call and the gatekeepers of most health services, are a dwindling army.

Take Lincolnshire. Before the arrival of Dr Margaritescu and 24 other doctors from eastern Europe, 104 of the county’s 434 potential spots for GPs were vacant. The Beechfield practice ran three recruitment rounds without finding a suitable candidate. “People drive past [Lincolnshire] on the way to Scotland, and then again on the way back to London,” says Kieran Sharrock, medical director of the local body that represents GPs. There is no medical school in the county, depriving it of a pipeline of talent. Doctors balk at joining remote practices with lots of old patients; in some Lincolnshire surgeries, half the patients have at least four chronic diseases.

Lincolnshire’s woes are particularly severe, but across the board the NHS is struggling to hire and retain GPs. It recently changed how it counts them, so deciphering trends is tricky, but the number of GPs has probably been falling since at least 2009, during which time the number of hospital consultants has risen by a third. In 2016 Simon Stevens, the chief executive of NHS England, pledged to recruit 5,000 more GPs over the next five years. But the count has fallen further, reaching the equivalent of 33,302 full-time GPs in September, 1,290 fewer than two years earlier. The number of surgeries has dropped to 7,674, from 8,451 a decade ago. Some towns face losing most of theirs; last year seven of the eight practices in Folkestone, on the south coast, said they intended to close.

Even before the creation of the NHS in 1948, family doctors played an outsized role in providing health care in England. Their pivotal position was described in the novels of Anthony Trollope and George Eliot. Today Mr Stevens calls the GP arguably the most important job in Britain. They decide when to refer patients for hospital care, and provide a wider range of services than their peers in many countries (Polish doctors in Lincolnshire note that back home they rarely saw children or dealt with gynaecological cases). And their role is set to become even more important: the government wants more patients with chronic conditions to be cared for outside hospital, which will require GPs to co-ordinate treatment.

What seems to be the problem?

The shortage of GPs partly reflects a change in the workforce. In 2006, 43% of GPs were women; a decade later the share was 55%. It is set to rise further, since male GPs are closer to retirement age, on average. Because only one-fifth of female GPs work full-time, compared with half of male GPs, more of them are needed. A recent analysis by Imperial College London suggests that an additional 12,000 GPs will be required by 2020—more than twice the NHS’s target.

Another reason is that the job has become less attractive. GPs complain of having to do more work for less pay—and they have a point. The English population has grown by 4.3m in the past decade, and patients are seeking help more often than they used to. The number of consultations per patient increased by about 10% between 2007 and 2014, according to a study in the Lancet, a medical journal. A survey of GPs in 11 countries by the Commonwealth Fund, a think-tank, found that 92% of British GPs reported typically spending less than 15 minutes with a patient, compared with 27% of GPs in other countries. British GPs were also the most likely to say they were stressed.

One London-based GP describes a “light day”: 25-30 scheduled appointments; five to ten emergency ones; one or two home visits; 30-50 replies to be written to hospital doctors, plus a similar pile of pathology reports to read; and 10-20 repeat prescriptions to process. Some feel like secretaries, writing referrals for ungrateful patients. It is a lonely job, without the camaraderie of a hospital ward.

Over the past decade GPs’ pay has fallen. In 2004 the Labour government agreed on a contract that raised the average pay of a partner in an English surgery to £136,665 ($185,000) in today’s prices. Since then partners’ pay has slipped to £104,900, as successive governments have made the contract less generous. Salaried GPs earn an average of £63,000, less than hospital doctors with similar experience. And, unlike those clinicians, GPs pay thousands of pounds a year in indemnity insurance.

In an ordinary labour market, employers could raise pay to fill vacancies. But the NHS, the world’s fifth-largest employer (behind the American and Chinese armed forces, Walmart and McDonald’s) does not operate in an ordinary labour market. In effect, pay is set at a national level. The number of doctors to be trained in each specialism is determined centrally years in advance. Since it typically takes ten years to train a GP, failures of planning mean shortages that take a decade or more to fix.

The government has said it will increase the number of places at medical schools by 25% from September. (Unlike other degrees, there is a cap on places to study medicine, because the course is heavily subsidised.) But that will take time to translate into more GPs. It will also require universities to improve the reputation of general practice; for a certain type of thrusting medical student, only dentists are viewed with more disdain than would-be GPs.

With no end to the staffing problem in sight, some surgeries are adapting. They are employing more paramedics, nurses and pharmacists to see patients. Several surgeries are becoming mega-practices, spreading the GPs they have across many sites. Others will increasingly rely on doctors from overseas. Britain already employs a higher share of foreign doctors (27%) than the average across the 28 members of the OECD club (17%). Of the 12,771 doctors who registered in Britain in 2016, 44% had qualified overseas.

According to research by Aneez Esmail of the University of Manchester, and colleagues, foreign-trained GPs are more likely than British ones to work in poor areas, earn less money and work longer shifts. But doctors trained abroad also score lower on postgraduate medical exams, and are more often subject to complaints. In Lincolnshire the doctors recognise they have a lot to learn. Accordingly, for their first two years they get twice as much time to spend with patients as other GPs do.

Those running the pilot believe that it will continue after Britain leaves the EU, given the need for GPs. The NHS has said it wants the programme to be scaled up to attract 2,000 foreign GPs. Tomasz Grela, a genial new Polish doctor in Spalding, is not too worried about Brexit. “The medical system needs us,” he says. And although he readily concedes that he needs to get up to speed with the British system, he is showing signs of acclimatisation. Asked what frustrates him most about the NHS, he gives the same response as most British doctors: “Bureaucracy.”

This article appeared in the Britain section of the print edition under the headline “A thinning front line”

Call Dr Stalin: the NHS must be forced to unify – Cash is not enough — the only cure is a properly joined-up health service

General Practice is “Closing Down” … Presentation for a unified IT system rejected 1996 / 2001

Facing an understaffing crisis….. Those rejected during the last 30 years should be asking why?

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

A retired GP says retiring “.. was like leaving an abusive relationship”

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

An exodus because of poor planning and the shape of the job. Deprofessionalisation….

Who wants to be a GP? Rebuiling Trust is not just needed for juniors… The NHS: How bad will it get?

Here is an idea to fix the NHS: let’s get rid of GPs. Lets see how Scotland’s GPs vote…Dementia is going to overwhelm all our services, including our GPs unless we address reality…

Despite “adequate or average” funding, our waiting lists are much higher than average. Even communication is failing at a basic level…

Public must pay for better NHS, says Stevens to spineless politicians at King’s Fund

The history of denial in GP recruitment: over 50 years. The result of a sustained collusion of denial.. It’s going to get worse..

The decline of General Practice.. Bribes may be too late…

Mr Hunt needs 40,000 GPs in the next 10 years. 1,500 extra per annum with a 10 year lead in will make no difference.

Severe shortage of GPs is reaching crisis-point in Derbyshire – only 37% of GP training places filled – due political rationing of Medical School places 10 years ago, and the shape of the job

Exhausted GPs shun out-of-hours work. The long term result of rationing medical school places, of declining skill standards, and governments showing they “couldn’t care less” for years.

would the British public be happy to swap a shorter GP consultation time for a longer one that involved payment of it and additional services?

GP premises development frozen, GPs forced to publish pay from 2015: What about comparing overhead?

Child health care: adequate training for all UK GPs is long overdue

The history of denial in GP recruitment: over 50 years. The result of a sustained collusion of denial.. It’s going to get worse..

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

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Household made 3,600 ambulance calls in one year….

When I was a new GP in 1979, patients called for “home visits” as if they were a “right”, and doctors rarely triaged their request calls. There were no “targets” to meet until I believe 1998 when smear and vaccination targets were begun. The day was structured by two surgeries (sometimes three in occasional practices) with visits in between the surgeries. The evening surgery ended around 18.00 officially, and if the doctor was on his own he would have visits after evening surgery, and then be on call until the following day. We knew most of our patients. 

One day a particularly nervous lady was on the visit list for headaches and I put her last out of 8 visits. I can still remember the house address, and the time of day (4.30 and before my lunch) when I arrived at the gate of the terraced house. I was met by an irate husband as I went through the gate. “You’re too late Doctor!”. Oh dear, I thought, with mental images of the GMC, and the MDU phone calls that I might have to make if the patient had died of, say, a sub arachnoid haemorrhage. “What’s happened?” I asked. “She’s better now came the reply”. I don’t remember whether I entered the house or not…

The perverse incentive to overuse a service when it is entirely free, and when patients regard the service as a right, has led to just a few families like this one all over the country. West Wales had one in Pembroke Dock, and during our co-operative out-of-hours days (The best teamwork of my GP career) we were warned about the family and dealt with them accordingly. Calls reduced. The cost of these families is enormous, and New Zealand type co-payments, are the way forward. However, Nationally, most GP consultations are appropriate, and it is only 25% in total that might be managed by others. Since we cannot charge, perhaps insisting on an unpleasant examination would work on the few..

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Fariha Karim on Jan 4th 2018 reports in the Times: Household made 3,600 ambulance calls in one year

Paramedics were called more than 10,000 times in a year to only ten households, despite few calls resulting in a hospital visit, figures suggest.

Frequent callers cost the NHS about £18.8 million a year, and the London Ambulance Service £4.4 million a year.

One household in Barnet, north London, called paramedics 3,594 times in 2016 to 2017, equivalent to more than ten times a day. An ambulance was sent 715 times, and a patient was taken to hospital 37 times, according to The Sun, which obtained the figures under a freedom of information request.

The NHS spends about £8 on average to answer a 999 call. Dispatching an ambulance to an address costs about £155, and taking a patient to hospital costs more than £250. This means that the calls from Barnet could have cost the NHS about £150,000.

Experts say that frequent callers often have numerous issues and phone “as a last resort”, or are isolated or have needs that are not being met elsewhere.

A spokeswoman for the London Ambulance Service said that around 1,600 callers dialled an ambulance nearly 50,000 times in total. “Although relatively small in number, these patients make it harder for us to reach others with more serious or potentially life-threatening conditions,” she said. “We recognise they will often have complex health and social circumstances which require us to work closely with other health and social care organisations.”

Understanding pressures in general practice – The King’s Fund

General Practice Workload Survey (NHSdigital, last done on 2006-7_

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Post code lottery on Prostate Cancer diagnosis and treatment. Fragmentation ensures private options flourish…..

Dead patients don’t vote, and uninformed families don’t complain. The result of early diagnosis and treatment is very good, but the result of a later diagnosis of cancer of the prostate, especially in younger men is poor. 25% of needle biopsies on cancer prostate patients are negative, so a more accurate diagnostic algorhythms is to be welcomed. Unfortunately, due to fragmentation and lack of choice, informed citizens may need to go privately. If you are unfortunate enough to be in a “worst” area you may have five times the risk of death from this disease. although hopefully some 9 years later things are better.   There are no approved screening tests for Ca Prostate, but serial PSA tests are reasonable.

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Obviously in Private Medical Care there is an incentive to screen (perverse?), and the Mayo Clinic gives good advice. Prostate cancer screening: Should you get a PSA test? The AUA (American Urological Association) recommends that beginning at age 55, men engage in shared decision-making with their doctors about whether to undergo PSA screening. The AUA doesn’t recommend routine PSA screening for men over age 70, or for any man with less than a 10- to 15-year life expectancy.

Recently some question has been raised on the use of hormonal therapies and a link with dementia, which emphasises the need for early curative treatment options.

In New Zealand the Health Navigator as a decision making aid: 

The pros and cons of screening for prostate cancer should be discussed with your doctor to help guide you in deciding if it is the right course of action. Routine screening for prostate cancer in all men without symptoms is not recommended in New Zealand at present. Experts have been unable to agree that prostate cancer screening helps patients. Use this decision aid to help you and your decide whether or not you will have a prostate specific antigen (PSA) test.

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The Times on 1st January 2018 reported (not on line) “Prostate scan lottery”: (Previously Chris Smyth had reported that One in ten men is refused prostate cancer test – June 13th 2017)

“Seven out of 1o men are missing out on the latest technology that detects prostate cancer. Prostate Cancer UK says that the availability of enhanced MRI scanning is patchy, with only 30% of men having access to the tests. More than 150,000 men a year have needle biopsies triggered by a high PSA  blood test. A third have the disease diagnosed and 11,000 men die each year.

Prostate Cancer UK: mpMRI: The new test with the potential to save thousands of men’s lives

Adrian Monti for the Mailonline 27th June 2017: The scientist who helped create a new prostate cancer scan (that’s now saved his life, too)

Nursing in Practice 17th June 2009: Postcode Lottery on Prostate Cancer – Campaigners have revealed official figures which indicate that men in some parts of England are almost five times as likely to die from prostate cancer as those in other areas.

Olivia Lurche in the Express reports: Prostate cancer treatment: New hope for patients suffering symptoms of DEADLY disease – PATIENTS with suspected prostate cancer should have an initial MRI scan to improve detection of aggressive forms of the disease in a bid to save lives.

Experts said the the scans could reduce the number of men undergoing unnecessary biopsies for prostate cancer.

A report, published in British medical journal The Lancet, estimates an MRI could help 27 per cent of men avoid an unwarranted biopsy, during which a small sample of tissue is removed from the body for examination.

Adding an early MRI scan could also reduce the number of men who are diagnosed with a cancer that later proves harmless by 5 per cent, researchers found.

Angela Culhane, chief executive for Prostate Cancer UK, praised the findings as a ‘huge leap forward’ for the ‘notoriously imperfect’ diagnostic processes currently used.

“The results from the (trial) make it clear that giving men with raised PSA an mpMRI scan before a biopsy can help increase the number of aggressive cancers detected whilst reducing the number of unnecessary biopsies for men.”

“This is the biggest leap forward in prostate cancer diagnosis in decades with the potential to save many lives.”

They found a specific form of scanning MRI scan can provide detailed information about the cancer, such as how well-connected to the bloodstream it is. Experts said this could in turn help distinguish between aggressive and harmless types of cancer.

As part of the study more than 570 men with suspected prostate cancer – those found to have elevated levels of the prostate-specific antigen (PSA) protein in their blood or other symptoms – were given an MRI scan followed by two types of biopsy.

Researchers found the MRI scan correctly identified 93 per cent of aggressive cancers, while most commonly used biopsy type only diagnosed about half.

Dr Hashim Ahmed, of the University College London Hospitals NHS Foundation Trust (UCLH), said the current biopsy test could be inaccurate because tissue samples were selected at random.

“This means it cannot confirm whether a cancer is aggressive or not and can miss aggressive cancers that are actually there,” he said.

”Because of this, some men with no cancer or harmless cancers are sometimes given the wrong diagnosis and are then treated even though this offers no survival benefit and can often cause side effects.”

“On top of these errors in diagnosis, the current biopsy test can cause side effects such as bleeding, pain and serious infections.”

The organisation was already working with clinical experts and professional bodies to investigate how a rollout of the MRI scan method may unfold, she said.

The Medical Research Council said an approximate 100,000 men every year in the UK undergo a type of biopsy – with about 66 per cent found to have no cancer or no life-threatening cancer.

The study was conducted by researchers from a range of institutions, including University College London, and funded by bodies including the UK Department of Health.

One PSA is not a screening test. Serial PSAs are a good indicator but they have not been sanctioned..

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Do we want reduced access and less efficiency? GPs are self employed, and they take dividends. Salaried staff are far less value to the state. Politicians are uninformed and short termist..

Especially when there is a shortage, and the politicians have dug their own hole for decades, it is wrong to suggest that highly skilled managers of teams should be punished. The real scandal is the lack of professional staff, and the low salary of the “juniors” who are not partners in the business. The rules allow for GP principals (senior partners) to be asked for accounts to show how much they earn gross, and net from state employment. The gross amount is before staff expenses, practice equipment and utilities. GPs are self employed, and as such they take dividends, not a salary. Most of us former GPs maintain that salaried staff are far less value to the state. Sickness rates in the Health Services are the highest in the world, but the exception (to date) has been GPs and Hospital Doctors. The demands for a salaried service will continue, especially under Labour and in Wales, but the result might be reduced access and less efficiency (Shape of a job). This is a smokescreen trying to get away from poor manpower planning. Indeed, GP profits are falling. GP Trainees are salaried, and may outnumber principals soon! In addition, the location of these “mega practices” managed by  GP experts (managers), is in city suburbs where there is more competition for posts. (Because schools are better there, and provide more places to medical school, and doctors want the same opportunity for their own). The knee jerk response form MPs reveals their ignorance.…… and their short termism.

The various newspapers cover the issue 28th December:

Britain’s highest-earning NHS family doctor rakes in £700000 a …The Sun28 Dec 2018

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The Times: Best-paid GP earns £700k from NHS and today Publish details of doctorspay, MPs demand

GP partner pay drops by 4.3% in the last six months Pulse December 18th

GP premises development frozen, GPs forced to publish pay from 2015: What about comparing overhead?

It’s the shape of the GP’s job that needs to change. The pharmacist will see you now: overstretched GPs get help…The fundamental ideology of the Health Services’ provision. Funding of this type admits 30 years’ manpower planning failure

The Guardian 4th November: Hundreds of trainee GPs facing hardship as a result of salary delays

Bad News: Sharp rise in sick days taken for mental illness – especially in the Health Service Trusts

The NHS culture is sick – and so are its staff – But is there any “quick fix”?

fewer women should be allowed to train as doctors because men are ‘better value for money’… The answer is graduate entry to medical school.

We are wasting money because politicians cannot think longer than 4 years..

The Times summarises in “Healthier and Wealthier” – the Leader 28th December

There is nothing wrong with entrepreneurial GPs earning more than average but when pay is excessive it is likely to be at the expense of patient care

Family doctors may seem an unassuming breed, but some of them have been quietly building empires. Gradually, over the past decade or so, small general practices have been absorbed into super-practices that have merged between two and forty-two surgeries. Many of the local-doctors-turned-tycoons have been doing rather well out of it. A freedom of information request has revealed that one doctor made more than £700,000 from the NHS in 2015-16, one of 200 to earn in excess of £200,000 that year.

The news has angered patient groups, who feel that these salaries are not appropriate, given the health service’s straitened times. The Taxpayers’ Alliance has called the figures evidence that “something is going badly wrong” with GP pay. But some of the sums may be justified if they have incentivised change for the better. Empires can in principle be good for general practice, and where they are, those building them should be rewarded.

Policymakers have long since hoped that enterprising doctors would start to merge practices. They have witnessed the struggle of tiny surgeries that often fail to keep up with the demands of an ageing population. Banded together, surgeries can cope better, as large practices are able to economise on administration costs and through bulk-buying. They can provide better services to patients, too. A larger pool of doctors means more flexibility in the rota, and therefore longer opening hours. At least one super-practice in Birmingham is open seven days a week. Many can afford to offer patients extra services, such as an onsite dentist or physiotherapist.

Large practices may also help to combat the burnout problems that plague the profession. GPs have been quitting the NHS at the rate of more than 400 a month. Many are fed up with the burden of the administrative work involved in managing small practices, along with cramped and inadequate premises. Life at a large clinic can be more varied as well as more comfortable: flexibility means that doctors can spend a couple of days a week pursuing a specialist interest, such as orthopaedics or physiotherapy. And a traditional perk of working at a small practice — rising to be partner more easily — is becoming less important with the proliferation of female GPs who often prefer the part-time options that come with working for a salary, rather than running a business.

The system is not perfect. Although the wealth of a practice, dependent on the number of patients it serves and government targets it meets, is tied to its success, the salary of its senior partner is not. Partners decide how much to take for themselves and how much to plough back into their businesses. The most dynamic are not necessarily those paying themselves the highest sums. An enterprising approach that improves both efficiency and patient care is to be applauded, but doctors who pay themselves very large salaries necessarily take resources from patients. For a GP to earn more than £700,000 seems excessive by any standards. This is nearly double the salary of even the controversially highly paid university vice-chancellors. It makes the case not for enterprise in primary care, but for restraint in GPs’ pay.

The second problem is that pay is not transparent. High rewards for the most enterprising doctors will not work as an incentive to others unless the sums are public and fair. More importantly, they are funded by taxpayers who have a right to know how their money is spent.

It is to be welcomed that GPs can be entrepreneurs as well as NHS employees. Indeed, it is partly for this reason that general practice has adapted to changing demands better than the rest of the health service. As practices have merged, patients are better served than with healthcare elsewhere. The more efficiently GPs’ surgeries are run, the lighter the pressure on the rest of the NHS.

Letters in the Times 30th December: 

Sir, GP practices are run on a business model in which earnings are related to meritorious performance and excellence (“Best-paid family doctor earns £700k from NHS”, Dec 29). If a highly paid GP provides exemplary care to his or her patients, should we begrudge the high pay? Further, if a university vice-chancellor can earn nearly £500k, there is no reason why a hard-working and efficient GP should not be paid a high emolument for his service.

With time being limited per patient, GPs are under considerable strain in taking clinical history, both recent and past, examining the patient, ordering investigations and referring to hospital when required. At present, many patients in general practice are elderly and suffer from multisystem diseases. On top of this, the average GP is lumbered with bureaucracy, paperwork and administrative duties. Whether they are in a large practice group or not, GPs work in isolation, unlike hospital consultants who tend to work as a team and referrals to specialised colleagues are relatively simple.

It is a stressful and onerous life for GPs.
Dr Sam Banik

London N10

Sir, What concerns me are not the enormous salaries drawn by a handful of GPs, a negligible consideration in the context of the NHS budget, but the £56,000 a year average pay drawn by non-partner GPs.

It is hardly surprising that we have a shortage of GPs when we pay these highly trained professionals with onerous responsibilities substantially less than a London train driver. Addressing this anomaly should be the priority for the government.
Martin Cragg

New Malden, Surrey

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