Category Archives: General Practitioners

Is tghere really a long term plan worth the name?

 GP shortage threatens long term plan. Gareth Iacobucci in the BMJ (BMJ 2019 ;364:1686)

Chronic staff shortages in key areas such as general practice are jeopardising the NHS’s long term plan to strengthen primary and community care in England, experts warn. New research by the Health Foundation has found “ongoing deterioration” in workforce numbers in primary and community care, nursing, and mental health services, with staff numbers failing to keep pace with demand. Shifting care out of hospitals and closer to people’s homes was identified as a priority in the long term plan, published in January. But Anita Charlesworth, a director at the Health Foundation, said, “If [the NHS] can’t recruit and retain more professionals in primary, mental health, and community care, this will continue to be an unrealised aspiration. There is no sign that the long term downward trend for key staff groups, most notably GPs, will be reversed.” The number of GPs in England fell by 1.6% (450 full time equivalent staff) in the year to September 2018, the report said, despite ministers’ pledge to recruit 5000 extra by 2020. The report also highlighted the continuing decline in numbers of community nurses and health visitors, falling by 1.2% (540 FTE staff) in the year to July 2018. It noted slow progress in
mental health recruitment. Psychiatrists saw the smallest percentage increase (0.6% or 50 FTE) among doctors, and numbers of mental health nurses rose by less than 0.5% (170 FTE) in the same period. The importance of international recruitment was being hampered by broader migration policies and Brexit uncertainties, the report said. Although the number of doctors from other EU countries had risen by 5.5% since 2016, recruitment of EU qualified nurses and midwives had fallen respectively by 8.5% and 3.1%. Charlesworth said, “So much now hinges on the workforce implementation plan. But to bring an end to chronic workforce shortages for good, action must address the underlying major fault lines in the current approach, particularly the lack of alignment between staffing and funding.” A Department of Health spokeswoman said some of the report’s figures were out of date. Latest statistics, from October 2018, showed 2564 more health visitors, 473 more mental health nurses, and 233 more psychiatrists than a year ago, she said, adding, “Last year a record number of doctors were recruited into GP training.”

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A GP in Milford Haven exposes the Inverse Care Law as applied by successive Governments, perversely and neglectfully..

The irony of the lack of doctors, and insufficient access to Primary Care is that it is government who is responsible, and it is successive governments who have ignored the advice of the profession. The Inverse Care Law as defined by Julian Tudor Hart, used to apply to citizens in poorer and deprived areas who got less resources when they needed most. Now it is government who are responsible for the inverse care law as applied to health. As private practice becomes more evident, it will be most available in those areas where people can afford it, and the people living in deprived areas will have to put up with a second class service. Doctors, knowing they are rare commodities, can choose where to live, and will mostly choose where infrastructure and education and housing are best. Most of them come from suburban and inner city schools and these doctors when qualified would rather work part time in their home city than full time in a challenging area.

Daniel Weaver, a GP in Milford Haven, has sent this out on facebook, and has been interviewed for the Milford Mercury. Dr Weaver is an experienced and altruistic GP. His cry for help comes too late in many ways. NHSreality has been highlighting the demise of the “Goose that laid the Golden Eggs” of efficiency and avoidance of overtreatment for 6 years. NHS reality has also pointed out the problems with GP recruitment on many occasions, and asked for more graduate entrants to medicine. NHSreality has also reported on the rejection of 9 out of every 11 applicants when they were all recommended to apply because they were good enough. Rationing of places to medical schools, uninformed manpower planning, and an over dependence on females as doctors (because they are better at undergraduate entry) have all conspired to get us to arrive at this point. The short termism of the First past the post electoral system means there is no incentive to plan capacity over 20 years. Obviously we need to address recruitment, but the  shape of the job also has to change. Golden Hellos are not enough…  The heartfelt letter below is a cry for help on one level, and a daming indictment of government at another. NHSreality only disagrees in that there is no “N”HS any longer. Here is Dr Weavers Post: “If anyone is in the Milford Haven area feel free to share this post”:

I wouldn’t normally do this but I feel compelled to put a message out in response to the increasing levels of aggression and abuse towards staff over recent months. Hopefully this will work as something of a FAQ about recent issues relating to the surgery. This may be a long post, stick with it though and hopefully it will give some clarity.

Currently Robert Street is effectively short of 2 doctors (which is 40% of our manpower) & this is less then ideal. This is in part because of maternity leave, and in part because despite spending thousands of pounds on advertising we haven’t had any success in recruiting since a doctor left a couple of years ago. Why haven’t you had success? Multiple factors including a national shortage of GPs in UK and especially in Wales. Wales is seen as less appealing to work in compared with rest of UK and Canada, Australia as earnings tend to be lower and due to harsher social service cuts problems with social care, social problems end up reaching general practice, and longer out patient waiting lists mean that people are seeing GPs more frequently so there is a harder workload. We are further west than most people want to work, and our practice area is one of relative deprivation, so any GP applying knows they will be busier then those working in more affluent areas.

I came to back to work in Milford because I enjoyed working in the town during my time training in Barlow house surgery and I have a family connection to the town, but unless someone has a connection to the area it’s not easy to get people to relocate from other areas. Many international Doctors in the NHS have families overseas and want to settle in a location with good access to airports etc. or to live in larger cities with people of similar faith or culture. We have up to 3 weeks less annual leave then several other local practices which has been cited as a factor when I’ve chatted to doctors who’ve moved elsewhere, especially doctors with children. We have specifically resisted increasing amount of annual leave we allow ourselves because it would pressurise appointments further.

There are higher paid practices in the region. (practice income is complex depends on multiple factors, like if practice is a dispensing practice or has branch surgeries etc) I have medical friends with whom I have discussed about working in Pembrokeshire. Feedback from them often revolves around issues like the above but more locally uncertainty about local hospital services making doctors nervous about possible knock in increased general practice workload in the region.

The loss of maternity services in the county and loss of 24 hour paediatrics is deterring younger doctors who either have children or are planning to have children. Also the state of the secondary schools in Pembrokeshire at the moment puts some off. Locum rates being paid within our health board and elsewhere mean that potentially a GP could earn more money in a week of locum work then if they were in a stable salaried or partnership role for a month. Locum doctors don’t have to follow up patients or results and usually will cap themselves to a limited number of consultations eg 12 in morning or afternoon and 1 home visit. Existing locums have low incentive to get permanent jobs with a practice. There is ironically also a shortage of locum doctors. We are continuously looking for locums, and getting them when we have a chance. We cannot compete with health board for locums as their rates far exceed what a normal general practice can pay.

Another factor is we are not a training practice, I will come back to this later. Would it be financially beneficial and better for work life balance for doctors to leave and do locum work? Yes in short, but if another doctor left it would cause the practice to collapse entirely and we feel a duty to each other, staff and the local area. This is the danger about locum work being so lucrative in the current climate, it actually risks destabilising things further. Why aren’t we a training practice? We’ve been desperate to get training status since I joined the practice, it’s something I’ve always wanted to do, I’m passionate about training and this is something I’ve always been involved in in different forms from my time in medical school. Aside from wanting to train there is also evidence that the surgeries that cannot recruit and have to close are much more likely to be non training practice. Why is that? GP training practices have a registrar or registrars who effectively work as a doctors while completing their GP training, this increases number of doctors available to see patients in training practices. It also allows doctors to test working in a practice. Many trainees will end up in taking a job in a practice they trained at if they had a good experience. The good news is that we have had the first indication that can start the process of becoming a training practice which gives possibility of progress in the next year towards this goal.

Why is it so hard to get routine appointments? Unfortunately at the moment we are often down to 2 doctors a day, as we are frequently seeing 40-60 emergency appointments daily there is limited capacity for routine appointments. This is entirely manpower related. We are working harder then ever. We have effectively close to 3000 patients per full time equivalent GP currently. To put this into perspective a Nuffield Health study in 2011 showed national averages for Scotland was 1400 per GP, England was 1500 and Wales a little over 1600. We are short staffed at the busiest time of the year without locums. If there are 3 doctors in, the routine slots are put on in addition to emergency but these obviously go quickly especially if people are trying to see a particular doctor.

Why don’t you see more patients? During the average day which is usually 10+hours, often the only break is to go out and get food to eat at desk while going through results or letters or for toilet. Although I was not on call today I didn’t get a chance to have lunch so when I got home at 6:45 I ate for the first time since breakfast. This isn’t unusual. I am on call on average 3 or 4x per week either in the AM & PM during an on call there is a continuous stream of messages, script requests queries etc. In addition to usual duties emergency surgeries and home visits and things are often very frenetic and pressurised. Apart from seeing patients in the surgery GPs have do go through letters from hospital, amending medication and arranging tests and referrals. We will often have many letters daily, for example I went through a little over 70 letters this morning. GPs have to write letters for referral or to other agencies, appeals, DWP forms, forms relating to end of life, death certificates, cremation forms. GPs have to also go through Emails from NHS/health board/and check safety updates on medications which get posted through. Review results, bloods results get reviewed and often require further action, same with scans, we will often get results for around 30 patients each daily to go through more if someone is away and we are covering them.

Home visits: these are the least time efficient part of the day. Often if spread out a GP can spend over an hour driving between houses and nursing homes which takes time away from doing other jobs. Phone calls: I can have up to an hour of phone call requests or more in a day. Prescriptions and sick notes. In a typical week each GP is signing several hundred repeat medication prescriptions, along with sick notes. OK, I get that you are busy, what else have you tried? We have tried employing a physiotherapist to see patients presenting with muscular/joint problems to take pressure of the on call, allowing GPs to see other patients. Did it work? No most patients refused to see a physiotherapist and they insisted on seeing a GP.

GP Triage: this is a service which exists due to pressurised situations. A lot of issues can be managed over the phone and potentially saves an unnecessary appointment being used on the on call which can be used for someone else. The GP can access the notes and takes a history/arranges investigations or a face to face appointment if required. We pay for this out of practice budgets. It’s not ideal but it is better then nothing and there is no alternative option at this moment in time.

What about health board? in June we applied with Barlow House and Neyland surgeries for some existing Welsh assembly sustainability money to go towards employing a paramedic practitioner who could take some pressure off the home visits situation. Nothing has been forthcoming. We, on a temporary basis, have attempted to close our practice list although the health board have resisted this. This is given current intense pressure a logical step to try to preserve our resources and time for existing patients as we are aware of the access issues. They are not offering help. What else are you doing? We have been training a practice nurse to become a nurse practitioner, meaning she will be able to see some of the simpler emergency appointments.

Why can’t I get through on the phones? It’s not ideal but we have a finite number of reception staff. At peak times we have up 100 people trying to get through and without a call centre there are likely to be delays. Being on hold is common for doctors too and I often have to wait 20 minutes+ when contacting the hospital to refer a patient in for other reasons.

Image result for overwork cartoonThe NHS in general is struggling to deal with the amount of people who use the service, it’s far from ideal but there is no obvious solution, and no additional funding to help with this. Why do routines only come out on a Thursday? If everyone who wanted a routine appointment phoned up every day it is going to increase phone traffic and difficulties getting through, in other words it would make the problem worse. It’s the same reason why people are encouraged to put in repeat medication requests through via their pharmacy or by dropping a slip in. There is the option of signing up to request repeats online which is super useful, but not many people do this. Thursday is traditionally the quietest day of the week so that time in the PM is least worst time of the week. Why don’t you just abandon all routine appointments and just do book on the day system? This gets discussed periodically but when it has been trialled before people complain about it. Why do reception staff ask me about my symptoms if I want an emergency appointment? They are not being nosy, sometimes people phone to get an appointment with a GP when actually it would be unwise & they should call 999 or go to A&E, for example if having a stroke or suspected fracture. Sometimes the issue is something that can be better dealt with by a pharmacist, a dentist or is completely non medical. Additionally if I am doing an on call, I need to be aware who the likely most ill people are, eg if someone is doubled over in agony with a possible appendicitis or acutely suicidal, I will need to see them before I see someone with mild earache or trapped wind. Will shouting at staff or being abusive help? No, please try and be patient and don’t take frustration out on staff. Everyone is working hard and it’s not an easy time for anyone. Taking it out on staff increases the likelihood of people walking away which makes the problem worse. I still want to complain! Feel free although hopefully this will help put your concerns into perspective. We are very stretched and this entirely relates to staffing issues beyond our control along with a difficult local healthcare environment. I am a doctor, I am not a politician and I have no influence on the larger, complex problems facing our county or country. There are multiple practices in difficulty in the county and elsewhere in Wales, and increasing numbers of doctors handing practices back to health boards due to being unsustainable and impossibly challenging working environments. In summary we are working hard and have been trying things. Why aren’t Barlow House having the same issues? It is harder to get an appointment with us then Barlow House Surgery but this is resource linked. They are fully staffed with permanent GPs and usually have between 2-3 GP trainees giving them roughly double our capacity, despite this they are still busy and working hard as well, as demand continues to rise in part because of problems in social care and secondary care being moved onto general practice. We get continuous complaints about difficulty getting appointments and problems with the phones but hopefully this gives extra insight into reality on the ground. Positive aspects for future are: more trainees coming from local scheme in next few years increases chances of us recruiting in a year or two. Dr Skitt won’t be on maternity leave for ever. We may be able to have trainees in the next 12 months which will help. We and another practice in Pembrokeshire will hopefully soon have a CPN attached to the surgery who may be able to help out with mental health related issues. This is a Welsh assembly funded pilot and hopefully will be positive. Age wise there are no doctors coming up to retirement soon unlike some other practices around the region. My colleagues are grafters and work as hard as any clinicians I’ve ever worked with in my entire career. If we do recruit and become a training practice Milford Haven is will be in an advantageous position compared with most of the rest of Wales with full compliment of relatively young doctors. I appreciate in the short term this isn’t much consolidation but at moment priority is survival. I apologise in advance but I’m not planning to respond to comments on this post as I made a decision some months ago to try and avoid social media and to try to prioritise spending any free time I have with family and friends rather then online. This was a decision ironically I took because of how late I tend to get home from work and the impact my job has on the people around me. Feel free to share this though.

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Deprivation differences…. especially across the UK – revisited

Early deaths: Regional variations ‘shocking’ – Hunt

Poverty in Wales

How to kill the goose and create a shortage of 10,000 GPs – Patients kept waiting as new doctors shun GP jobs

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..

The Horse has bolted but “play it again Sam”…

“GPs to receive ‘golden hellos’ in hiring drive”….

The reality of the post-code lottery and rationing of health and social care. It will just have to get worse before the “honest debate”…

I had some unsolicited mail this week. The company was advertising a Peoples Postcode Lottery. You can easily find their website saying how many good causes they support: many medically related. Why in a comprehensive and free health service are such charities needed at all? The flyer does not say what overhead is taken out for admin, and the distribution as a percentage, and the rules are unclear. Just like the 4 health services. It is covert. And they make profit as well… also not stated in the flyer. On Sky TV I watched the Test Match and between each over there was an advert for at least one and sometimes two gambling outlets. The “profit” for the health services is missing. The overhead is mainly on staff. Capital investment is missing. 

There have been a number of “news” items in the last few days/weeks which are as depressing as Brexit. The denial and obfuscation on the 4 UK Health Services is similar to that on our relationship with the EU. There are “hard truths” to be discussed but the informal collusion between he media and the politicians means that no honest debate is possible – until it gets much worse. Infections that used to be rare are now commonplace. Access and recruitment are becoming so difficult that private GP practice will start to spread. The cost of care in homes (Usually residential, but Nursing and EMI as well) is escalating as the owners are unable to make ends meet. Staff are mainly from overseas, so restraints on immigration will hurt and escalate costs further.

Surely we all have a right to know what will not be covered, and this void should be national and fair?

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Care Home Professional reports 11th Feb 2019: Fully funded care four times more likely in some parts of the country.

Edmund Greaves on 8th Feb 2019 in Moneywise says its six times more likely in some areas.

Lynn Davidson in the Sun 23rd Jan 2019 reports: Children in Care face post code lottery with some areas spending 10 times as much as others – A ten fold increase in children in care!

Tom Martin in the Express 30th Jan 2019 (Scotland) calls for “An end to the post code lottery of Hospital Cleaning” – Getting at the number of infections in state run DGHs (District General Hospitals)

Zoe Drewlett on 14th Jan in the Metro reports that “Over 100000 people have called for the end to the post code lottery in IVF”

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Collette Hume for BBC News Wales reports 4th Feb 2019: Parents of deaf children face funding ‘postcode lottery’

Stephen Matthews for the Mailonline 8th Feb 2019 reports: The Post code lottery of seeing your GP. Shocking map reveals the 10 areas of England where most patients are waiting over two weeks for an appointment.

 

Britain is worse off for GP cover than Malta, Romania and Estonia

Its ironic that the chiefs who have decided to advertise in Australia don’t mention the land of Aneurin Bevan and Beveridge. Yes, their plans were over ambitious, and yes we have planned our manpower woefully for the last 30 years. The blame for this lies with successive governments of all colours, and the first past the post electoral system which encourages short termism, and discourages longer term financial commitment and planning. Now we are at risk of banning doctors from the EU, and of those that are here feeling rejected and leaving, and the result of our shortage could simply be more doctors from the old commonwealth countries. When I was training, more of my trainees went to Aus than came from them.. and that trend is set to continue for a decade or so.. Its still better for the population than the US system, but it is worse than many others in the G7. It is worse for rich individuals but then they can go privately.

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On 25th January 1019 – Britain is worse off for GP cover than Malta, Romania and Estonia …

[PDF] Malta: health system review – LSE Research Online

Laura Donelly in the Telegraph 27th Jan 2019 reports: Aussie doctors urged to work for the NHS – in land of Harry Potter, Shakespeare and Manchester United

Health chiefs will attempt to recruit doctors from Down Under with a new campaign urging them to come to the land of Shakespeare, Harry Potter and Manchester United.

Australian GPs are being targeted by the new drive, in a desperate bid to plug shortages of family doctors across England.

In September 2015, then-Health Secretary, Jeremy Hunt, pledged there would be 5,000 extra GPs in England by 2020. But since then the number of full-time doctors in the workforce has fallen.

The new social media campaign will attempt to persuade doctors abroad to come to the NHS and work for “a national treasure”….

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A series of intellectually and ideologically bancrupt administrations has led us to a GP recruitment crisis.

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

The GP – his future as a permanent locum? Inadequate manpower planning gives a wonderful business opportunity to some..

An American compares the two systems: USA and UK. 

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Closure of Hospital inevitable. Enormous shortage of GPs. A&E target times in Wales worse than last winter

Yes, its going to get even worse. Despite the Brexit promise to let fewer immigrants into the UK, we are going to have to reverse this for doctors. Will they be trained adequately? Will their communication skills,  and cultural awareness be enough? Will they incur more litigation? and Will they be needed more where they come from? Will they deny our own medical students places in GP? The promise of 5000 extra GPs is beyond belief, as it will take another 10 years to train enough. Those working can pick and choose, and it can be lucrative to burn yourself out. 

This is all the result of the rationing of medical school places, the power of Deaneries, and their inability to embrace on line learning. The virtual medical school is an urgent need..

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Owain Clarke for BBC News 24th January reports: A&E target times in Wales worse than last winter

And another Hospital will close: Rothbury Hospital future ‘to be decided in summer’. The delay is just window dressing for the inevitable. Its a GP Hospital, after all….

GP recruitment is getting worse too. Even in the richer and more desirable areas of the UK.

Kentonline 21st Jan 2019: GP numbers in Swale and Thanet among worst in England as NHS … and Luke May reports: GP surgeries in parts of Kent have just one doctor looking after thousands 

Worcestershire one of the worst areas for recruiting GPs

£20000 ‘golden hello’ doubles GP recruitment in under-doctored areas

Demand for Wokingham health services leaves NHS with recruitment challenges

Fancy £20000? Trainee GPs given cash windfall to work in Staffordshire

16th Jan 2019 from GPonline: GMC to double PLAB test capacity to boost recruitment of overseas …

Pulse on 10th Jan reports: No target date for recruiting 5000 extra GPs, says health secretary

‘There’s no easy fix’ warns GP as scale of doctor shortage revealed

The Lynn News: National scheme hopes to boost trainee GP numbers in West Norfolk

The Guardian: New GPs sign up to poorest areas after £20000 incentives

Some parts of England have three times as many people per GP than … (INews) . West Sussex, the second worst place to get sick, there are 2,997 people per GP. … There are areas that aren’t seeing investment in GPs, and RCGP … Hello scheme to attract GPs to areas struggling to recruit GPs, Pulse, ..

Renfrewshire medical practice left with no permanent GPs after doctor …

TheGazette.co.uk22 Jan 2019
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Interviewed, but not examined. Surely the internet is not capacle of that!

Chloe Holmwood reports in KentonLine 20th March 2018 : Islanders can now be examined by a doctor who is up to hundreds of miles away using digital technology:

Well lets hear the feedback including referral rates and litigation costs. Is the service, now nearly a year old, used for anything other than skin conditions and psychiatry, and repeat prescriptions. The idea of an abdominal or a rectal examination “on line” defeats me. It is not the first “mad idea” in primary care, but it is necessary because of the paucity of GPs.

We need so many more doctors and nurses its untrue.

 

Doctors to see groups of patients – is probably madness. The fox is waiting..

Any GP you want: so long as you’re healthy

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

Referrak thresholds are different for different doctors… computer data could help.

A colleague of mine tells the story of the city GP who was not really qualified. He survived for years, and when “exposed” his patients queued around the block to complain that he would be leaving. His technique was to refer everything to the local A&E….with a “Please see and advise” letter. He thus never made a mistake or diagnosed late.

As an example of the “split personality” of the administrators in the departments of health, please consider todays report in the Times. Chris Myth reports: Rivalry can help save lives of cancer patients. We know that performance related pay has a short term benefit and a long term negative effect. What makes a GP efficient is when he does not refer. If GPs referred everything and did not allow “time” to help sort common problems, there would be little point in having them. They are the goose that laid the golden eggs of efficiency – in the past. Will the days of the GP as symptom sorter and access door to more expensive tests be stopped? The split personality is reflected in the opposite – “non referral,” which was encouraged in 2015! Several articles in 2015/2016 in the Guardian and the BMJ offer advice that tribal rivalries are destructive. There will be many confounding factors and perverse incentives in every health system, but if we want efficiency for the population, we need GPs who can live with uncertainty, and refer appropriately. Abandoning the GP will mean the state service implodes and private care will expand rapidly. Giving incentives to refer is perverse as far as the state efficiency is concerned. Providing health to populations is different to providing it for individuals. What may be of help is ratios showing how many referrals per female aged 60-70 with say, indigestion for a few days, are made compared to the mean. Some doctors have low and some have high thresholds, and they should be aware of this.

GPs have been trained for about 10 years to do what they do. We just need more of them.

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Chris Myth reports: Rivalry can help save lives of cancer patients. 

Telling GPs that they are sending fewer patients for cancer tests than their colleagues can save lives by boosting referrals by up to 20 per cent, an NHS trial has found.

Sending letters to doctors with low rates of referral pointing out that others are doing better spurs them to improve, the study concluded. Health chiefs are considering whether to adopt the plan more widely in response to calculations that 2,500 cancers could be spotted a year earlier as a result.

Late diagnosis is thought to be one of the reasons why cancer survival in Britain is notably worse than in other rich countries. A report by Sir Mike Richards, the government’s former cancer chief, concluded last year that one explanation for late diagnosis was that GPs were sending too few patients for tests.

The study in Manchester involved sending letters to 244 GP surgeries with below-average referral rates. While the effect was limited among surgeries just below average, those in the bottom 30 per cent increased referrals by 20 per cent compared with similar surgeries not sent letters. Below-average prescribers increased referrals by 10 per cent overall.

Felicity Algate of the Behavioural Insights Team, a social-purpose company spun out of Whitehall, said that the idea came about after letters sent to GPs who prescribed large amounts of antibiotics led to the number of prescriptions falling by 3 per cent. “Just browbeating people or just giving information, that’s not effective in changing behaviour [but] social norms are a very, very powerful factor,” she said.

Ms Algate was surprised by the size of the effect, suggesting that it also involved professional competitiveness and reassurance that the surgeries were not referring too many patients. “There are conflicting messages because there is quite strong pressure not to refer too many people,” she said.

Jodie Moffat, of Cancer Research UK, said that the charity would look at the scheme in more detail, adding: “Building the evidence to understand how the NHS can improve urgent cancer referrals is really important.”

However, Helen Stokes-Lampard, of the Royal College of GPs, said that putting GP surgeries under more pressure could “cause more harm than good”.

She said that GPs were often berated for sending too many people to hospital, adding: “When some cancers are in the early stages they display similar symptoms to many much more common illnesses that must first be ruled out . . . The real problem lies with the lack of resources, including diagnostic tests in the community.”

NHS England is studying the results.

Doctor and nurse rivalries ‘undermine NHS reforms’ | Society | The Guardian 2001…

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

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?