Category Archives: General Practitioners

The revolving door of health service managers….. mismanagement is nothiong less than neglect.

The mismanagement of the 4 health services that used to be the “National Health Service” amounts to nothing less than neglect.

We medics all know managers who move on quickly. Being fast on your feet is essential in a  service where nothing is addressed long term. Recruitment is a nightmare of under capacity, female bias, and the resultant manpower disaster means we need to recruit from overseas for decades. NHS looks abroad for thousands of nurses – Health chiefs admit failing to plan for elderly care

We jaundiced GPs and Consultants can only assume that these managers have no exit interviews, and that nobody wants to hear what they have to say any more than the professionals.

Chris Smyth reports 7th May 2019 in the Times: NHS register to stop ‘revolving door’

A professional register of NHS managers and a values test for senior leaders are being planned to stop a “revolving door” for failed bosses.

A health service scarred by bullying and stress “needs to be a better place to work”, an interim workforce plan concedes. Although the NHS acknowledges that unexpected pension tax bills are forcing doctors to retire early and work fewer shifts, plans to tackle that issue have been removed from a final version.

The NHS interim people plan makes the starkest acknowledgement yet that staff are leaving the health service because they are overworked, with increases in bullying, harassment and abuse all reported recently.

The plan promises staff that they can expect support on work-life balance, whistleblowing protection and equal opportunities. Specific details are yet to be decided but the plan pledges that more jobs should be part-time or term-time only.

The plan lays out how the management culture of the NHS had to change to “root out bullying and harassment” with an admission that all staff will have experienced a dysfunctional working environment at some point.

“It cannot be right that there are no agreed competencies for holding senior positions in the NHS or that we hold so little information about the skills, qualification or career history of our leaders,” the plan states.

“A series of reports over the last decade have all highlighted a ‘revolving door’ culture where leaders are quietly moved elsewhere in the NHS, facilitated by ‘vanilla’ references,” the plan continues. “These practices must end.”

A government-ordered review has previously recommended a set of core skills for managers. The NHS has now pledged to draw up “an explicit set of competencies, values and behaviours required in different senior leadership roles”. This could include, for example, honesty and protecting patient safety.

Ministers have previously promised a central database of directors’ qualifications. The NHS has now pledged to “develop options to create a registration scheme for NHS managers similar to those used in other healthcare professions and in finance”. It is unclear whether such registration would be compulsory. The plan concedes: “The lack of a transparent, fair and consistent process for the appraisal of senior leaders has contributed substantially to the challenges we face today.”

The plans do not address higher pension taxes for top earners, which are forcing many consultants to retire early or turn down extra shifts to avoid bills for tens of thousands of pounds.

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians… “Wise doctors will retreat from the front line now?”

The Health Services Procurement – inefficient and risky… Centralisation and management control is needed

This mismanagement of the NHS amounts to neglect

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The four GP dispensations / jurisdictions. Nothing “national” about GP contracts.

There is nothing “national” about the GP contracts around the UK. The only way to ensure adequate supply is to train enough. NHSreality believes we should aim at overcapacity to ensure both supply and financial control. The contracts seem to endorse “private practice” but at the same time stop GP premises being used at all for private activity. Will this include Insurance and DVLA medicals? We are all in the UK (just) and pay the same taxes, and yet we have dofferential, hidden, randomised post code rationing.

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The BMA in England has produced “A five-year framework for GP contract reform to implement The NHS Long Term Plan” but this does not apply to Scotland N Ireland and Wales, and indeed, it has not been agreed by NHS England in it’s entirety. Despite the lack of recruitment, loss and early retirement of GPs, the whole edifice is falling like a pack of cards.

Pulse commented on the headlines in January observing that this was the most significant reform since 2004. The comments on line are “looks like the exodus will continue” and “150K lloks like a lot but after tax and pension it’s a much more modest sum.” Another is “Well if you are close to the !%)K limit …. what will happen is GPs will simply stop doing NHS work”.

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In Northern Ireland the HSC (Health and Social Care) Board rules.

In Wales the GPone website from the Welsh Government supplies their details. In Wales agreement has not been reached on the litigation funding arrangements, which at present may be top-sliced obligatorily, and causing resentment. In Wales we even cerebrate a reduction in the degree of bankruptcy…   and the poorest standards in Bowel Cancer screening, results, and Waiting times.

The Scottish Government contract and website is different again

NHS England contract 2019 which all the headlines are about. They ignore the other 3 dispensations. The Medical Indemnity scheme is funded separately in England, and will not be top-sliced as threatened in Wales.

“A new state backed indemnity scheme will start from April 2019 for all general practice staff including out-of-hours.” (NHS England)

See the source image

See the source image

No Out of Hours service for taxpayers in Pembrokeshire. Be prepared to camp wherever you are sent…

As readers know there is no NHS, and in Pembrokeshire citizens who pay their taxes have no  GP Out of Hours Service/ Doctors on Call – in Pembrokeshire County …  

If you are elderly, or have young children, it looks as if you will have to camp in Casualty, and even that is poorly staffed, incompletely covered, and failing. NHS 111 is an appalling service. Confidence is failing, and private care will have to step in when the demand for it occurs. If there are deaths this might be sooner rather than later.

ITV news reports that for the second week running “GP shortages mean Out of Hours closures. 5th April 2019.

and prior to this, on 29th March: Out of Hours GP service closed again at Withybush Hospital this weekend.

For those who don’t know the area, the nearest (and also failing) DGH is 35 miles and many agricultural vehicle obstructions away, in Carmarthen. The situation is akin to the loss of services in Chester, except this is worse: it is access to emergency care rather than cold planned care that has been rationed out by successive administrations (of all colour).

The service in West Wales is now an official failure… but nobody is admitting their complicity in this disaster. The Post Code lottery is worse for distant and remote places. We are expecting a decision on a new hospital… 

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GP shortages this weekend mean that out of hours services in Carmarthenshire and Pembrokeshire will be closed intermittently. 5th April ITV News 

Hywel Dda University Health Board says they are continuing efforts to fill the shifts but expect the following disruptions:

  • Withybush General Hospital – closed 12am to 8am on Sunday.
  • Prince Philip Hospital – closed 2pm on Saturday until 8am on Sunday.
  • Glangwili General Hospital – closed from 10:30pm on Saturday to 8am on Sunday.

Analysis by Health Reporter James Crichton-Smith:

The fact that Hywel Dda is struggling to fill its GP out of hours rota is not a new one.

Health boards across Wales regularly have gaps in GP out of hours cover and Hywel Dda has previously warned of a shortfall at weekends, like it has this afternoon.

Read more:

Staffing problems and poor morale affecting GP out of hours

Health Board has had no doctor available overnight

The cause is a simple, and familiar, one. There simply aren’t enough GPs in Wales.

Efforts are ongoing to try and change this. The Welsh Government has its Train. Work. Live. campaign – and it has been getting results.

But training new GPs and attracting them to Wales takes time. The challenges are in the here and now.

August 2013:A series of intellectually and ideologically bancrupt administrations has led us to a GP recruitment crisis.

April 2019: GP suicides: LMCs call for action to reduce “appalling” numbers

March 2016: Top GP warns of threat to NHS as BMA calls emergency conference

August 2014: Recruitment rationing: GP magazine calls on political parties to support general practice

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You can’t get no satisfaction – and its going to get worse….

The 4 health services need money, especially if they are “free at the point of access”, and cradle to grave, without reference to means etc. Unfortunately we in the profession know this is unsustainable and hence the problems at Chester – refusing Welsh Patients. The money moves with the patient all around the 4 Health Services, so no wonder the commissioners refuse second opinions from outside their trust (These are the only ones that matter), and refuse inter trust transfers and referrals whenever possible. Just like in Dentistry, private services are going to thrive, whether GP advertising is banned or not… Cutting referrals means more private care.. 

The fines for long waiting lists have to be more than the cost of extra contractual referrals! Commissioners will coolly calculate the difference and lives will not be considered. 

We shame Aneurin Bevan’s ideal and even Stephen Hawking realised this.

Nick Triggle for BBC news 7th March reports: Satisfaction with NHS ‘hits 11-year low’

and this is particularly true in the Walsh border area around Chester.#

The Chester Chronicle reports: Satisfaction with NHS “at lowest since 2007”.

Public satisfaction with the NHS has fallen to its lowest level in more than a decade, despite the Government’s announcement of a funding boost, new research suggests.

Just over half of people (53%) in 2018 said they were very or quite satisfied with the way the health service is run, the British Social Attitudes (BSA) survey found.

This is down three percentage points from 2017 and the lowest proportion since 2007, according to analysis by the King’s Fund and Nuffield Trust.

In 2016, 63% of people were satisfied, compared to 65% in 2014.

Satisfaction with how the NHS is run is at its lowest since 2007 (PA Graphics)


(PA Graphics)

Ruth Robertson, senior fellow at the King’s Fund, said she was “surprised” by the results of the survey, in the year the NHS celebrated its 70th anniversary and was promised an additional £20.5 billion per year.

“We didn’t see this ‘birthday bounce’ that you might have expected in satisfaction,” she said.

The survey of almost 3,000 people in England, Scotland and Wales was carried out between July and October, after the funding announcement.

The main reasons people gave for being dissatisfied with the NHS overall were long waits for GP and hospital appointments (53%), not enough staff (52%), a lack of funding (49%) and money being wasted (33%).

More than two-thirds (71%) of those who were satisfied with the health service said it was because of the high quality of care, while 62% said it was the fact it is free at the point of use.

Older people were happier with how the NHS is run than younger people, with 61% of those aged 65 and over satisfied compared to 51% of those aged 18 to 64.

“Despite the outpouring of public affection around the NHS’s 70th birthday and the Prime Minister’s ‘gift’ of a funding boost, public satisfaction with how the NHS is run now stands at its lowest level in over a decade,” Ms Robertson said:

“In the short term at least, the promise of more money doesn’t appear to buy satisfaction.

“The public identified long-standing issues such as staff shortages and waiting times amongst the main reasons for their dissatisfaction and cash alone will not solve these.”

Satisfaction with GPs has hit its lowest level since the survey began (PA Graphics)

Satisfaction with GPs has also dropped two percentage points to 63%, the lowest level since the survey was first carried out in 1983.

Professor John Appleby, director of research and chief economist at The Nuffield Trust, said: “This may reflect continued strain on general practice, with mounting workloads and staff shortages and the evidence shows that people are finding it harder to get appointments than before.

“The NHS long-term plan expects even more of general practice – these problems will need to be addressed quickly if that vision is to be made possible.”

The analysts cautioned that there may be a “lag” before the money pledged by Theresa May has an impact on satisfaction levels.

However Ms Robertson added: “Two of the factors that people are telling us are big drivers of their dissatisfaction – waiting times and a lack of staff – are things that aren’t actually addressed in the long-term plan.

“We are waiting for the workforce strategy to come out to deal with the crisis we’ve got around workforce, and a review of waiting times as well.”

A spokesman for the NHS said: “For the third year in a row, public satisfaction with the quality of NHS care has improved and satisfaction with inpatient services is now at its highest level since 1993, however the results as a whole understandably reflect a health service still under pressure.

“The Long Term Plan sets out an effective blueprint for making the NHS fit for the future as funding comes on stream and does so on the back of the public’s enduring support for NHS services, with increasing satisfaction scores in the survey for both outpatients and inpatients.”

The Health Service is no longer National, and there is blatant finacial rationing because Wales has not paid up!

April 5th Chester Chronicle: English health trust accused of using Welsh patients as ‘bargaining …

BMJ 3rd April: David Oliver: The revolving door to the NHS lobby

The Guardian 31st Jan 2019: NHS England to ban GPs from advertising private services

The Herald Scotland 1st April: Margaret Taylor: It’s unforgivable for MPs to fiddle while our NHS burns

26th March 2019: CCGs continue to offer cash rewards for GPs to cut referrals

The Independent 15th February 2019: Tens of thousands of cancer patients left waiting months to start …



Universal (NHS Scotland) telephone triage… a way to foster private practice

If the Scots do decide to telephone triage all callers to GPs, they will create a monster. The perverse outcome could well be an expansion of private practice. This is already happening in consultant care, and needs only this sort of small push to apply equally to General Practice. It is only by co-payments that the system can be saved now.. The gap between rich and poor is widening….. (Philip Aldrick 27th Feb 2019: Gap between rich and poor at five-year high)

Jo Carlowe in Onmedica reports 27th March 2019: Online triage ‘not a solution’ to GP workload pressures

Online triage will not solve GP workload pressures, a lead GP warns.

Professor Helen Stokes-Lampard, chair of the Royal College of General Practitioners, acknowledges that online triage systems are convenient for some patients, but points to the fact that they do not always reduce GP workload.

Her comments come in a response to a study* in the British Journal of General Practice about online triage systems.

Abi Eccles and colleagues at the University of Warwick studied information from over 5,000 patients using online triage systems. Two-thirds of users were female and almost a quarter were aged between 25 and 34.

Highest levels of use were between 8am and 10am on weekdays (at their highest on Mondays and Tuesdays) and 8pm and 10pm at weekends. The commonest reason for using the service was to enquire about medication, followed by administrative requests and reporting specific symptoms, with skin conditions, ear nose and throat queries and musculoskeletal problems leading the list. Less than one in 20 contacts were for mental health problems.

Many patients found the system convenient and said that it gave them the opportunity to describe their symptoms fully, whilst others were less satisfied, with their views often depending on how easily they can normally get access to their practice, and on the specific problem they are reporting. The authors comment that the pattern of use of online triage is very similar to that of telephone contact with practices and a clear understanding of their needs is required to capture the potential benefits of this technology.

Commenting to the findings, Professor Stokes-Lampard said: “GPs and our teams have always made the most of technology as part of our ongoing commitment to provide the best possible care to patients.

“We were the first NHS sector to implement both electronic patient records and electronic prescribing, and we will continue to explore how using new technology in practice can benefit our patients, including through online consultations, which many practices across the country are already using in some form.

“There’s no denying that online triage systems are convenient for some patients, particularly people who are generally fit and well and work full-time, or for people uncertain if their problem is significant or not, but as this study shows, they do not always reduce GP workload – a major pressure currently facing general practice.

“The goal of adopting any new technology is to not only make sure it is safe and effective, but that it actively complements the work we already do. It is good to see robust research emerging about online triage systems in action.”

2013: Caroline White in OnMedica: Increasing workload boosts use of telephone triage in GP practices

Methods of rationing in the news… Telephone triage, scrutiny of referrals, larger practices, reducing standards, reducing access, excluding treatments. So many different and covert methods of rationing. No political party offers the honest option. No wonder we are disengaged.

Primary care telephone triage does not save money or reduce practice workload

GP A&E Triage – would be a good idea if we had planned for the numbers needed. We have not.. and GP partnership and continuity of care is in decline

The access to services (especially emergency ones) is getting worse, and worse, and worse….. and its going to get even worse.

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

Back to the future: Look again at what we used to do well – before it’s too late.

Having the same GP halves chance of early death. Seeing the same GP will help older people… An association is not however a cause..

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

IT – the solution and a problem… Every patient deserves an examination. GPs must not be robots..

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If there are too few gatekeepers – they are set up to fail

GPs as gatekeepers have been set up to fail as a profession. There are just not enough of them. In an unattributed and unreproduced on line article, an unknown source opines that “Gatekeeping by GPs called into question“. The rationing of medical school places, over decades, now results in so much spin that the public are dizzy with it. The fact that nurses and paramedics are not trained to do the job does not seem to occur to the media. The result will be disastrous.

NHSreality can only speculate on the source. The clue is to answer “who gains by the failure of the GP system?” Government wants a cheaper system, and is unconcerned with the health of individuals. As population controls have to take precedence, and more and more taxpayers choose to go private, the two tier system us here and now.  Life expectancy for the poor will decline further…

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The Dutch  and the English questioned gatekeeping in 2014: Is the role as gatekeeper still feasible? A survey among Dutch … – NCBI

Is the role as gatekeeper still feasible? A survey … – Oxford Journals

and in 2016: the BMJ says that GPs are much more than gatekeepers | The BMJ and 

Stop calling GPs gatekeepers | The BMJ

BBC News 27th March: Life expectancy drops among poorer women in England

Pulse 1st March: Scottish Parliament launches public survey on the GP independent …

The Daily Mail Scotland is very critical about having to ring before seeing a GP. Dangerous?

WANT TO SEE A GP? TALK TO NHS24 FIRST; Anger over ‘dangerous’ plan forcing 150,000 Scots to speak to helpline BEFORE visiting their doctor’Patients are pushed from pillar to post – that’s dangerous’


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Read the damning nature of this joint report.. GP shortages …. Our very own post-code lottery.

Just read the joint report of the Nuffield Trust, Kings fund, and Health Foundation reflect on the retired doctor commenting below the Times report. Developing a strategy for the Health and Care workforce In England: Summary of a roundtable discussion. 

This crisis was seen 20 years ago. What the media and the politicians should be asking is why nothing has been done, and what options are possible. The implications of doing nothing are too important. There are not enough physiotherapists, nurses, Occupational Therapists, Psychologists etc. as well as GPs and Oncologists. 

The report does not cover the other 3 health dispensations, and the situation is just as bad in Scotland N Ireland and Wales. Wales in particular has a tradition of exporting professionals, and at least 20% of all graduates leave. It will be much more for the medical professions….

I have no good news to counter this abrogation of planning. I can only apologise to the Times for reproducing their whole article as it is so important. There is a world shortage of doctors…. If we still believe in open markets then every country has to train more. Meanwhile it has to get worse, and private care will flourish, especially in cities. The Health Divide will worsen. 

Chris Smyth reports this in the Times 21st March 2019: Experts warn shortage of GPs will last for at least a decade

The shortage of GPs will last for at least another decade and patients will have to be treated by physiotherapists and pharmacists instead, a report on the NHS staff crisis has concluded.

The shortfall of nurses will also triple to more than 100,000 unless almost £1 billion is spent on training and hiring thousands from abroad, it added.

“Dire” workforce planning may derail the NHS ten-year plan because there will not be the staff to hire with £20 billion budget boost, three think tanks have said. The Nuffield Trust, King’s Fund and Health Foundation united to warn that a dearth of qualified professionals has become the critical problem facing the NHS.

They said it “defied all logic” that training budgets have been cut by 17 per cent to funnel money into NHS England as the shortage worsened. The NHS has 100,000 vacant posts in a workforce of more than 1.2 million.

“You have to run to stand still in the NHS,” said Anita Charlesworth of the Health Foundation. Ministers must restore bursaries for nursing students, giving them £5,200 a year to reduce an attrition rate in which only three in five who enrol become full-time nurses, she said, adding that overseas recruitment should grow from 1,600 a year to 5,000 annually.

The report said that for GPs there was no prospect of closing the gap for at least a decade. In 2015 ministers promised 5,000 more GPs by next year but numbers have since fallen by 1,000.

The shortfall of 2,700 will triple in five years without action, but even an intensification of efforts to train more and stop early retirement will produce only 3,500 more over a decade, leaving the NHS more than 7,000 short, the report estimated. The gap can be closed only by sending more patients to see physios and pharmacists for problems such as back pain and medicine reviews, it suggested.

Efforts to hire GPs from abroad had been unsuccessful Richard Murray, chief executive of the King’s Fund, said. “We are just not that competitive on pay and lifestyle. The numbers just haven’t come through but that isn’t for want of trying,” he said.

Baroness Harding, chairwoman of NHS Improvement, welcomed the review. “Our staff are our biggest asset and so it is vital we do more to retain, recruit and develop them,” she said.

Times on line comment:

“Baroness Harding, chairwoman of NHS Improvement, welcomed the review. “Our staff are our biggest asset and so it is vital we do more to retain, recruit and develop them,” she said.”
Staff are treated abysmally so what is actually being done. Not much. Anyone who works in a hospital who trys to raise a problem is silenced and hounded out.

World shortage of doctors:

Research Shows Shortage of More than 100,000 Doctors by 2030

U.S. faces 90,000 doctor shortage by 2025, medical school …

Canada’s doctor shortage will only worsen in the coming …

On solutions to the shortage of doctors in Australia and …

NZ’s doctor shortage: What needs to be done? – NZ Herald