Category Archives: Nurses

44,000 Nurse vacancies = 12% of the workforce. Cheaper staff and less spend means more deaths…

Shaun Lintern on 3rd December for The Independent reports: Leaked NHS document reveals government plans to use cheaper staff to fill nurse vacancies.

A leaked NHS document reveals that plans to grow the number of nurses rely on using 10,000 cheaper and less qualified staff.

Even then, the health service will still be more than 20,000 nurses short of what is needed in five years’ time, according to the file seen by the Health Service Journal and The Independent, for the as yet unpublished NHS People Plan.

The projections could be problematic for Boris Johnson, who has promised 50,000 more nurses by 2024 – although 18,500 of these are existing staff he hopes to retain….

Meanwhile the Times reported: nursing applicants fall by almost 20% in two years

Rebecca Taylor for Sky News reports: Leak of Jeremy Corbyn’s NHS papers raises ‘spectre of foreign influence’  – Researchers from a think tank say the papers emerged in a similar way to a former disinformation campaign from Russia.

The leak of documents which Labour claim show the NHS is on the table in trade talks with the US resembles a former Russian disinformation campaign, experts have said……

2019 – James Buchan’s report for “” Falling short: the NHS workforce challenge – …

2017 – The nursing workforce – Parliament (publications)

Richard Stephens in the Times 29th November 2019: NHS uses healthcare assistants and nursing associates to fill big staffing gaps

The Conservatives’ pledge to provide 50,000 more nurses was thrown into doubt as a report showed that the health service was relying on less qualified staff to plug huge gaps.

There are almost 44,000 nursing vacancies across the NHS, 12 per cent of the nursing workforce, but this could hit 100,000 vacancies in a decade, the Health Foundation charity said.

Support staff, such as healthcare assistants and nursing associates, have been used to shore up staffing numbers, according to the charity.

Its report also found that the number of full-time equivalent GPs fell by 1.6 per cent, from 27,834 in March last year to 27,381 in March this year. It showed that the biggest increase in NHS staff was among managers (6.2 per cent) and senior managers (5.7 per cent).

The report stated that a government target to recruit 5,000 more GPs by next year would be impossible to meet. Temporary staff and GPs in training were making up a greater proportion of the GP workforce than ever before, while non-GP clinical staff were playing an “increasing role in the delivery of care”.

The Tories say that the 50,000 nursing jobs will be achieved by training more staff, international recruitment and better retention.

Anita Charlesworth of the Health Foundation, said the shortages were “impacting on the front line”. “Services are being forced to make do with shortfalls of increasingly pressured nurses and rely on less-skilled support staff to pick up the slack,” she said.

A separate study suggested that the number of people searching for nursing jobs had slumped in the past two years. The online job site Indeed found that potential applicants fell by more than 17 per cent in the two years to October…..

Rhys Blakely reported 28th November in the Times: NHS spends least on patient health

The NHS is lagging behind the healthcare systems of other developed countries in spending, staff numbers and avoidable deaths, a study has found.

A comparison with the healthcare systems of nine other wealthy countries suggested that austerity policies and lower numbers of staff from the EU because of Brexit had taken a toll.

It showed, however, that patients were about as satisfied with their healthcare as citizens in other countries, with waiting times that compared favourably.

The study in the BMJ looked at healthcare in Britain, Australia, Canada, Denmark, France, Germany, the Netherlands, Sweden, Switzerland and the US. It said: “The NHS showed pockets of good performance but spending, patient safety and population health were below average to average at best.”

Britain spent the least on health, £3,000 per person, compared with an average of £4,400, and had the highest number of deaths that might have been prevented with prompt treatment.

It had the lowest number of nurses per capita and was the only country where the figure fell between 2010 and 2017, the most recent year in the study.

“Relative to other countries, the NHS has lower amounts of labour, which have been decreasing at a faster rate, particularly after 2015, when large decreases in the annual inflow of EU-trained healthcare professionals have been seen,” the report said.

Survival rates for breast and colon cancer were the lowest and second lowest for rectal and cervical cancer. The chances of dying a month after having a stroke or heart attack in the UK were well above the average. Average life expectancy, however, was only just below the average of 81.7 years, at 81.3 years.

The UK had the lowest percentage of doctors dissatisfied with the time they could spend with patients and the lowest percentage of doctors along with Canada and Netherlands who were dissatisfied with their income.

In Britain, 65 per cent of patients reported seeing the doctor or nurse the next day when they last needed care, in line with the average of 67 per cent.

Forty-four per cent of UK adults thought the healthcare system worked well, compared with an average of 45 per cent. The UK figure had declined by 19 percentage points since 2010.

It said that the UK appeared to have higher rates of informal care “with high proportions of the workforce out of work or in part-time employment because they are providing care”.

A separate report from the Health Foundation charity said that the NHS was relying on less qualified staff to plug gaps because of a nursing shortage.

There are almost 44,000 nursing vacancies across the NHS, equivalent to about 12 per cent of the nursing workforce. This could more than double in a decade, the report warned.

update 4th December:

Chris Smyth in the Times 3rd December 2019: Immigration crackdown spells disaster for NHS, says report

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

It looks as if the implosion of the different dispensations will begin in N Ireland where, without leadership and government for some years, the health budget and the recruitment are both broken. It would be kinder to bring in co-payments immediately… than to let more and more people suffer.

NHSreality appreciates that the 4 health services in the UK are all dependent on overseas staffing. We will need these people for a lot longer yet…

Claire McNeilly in the Belfast Telegraph 21st November 2019 reports: Nurses believe Northern Ireland health service is near to collapse, says frontline professional

Northern Ireland nurses are chronically stressed, suffering sleepless nights and pushed to the brink of exhaustion – with some even ending up crying in hospital sluice rooms.

The shocking revelation comes as the Royal College of Nursing (RCN) prepares for strike action, amid a dispute around staffing and pay, for the first time in its 103-year history.

Such an unprecedented move “goes against the grain of every single carer in the profession”, an experienced frontline nurse and RCN Northern Ireland board member told the Belfast Telegraph.

But Helen McNeilly said her colleagues – who number around 8,000 – have been pushed into making the difficult and highly contentious decision to down tools on December 18, after a two-week ‘work to rule’ period leading up to that date.

“Nurses are telling us there isn’t enough staff to deal with the ever-increasing number of patients that need to be treated… and they feel the whole system is close to collapse,” said Helen.

“Nurses are working 13-hour shifts without breaks, they’re stressed and they’re having sleepless nights worrying about work.

“Not only are they lucky if they get a 20-minute break during a shift that lasts from 7.30am until 8.30pm, many are then staying late to complete documentation and quite often that’s unclaimed overtime.

Just a name on a rota? An adverse environment is holding back staff and affecting patients….

Update 26th October 2019: Shrewsbury Mum wants better care for doctors. Clare Gerada “”When they sign up to be a doctor in the first place they are signing up to give their working life to the care of others and we need to care for them.” The junior doctors don’t feel cared for.

From rags to Richer in the Economist October 3rd describes how one man, Mr Julian Richer, who is a fan of “In Search of Excellence”, a business bestseller by Tom Peters and Robert Waterman which came out in 1982, built his business and then sold over half to his staff. Bartleby describes this as A business success story built on treating people well”.  (There are few Health Service staff surveys which can be trusted, and exit interviews are rare …. Mr Richer does staff surveys every week.).

How does he keep staff loyal? One way is to survey morale every week.

The 4 Health Services of the UK need to treat their people well, but they don’t. Politicians and Trust Board members and managers should re-read Peters and Waterman, whose motto used to be the legend above my own local trust here in West Wales. I wonder what made them abandon it?

Image result for organisational culture cartoon

In the BMJ 10th October 2019 Dr Chaand Nagpaul comments on an article written for Dr Tameem, a ST6 who has had experience in Australia where juniors feel much more valued. His account in ” More than just a name on a rota” in explicit and represents what is going on nationally, in all 4 dispensations. It is the culture of the organisation which is wrong. The rules of the game, decided by politicians, don’t allow people like Mr Richer to run the business….. Excellence has been written out of the script for most on call STs in DGHs. Surviving that shift, night or day, is the name of the game.

An adverse environment is holding back staff and affecting patients, says BMA council chair Chaand Nagpaul

People become doctors because this career embodies their values. It’s a long and arduous journey and it is a commitment that extends beyond working days.

Yet many doctors find themselves in a working environment that, instead or recognising this commitment, perversely works against them. Our own survey shows that nine out of 10 doctors feel they can’t provide safe, high-quality care because of the stress and strain placed on themselves, colleagues and the wider system.

To add insult to injury, if things do go wrong, more than half of doctors fear they will be blamed for errors caused by system and capacity issues and only half of doctors would feel confident to raise concerns.

Not only does this adverse environment prevent doctors from achieving their best but it is also denying patients the full potential skills and capability of care from our medical workforce.

Given this tough – and often unfair – working environment, one would expect employers to support frontline staff and offer them gratitude, understanding and support – rather than a culture many doctors inhabit of fear, blame and isolation.

As part of our Caring, supportive, collaborative project, the BMA will continue to campaign for an NHS that has adequate resources so that doctors can do their best for patients, underpinned by a culture rooted in learning and improvement rather than blame, and which values its workforce as its strongest asset.

Find out more about the BMA’s Caring, supportive, collaborative project

There is a toxic culture, and disengagement everywhere in Health and Social Care. Also in the

Changing a culture of fear, bullying and gagging…… Start again with local pride….


No need to comment on the “Culture of fear”

Despite the evidence, the health services culture crisis will be ignored by those with the power to act… It’s going to get worse..

The culture of the NHS has yet to catch up with the rhetoric as this speech from the GPC leader underlines.

Cleaning up the UK Health Services, changing the culture and importing honesty..

Welsh NHS ‘is a scandal’, says David Cameron. The philosophy of not aspiring to excellence, but rather to reducing inequalities

Clinical excellence may become impossible in state provided health care.

‘My local practice was a centre of excellence. Now we face a future of depersonalised, rationed healthcare’

All education is divisive – We must all aspire to excellence, and speak out.

Sir Bruce Keogh: “I am not interested in an NHS that aspires to mediocrity, the European average or whatever. We should set ourselves the achievable ambition of raising our cancer survival rates to match the very best in Europe.”

Image result for organisational culture cartoon




Incremental neglect tips over into significant and costly malfunction, as rationing is denied but extended..

The damning statements from the finance officers show how neglect and denial have built up to a point where it will take 15 years, and the importing of many overseas nurses and doctors to even start to put our 4 health services right. Since devolution has failed in Wales it will be even harder here, where I am based. “…..Incremental neglect tips over into significant and costly malfunction, and opportunities for strategic renewal and improvement are being squandered. Many interviewees identified ways that their trusts could better manage their capital investment programme, but these were eclipsed by the near-universal call for increased funding and a relaxation of central controls. 

Iestin Williams reports for the Health Foundation 8th March 2019: Views of NHS finance officers on limited capital.  see below…

Laura Donelly on 28th May 2019 in the Telegraph reports: A doubling in rationing of cataract surgery

BMJ 2017; 358 doi: (Published 04 July 2017) Cite this as: BMJ 2017;358:j3190

Laura Donelly in the Telegraph 11th August 2018: Numbers “going private” for surgery soaring as NHS rationing deepens.

Nick Triggle for BBC News 4th July 2017: NHS ‘rationing leaves patients in pain’

Pressure on NHS finances drives new wave of postcode rationing
(Published 04 July 2017)  BMJ 2017;358:j3190

[PDF] NHS Rationing and the Law. Warwick Heale. MA Medical Ethics. Interest in legal and ethical issues in treatment funding decisions.

Iestin Williams reports for the Health Foundation 8th March 2019: Views of NHS finance officers on limited capital.

Fixing leaky roofs, servicing ageing scanners and updating antique IT systems – the maintenance of capital infrastructure in the NHS isn’t the most enthralling of topics, and it’s generally only talked about when things start to go wrong. However, recent warnings about the lack of NHS capital investment and controls on capital spending by trusts have put this issue very much in the spotlight.

At a national level, we know that for some time now, money has been diverted towards the day-to-day costs of health care and away from capital budgets, leaving them severely squeezed. However, less is known about what this means for the trusts affected and the services they provide. We tried to find out more by speaking to finance directors at NHS trusts across England.

Squeezed to breaking point?

The trusts involved in our study were clearly feeling the financial pinch. In itself, this is nothing new. For example, taking out loans to pay for new IT systems or delaying the overhaul of outdated estates are commonplace. However, when basic maintenance work starts to be repeatedly postponed, the concerns voiced become a little more insistent. This was the tone of many of our interviews. We were struck by the prominence of the word ‘crisis’ – one not used lightly by seasoned finance personnel.


The squeeze on budgets has necessitated tough decisions about what to fund and what not to fund, and in what order. As a result, all but the most urgent of capital plans were frequently being abandoned or at least put on hold. In many cases, considerations around efficiency and improvement have been crowded out by more immediate concerns over safety and service viability. However, while this has mitigated the short-term impacts on patients and services, finance directors frequently lamented the potential long-term harm. In short, organisations were engaged in reactive rationing, rather than proactive priority setting.

Navigating the system

Interviewees described a much-changed environment in which sources of funding they had previously used for major capital projects were increasingly unavailable. Many trusts have found themselves unable to generate revenues to pay for capital projects, and were frustrated by the central financial controls imposed upon them. Others argued that the process for applying for centrally held NHS funds, including through partnerships arrangements such as STPs, was increasingly complex and inaccessible. Opportunism – for example, in the form of asset sales and charitable fund raising – offered only a partial solution to those trusts with access to these options.

All these factors are building towards something of a ‘perfect storm’, in which incremental neglect tips over into significant and costly malfunction, and opportunities for strategic renewal and improvement are being squandered. Many interviewees identified ways that their trusts could better manage their capital investment programme, but these were eclipsed by the near-universal call for increased funding and a relaxation of central controls.

Dr Iestyn Williams (@IestynPWilliams) is a Reader in Health Policy and Management and Director of Research at the Health Services Management Centre at the University of Birmingham 



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

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

Link to his book published by the Socialist Health Association

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

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

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

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

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

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

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

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

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

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

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

Pembrokeshire Oncology cancer services in crisis

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

Desperate NHS needs a desperate remedy – care is already rationed

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Enoch Powell 4 Supply and Demand – Rationing


Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

The reality that Health and Social Care are not either of them free, has not sunk in to the politicians yet. We cannot have “Everything for everyone for ever” and for free, and in their denial, both houses thus conspire to avoid the important debate that Mr Stevens called for on 4th June 2014, almost exactly 5 years ago. If Social Care is means tested, why not Health Care? 

The unedifying spectacle of two potential leaders trying to bribe 160,000 older and richer people who happen to be their members, is the reality of todays politics. No wonder so many people dont vote. We need an honest party to speak “hard truths” to the nation. NHSreality believes the first party to do this, and be understood as honest and working for the overall good of us all, fairly, will eventually win a landslide. It will also win the hearts and minds of the medical professionals….. and they are trusted, and speak to many people daily.

Our political (moron) representatives need to permit commissioners and trust boards to ration overtly, so that their citizens know what is not available. Initially this will have to be by post code, but national guidelines from NICE would help. Eventually, for those services and treatments that none of us can afford, cancer and big operations for example, there can be a National Health Service again, and for cheap and cheerful, high volume low cost services, we can have local post code rationing if we still want it…

Image result for honest politics cartoon

BBC News reports 4th July: Social care: Hunt and Johnson urged to consider NHS-style free service

Public Service Executive reports: Peers call for NHS-style free social care system and an extra £8bn to tackle funding crisis

and the Guardian today also reports the Peers asking for an extra £80m for “vulnerable elderly people”. 

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?

New and higher taxes will never solve the problems of health and social care…

There is a toxic culture, and disengagement everywhere in Health and Social Care. Also in the CQC …

What principles should underpin the funding system for social care? Surely an ID card with tax status and means is now essential….

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”…

A Happy Brexmas to everyone as our leaders duck health and social care funding crisis.. The media failure, and political denial can only get worse..

Nov 2016 NHSreality: NHS funding and rationing: The debate (and the denial) intensifies… It’s going to get worse..

Reality is a word rarely used in Health debate and discussion. The Economist comments on post election realities..

A dishonest and covert dialogue is all that is happening at present.. Simon Stevens says he would like to change this. (U tube 4th June 2014)

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Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding? If we don’t keep the gatekeeper role for GPs the system will get constipated.

A recent report in the Times (Not on line) opines “Gatekeeping by GPs called into question. This is not new, as you can see from the debate following Matthew Paris’ article in 2015. The problem is not referrals, but the 90% who do not need a referral. Allowing others, less trained in dealing with uncertainty, will lead to more referrals, longer waits and a constipated system. The useless 111 service where there has seen no reduction in GP workload is another attempt to wriggle off the hook of under capacity and poor manpower planning. In his Imperial College funded report, Geva Greenfield and others report: “Rethinking primary care user fees: is charging a fee for appointments a solution to underfunding?”.

One solution is to make patients pay for their GPs and let them have appointments free with the nurses and paramedics. A two tier system by design. Lets see the comparisons in referral rates, expense and survival!! The result would be anarchy.. (sic) Geva Greenfield says “There is a trade-off that needs to be found between GPs serving as hgatekeepers to secondary care, and at the same time allowing patients to see a consultant when they wish”. We are trying to treat patients, and the governement are treating populations. Money matters, and the services are all rationed. (covertly)

Image result for money and NHS cartoon

Image result for money and NHS cartoon

This is the sort of thinking “outside the box” of current opinion that we have to get to talking about openly.

On November 26th 2018 Chris Smyth reported in the Times: Bypassing GPs could help to diagnose cancer sooner

In Pulse 2015: GPs should give up their Gatekeeping Roles

Matthew Paris on June 16th 2012 reported in the Times: GPs – little more than glorified receptionists

In this age of medical specialisation, if family doctors didn’t exist we wouldn’t feel the need to invent them

Next Thursday, family doctors plan to strike. Striking doesn’t suit the profession’s humanitarian image. Interviewed, doctors’ leaders struggle to insist (on the one hand) that nobody needing medical attention will be denied it, without implying (on the other) that few will suffer if doctors aren’t there.

How much, though, would we suffer? If family doctors had not existed, would we today have found it necessary to invent them?

We pay general practitioners more than we pay airline pilots, but they are becoming glorified gatekeepers: a portal to the more specialist medical care that our health service offers in growing measure. As GPs have receptionists, so the NHS itself uses GPs as its receptionists. Are we investing too much in the citizen’s first port of call, to the detriment of investment in the specialist attention to which, to an increasing degree, surgeries are likely to end up referring the patient?……..

……..Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results. Walk-in and appointment clinics are becoming more common, especially evening clinics. Sexually transmitted disease, family planning, coughs and colds, eye, ear nose and throat … in all these fields specialist practices staffed by nurses and pooled doctors, rather than personal GPs, are where we’re going.

The only question is how fast. Let’s hope next Thursday’s strike prompts us to speed this thinking up. Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.

The response June 18th 2012:

Sir, Matthew Parris (Opinion, June 16) is not quite correct in describing GPs as “becoming glorified gatekeepers”. We have already had that role (among others) for decades.

It is true that part of this role is to refer to secondary care, but he seems to miss the corollary of this; that we also judge when not to refer, thus saving patients, and the country, the burden of over-investigation and over-treating. The internet has expanded everyone’s access to specialist knowledge, but has not, perhaps, increased our ability to apply that knowledge appropriately. We know more, but understand less.

Mr Parris also fails to acknowledge that GPs have a vital role in the other direction of travel; from specialist care to the community. In this past week I have picked up the care of patients after their discharge from heart by-pass surgery, psychiatric in-patient treatment, dermatology, gynaecology, child autism and palliative care clinics.

In addition, we need to manage patients whose symptoms and conditions cover several specialties, as well as those who have exhausted all secondary care investigation without any diagnosis being reached.

“A decent grasp of the whole thing” is exactly what GPs need.

Dr Jonathan Knight
GP, Ipswich

Sir, Matthew Parris assumes that his interaction with his GP is typical of the work that GPs do. I have been working in general practice since 1987 and my experience is very different. We spend most of our time managing long-term illness such as high blood pressure, diabetes, kidney disease and asthma. When I was in training in the 1980s these conditions were managed in hospital but are now managed mainly in primary care. Of course I do not profess to be an expert in everything so I may refer to colleagues for opinions about aspects of a patient’s care, but they are then usually discharged to my care.

Allowing less-qualified health professionals to manage patients has never been shown to be more cost effective than using GPs.

It is this system of every patient having a GP, enshrined in Bevan’s original vision for the NHS, that other health systems around the world have strived to emulate. We should not discard it lightly.

Steve Charkin
London NW3

Sir, Matthew Parris says that he believes he could refer himself appropriately to a specialist, but he is not our typical patient. GPs’ time is predominantly taken up with the very young and the elderly, particularly those with chronic, complex and multifaceted medical conditions. For these folk, it is their GP who sees the “big picture”, the context and impact on the individual and their family, while each specialist focuses in on his own area of expertise. Approximately 90 per cent of healthcare needs are met in the community, by GPs and their practice nurses, with only 10 per cent of care being hospital-based, at far greater expense. It is true that a GP’s role includes “gate keeping” access to expensive specialist opinion, but I would suggest this is essential.

As Mr Parris concedes, most GP consultations do not lead to a referral to a specialist. His vision of a future without GPs to manage the majority of our health concerns would be financially unsustainable and bewildering to many. Would a woman with lower abdominal pain and back ache refer herself to a gynaecologist, urologist, gastroenterologist, oncologist or orthopaedic surgeon? Does she need a specialist at all if it is just a urine infection? How does she know?

While a single day of industrial action will cause no more inconvenience than the extra bank holiday for the Diamond Jubilee, Mr Parris belittles our role at his peril.

Dr Isabel Cook

Sir, Before getting rid of GPs Matthew Parris might be wise to wait until he is a bit older when he may have to see more than one specialist at the same time. He will find that the treatment for one condition often aggravates another and he will then be grateful for a generalist’s opinion. He will also find it more efficient to keep seeing the same GP so that he does not have to keep repeating his past history.

Dr Richard Stott
Epsom, Surrey

Sir, As a GP I know Matthew Parris is right. A lot of what GPs do is pointless or could be done by others. So there is a simple solution: stop giving us work.

John Booth

Sir, There is overwhelming evidence that GPs deliver highly effective, cost-effective care to our patients. Moreover, we do so with the trust of our patients, and with care and kindness.

I invite Mr Parris to sit through a surgery with me at any time, where he will see first hand how GPs care for the elderly, the frail, the disadvantaged and the ill. I’m sure that afterwards his perceptions of general practice will be different.

Professor Clare Gerada
Chair of Council, Royal College of General Practitio