People’s March for the NHS


A number of good ladies have marched from Jarrow to Trafalgar Square.

I saw this video about a month ago.

So I joined the march today, the final leg to Trafalgar Square.

For about 5 miles, I walked with an 80 year old man from south London; this man has had two knee replacements (on the NHS). He was marching because he was worried about the NHS and the next generation.

Later, nearing the Aldwych I saw a placard; I asked the owner if I could photograph it. Her husband asked me to share it with my friends.

So I Tweeted it. So far it has, it seems, been Retweeted by about 400 people, and favorited by 150. The Huffington Post online has asked if they can use it. I said of course.








I smell a rat. Is Monitor working in the interests of patients or free market healthcare?


I recently set up a Google news alert for articles on GP practice boundaries.

It threw this article up this morning.

“Monitor senior policy adviser Paul Dinkin, the man heading its primary care consultation, said his initial conclusion was that Monitor would play a major part in primary care.”

“Mr Dinkin said his review was looking at barriers to entry into general practice, such as practice boundaries and registered lists.”

“He said the BMA and the RCGP were wrong to say general practice needed more funding. ‘Our suspicion is not more money for the current model, but to rethink who does what.'”

And my suspicion is that Mr Dinkin does not know a great deal about the ecology of general practice, and that he has little interest in finding out.

Checking on the Monitor website, I found a Call for evidence on general practice services sector in England.  Issued on 1 July 2013, deadline for responses 1 August 2013. So I won’t be offering my views.

Who is Paul Dinkin and what is his background? I could find precious little online. Even on Monitor’s website there is no information.

Can we have some transparency, please?

Are GPs too lazy?


Two evenings ago, when I arrived home at 9pm for supper, my daughter, with a smile on her face, pointed me to the front cover of the current edition of The Week which asks Are GPs too lazy?’ She and her brother were always clear that they were not going to study medicine because they thought their parents, both GPs, worked too hard.

I wish journalists were more precise in their use of language. Why not ask, ‘Are some GPs too lazy?’ Why not find out what it is like for a significant number of GPs?

It is 9am on Sunday morning and I am at work, trying to catch up on my mountain of work. I arrive at work at 7am weekdays, and leave on an early night at 8, other nights at 9. And I will not have finished. I work at least one day of every weekend. It is unsustainable. I will be 60 years old in 3 weeks. In our practice we try to provide good quality, evidence-based medicine in a respectful and compassionate way. But it is a real struggle. I would like to work on until I am 65. I have a sense of commitment to our population, I am aware that the role that I play is an important one.

Ultimately, there is a real problem with capacity. The demand outstrips the resources.

We have 10 minute consultations. Many of our patients require 15 minutes, some longer. The job I do now is far more complex than it was 15 years ago, it requires more time.

Yes, it is a bit of a slog for some to get appointments at times that suit their schedules. I am not happy about that.

The politicians and Department of Health set us Herculean tasks which undermine quality.

Politicians, journalists, citizens: be careful, if you blame us and ‘shame’ us in a mindless way, a significant number of us will just give up, and leave you to get on with it on your own. Let Jeremy Hunt do it; let the Department of Health spokesperson do it; let Janet Street-Porter do it.

If you want a better system, let people who understand the complexity of primary care design it and cost it. Then resource it.

GPs are paid way too much!


It is my birthday today. I had promised myself the afternoon off. I went into work this morning to tackle on an enormous backlog (blood results, hospital correspondence, DWP reports, issues relating to patients with complex medical problems). My wife and I then met up for a birthday lunch, and my plan was to indulge myself and read Simon Schama’s Citizens this afternoon.

But then I saw a comment on this blog from David Read (see Home Page). He commented on 21/6/12, and ‘Can’t think of a name’ replied on 22/6/12, to which David Read replied today. David Read takes issue with the fact that GPs earn, on average £106,000. (These are his figures, I don’t know what the true figures are). He is of the opinion, if I understand correctly, that GPs are actually not needed, that we could remove them from the system without losing a great deal (this is the line articulated by Matthew Parris in his article on 16 June, behind paywall; for a summary see here, and my reply).

There was some comment on last Thursday, 20 June, which was the day of ‘industrial action’* on the part of doctors. Some people were outraged about how much GPs earned.

I am aware that some GPs in England make a lot of money. But it is important to realise that the amount that GPs accrue as profit will vary widely. A significant factor is where the GPs are located. I am aware that a small number of GPs in the borough where I work have a profit which is more than twice ours. I don’t really understand why this is, our accountant understands these things. The issue of GP earnings probably needs some attention, because there is a narrative about that GPs are greedy bastards, look how much they earn. I might write a post about this, from my perspective, in the future.

However, for the moment, so that I can get a little time for reading on my birthday, I just want to say this: focusing on how much GPs earn is perhaps a red herring. Let me tell you how much we get to provide primary care services for our patients. I am using our 2010 accounts (the 2011 are pretty similar, but I don’t have them to hand). I looked this up 18 months ago because we had a complaint from a patient who thought it was outrageous that he/she could not be seen within 20-30 minutes on a Thursday morning, having developed symptoms the night before at 1 am. In his/her complaint, the patient alluded to all the money we had, and that we should be providing a better service.

Well the facts are as follows. We have 3,500 patients. Our NHS income is divided into Gobal Sum (which is a lump sum which covers a number of items, but is essentially for looking after people who present sick), QOF income (Quality Outcome Framework: this is for looking after people with chronic diseases, such as diabetes, COPD, asthma, heart disease, and others), and Enhanced Services (this covers services that are not covered by QOF, such as managing patients with substance misuse, terminally ill patients, running a patients participation group, and so on, more than twenty areas).

Our income, per patient, per annum, is as follows:

Global sum:    £74
QOF:               18
ES:                   23

Total:         £ 113

This means that we provide primary care services for our patients for £113 per year. Some patients (a minority) will not come at all during the year; some will come a few times; some will come 4-5 times; some will come often. This includes visits to the GPs; the practice nurse; the nurse practitioner; the Health Care Assistant for the cardiovascular disease prevention programme; home visits; travel vaccinations; antenatal care; baby clinics; mental health; the list goes on and on.

The patient who complained (who was actually seen at 8:50 am that morning, the complaint was composed at the end of the day) had symptoms of cystitis. If you were to go to Medicentre, a private primary care walk in service which operates in various locations in London, the cost of the visit (at the time of the complaint) was £67, plus £9 for dipsticking the urine. Our patient had a urine dipstick and urine sent to the lab (which would have been an additional cost if done privately). That is one visit.

I met with the patient who made the complaint and explained how the system worked, what the limitations were. I outlined the resources, as above. He/she had spent a year or two in the US; he/she had paid in the region of $5,000 per annum for health insurance cover. Having had this explained, the patient withdrew his/her complaint.

The system in the UK is about covering the whole population. The cost is spread. I would suggest that £113 per head is not exhorbitant for providing all primary care services. Out of this we pay staff, utilities, and all other overheads. Oh, I forgot, rent and rates are not included; these are paid directly (£30,000, or £8-60 per patient).


*[Day of action: We took action which in fact had no impact on patients (we wore badges, and put up some posters in the waiting room to inform the patients as to why it was happening), but patients were seen as per normal.]

Invitation to Matthew Parris; & the response


Dear Matthew,

I noticed consternation from GPs on Twitter this morning in connection to a comment that GPs were little more than glorified receptionists. I assumed they were overreacting. I get a podcast of your Great Lives programme and enjoy it. You come across as an intelligent, curious, and nuanced man.

Unable to view the offending piece online, I actually bought the print copy of today’s Times, and have read your article. I can see why they were annoyed.

I work as a GP in Tower Hamlets; I’ve worked in general practice for almost 25 years. It is quite clear to me that good GPs (and their practice teams) are a national treasure. Yes, we are able to keep up with changes in the science and the evidence. Indeed, we are the last of the generalists.

I am quite confident that what we do is important and irreplaceable, so I do not feel threatened by your piece. But it is quite wrong on a number of counts. I will trust that you wrote it in good faith.

I send you a good-natured invitation and challenge: come and shadow me for a day, watch what I do and what my colleagues do; meet some patients, ask them what they think. Meet our receptionists: ask them if they can do my job.

Best wishes,


The Tredegar Practice
35 St Stephens Road
E3 5JD


Saturday 23 June 2012

I sent the above as an email to The Times and posted a hardcopy to Matthew Parris, and left a message on an answerphone at The Times. I received an email from his PA, asking me to forward her a copy of the email.

This is the PA’s reply:

“I shall see that he gets it on his return. He is unlikely to take up your offer to shadow you because there are not enough hours in a day when he is in  London.”

And my reply to the PA:

“I quite understand Matthew is a busy man. Please pass on my suggestion that in future if he decides to write about a given topic that he take time in advance to check how things actually work on the ground. Otherwise he will lose the respect of those he misrepresents.”


For a summary and few excerpts from Matthew Parris’ Opinion piece, Click Here


Tuesday 3 July 2012

I am pleased to say that Matthew Parris has written, accepting the invitation to visit us in Bow. I am thankful for this. All I ask is that people investigate with curiosity, reflect, and then judge. 


20 October 2012

I am writing up my year’s work in preparation for my annual appraisal. I am including this letter in my portfolio. I should add that Matthew Parris did visit us for a rather full day in July. He was a gentleman; he watched and listened carefully. He wrote two subsequent articles, and was scrupulous in disguising where he had been.

I may write something at a later date about this.

Troubling Patients in Troubling Times: workshop at RCGP


I’m just back from a day’s workshop at the Royal College of General Practitioners. The title: Troubling Patients in Troubling Times. This was a joint venture by the APP (Association for Psychoanalytic Psychotherapy in the NHS), The Balint Society, and the Royal College of General Practitioners. The participants were psychologists, psychotherapists, counsellors, GPs.

As is often the case with things named by psychotherapists, the title is a bit ambiguous, thought provoking. It was not about professionals troubling patients in troubling times, which is one possible reading. It was about, in part, patients troubled in these troubling times. Patients who bring their distress to the GP, the psychologist, the counsellor, the psychotherapist. ‘Troubling Times’: of course, this refers to the current context, with cuts in services, more pressure on the remaining services, with ‘reforms’ which are wolves clothed as lambs. But in some ways, all times are Troubling; but perhaps some more than others.

The introductory talk was given by Jan Wiener, a psychotherapist with many years experience of working in the primary care setting in partnership with GPs. Her talk, which I will not summarise, was entitled ‘Mindlessness in Troubled Times’. The title, I think, is enough to give pause for reflection.

We had a series of GP consultation vignettes, acted by the organising committee members which captured a wide variety of common primary care dilemmas and challenges. Some were troubling, some gave us to laugh.

Then small group work, a Balint group watched by the wider group, a small group Balint case discussion, and then a plenary session.

Many themes emerged. The ones I recall at this moment: with services being cut, there are people with significant distress who are then left without an important support; the importance of the work of psychologists/counsellors/psychotherapists; the central role of the GP; the importance of collaboration, communication; the (occasional, ? frequent) breakdown in communication between hospital and primary care; the mindlessness of some ‘reforms’, some protocols; a feeling of powerlessness in the face of the mindlessness (who do you take your concerns to? if your manager does not understand the work you do, what do you do?; and so on).

There was a sense that people had significant grievances which they needed to address to those in charge. I encouraged them to find out who these people were, to speak out, to protest. A few asked me about this blog. I gave them some advice about starting their own blogs. I wish them all the best.

One young GP voiced this: the bewilderment at the government asking us GPs to do things that make our job more difficult. Ah, yes, a familiar story.

You need to keep shouting and protesting


Just received this comment to the Home Page, which I think is most eloquent:

‘I have been  married to my husband, a GP for 15 years. We live in Cambridgeshire with our three children. I cannot believe the way in which the profession is being treated, its terrible. I have watched a dedicated, excellent doctor slowly become more pressured, stressed and withdrawn due to the hassle that is being created by this government and their reforms. The hours are increasing to sometimes 90 hours per week, the nature of the job is changing and the finances are being withdrawn. I lecture and work in America at times and see the difficulties with the medical system there. The poor are discriminated against and now due to the recession even the more affluent of folk have stopped paying into health plans as they cannot afford it. They pray that they do not become sick! Is this what we want here in the UK because this is where we are heading. We have become so fed up with the NHS that we have decided to move to Canada in November. We have had enough of the battles and the stress. The NHS is losing a fantastic doctor in the prime of his career. We are one of many! You need to keep shouting and protesting because this government does not have a clue about the implications.’

Getting back to work on this blog….


I have had to take a break from this blog, partly due to a 1 week holiday, and also because March is the GP ‘end of year’ so lots of deadlines fall on March 31st.

There has been lots of controversy about the Health and Social Care Bill recently. The coalition government has had to call a pause to review it. Good. But is this just a PR exercise, a strategy to turn down the heat, make some minor compromises, and then proceed?

I had set myself a goal of writing to all MPs. It is slower than I had anticipated. Today I am doing the C’s.

Email to MPs, beginning with the A’s



I have circulated this blog to everyone I can think of: local GPs in Tower Hamlets (thanks for your support), journalists, health think tanks, MPs, medical students I meet, and so on.

MPs: these were my first priority. The Health Select Committee, Health Ministers (government and opposition), and a handful of others in the first attempt (constituency MP where I live, where I work, and a few others).

Now I am emailing MPs systematically, starting with the A’s. Perhaps there is some clever way of doing a mailshot to all of them at once. I am doing it one at a time. I have a look at their photo, copy their email address, and paste it into my database as a distribution list: MPs A for tonight. I decided to type each of their names, methodically; so as to address each of them personally.

This is what I wrote:

Dear Adam, Bob, Danny, David Amess, David Anderson, Debbie, Douglas, Graham, Heidi, Ian, James, Nigel, Peter, Stuart,

I am a GP in Tower Hamlets. I am afraid my judgement at present, not without evidence, is that the political process, which includes Parliament, and the DOH, does not seem to be able to produce an intelligent management of the NHS. I am sure that most of you MPs mean well; and yet the results are lamentable, in some cases.

I have put together an argument about this which I feel does not rely on buzz words but concrete examples of problems out here (see link below).

I am circulating this to all and sundry. This is a quixotic venture. And I am including all MPs. My plan is to go through the list one letter a day, after work.

Why? Because, at the very least, you will not be able to say that nobody warned you.

 Best wishes,


The Tredegar Practice, 35 St Stephens Road, London, E3 5JD

(Rushanara Ali and Diane Abbott were included in a previous email)

Tomorrow night I will do the B’s.

The Central Question: Are they using a sound methodology?


These are feverish times. Probably not the the most propitious time for standing back and having a measured conversation.

My problems (the problem of list size and quality; the problem of patient choice of GP) are not on the agenda. And yet they are important, central to the quality of general practice and patient care.

It seems to me that the root problem here is a very faulty methodology being used to develop and implement this policy. Let me make it clear: I am not saying that all policy planning and implementation is faulty. Some of it is. Consider the following hypothetical rating scale:

Rating Health Care Policies

You will notice that I scored 10 points in the Excellent Policy box, 20 in the Good box, 30 in the Fair, 20 in the Poor. The remaining 20 out of the hundred points I put in the Kafkaesque box. That is policies which by their very design undermine quality and actually drive quality down predictably. The planners and politicians think they are doing something good, but they are actually causing harm. But they don’t know it; they don’t want to know it.

Let me outline what seems to me to be the way a Kafkaesque policy comes to life. A minister has an idea; it sounds like a good idea, something that will improve things, please the public. He goes to the DOH and lets it be known that this policy needs to be implemented, he gives it his full backing, he doesn’t want to hear any negativity, we’ve really go to follow through on this, remember I am the Secretary of State for Health, the PM is behind me on this. The DOH officials package it, dress it up with a nice cover, smiling faces, and words like Choice, Excellence, Making Things Even Better….and so on. The order goes down the chain to PCTs: implement Policy K. They might shake their heads a bit at the PCT; the primary care people (GPs, nurses) shake their heads and wonder how they can minimise the harm this is going to cause, and muddle along. There is no mechanism put in place to check how this is working. There is no way of feeding back to the people at the top, letting them know there’s a problem at the ground level.


What would a sound methodology look like? I would propose the following, just a rough outline. A minister has an idea; he takes it to the DOH; he presents the idea to the DOH people. ‘I really like this idea but I need you to evaluate it: will it work the way we hope it will?’ They gather the appropriate people to think about this, and they do an initial assessment of the idea. They ask questions like: what do we need to know in order to think clearly about this proposal; what is the aim of this proposal, what is the desired outcome; how would this work (do a walk through, modelling it); what are the unintended consequences; how might we get around the unintended consequences; and so on. Then they write up their findings in a preliminary report, and show it to the Minister. It would begin something like this: ‘We are thinking about a policy to do X. We are hopeful that this might bring about significant benefits, but we have also identified some constraints. Here is our outline:  [listing aims, benefits, costs, unintended consequences/risks, thoughts about how to avoid or minimise the risks, how it would work, how it would be implemented, etc]. [The last paragraph would be something like this]: We would be grateful for your thoughts on this. Are there any downsides or costs we have missed, are there any gains we have missed? Don’t pull any punches, we want to get this right…” And then they would send this initial draft proposal out to some sensible, intelligent, practical, straight talking people who will give their honest opinion (in the case of primary care issues, you would have a list of GPs, nurses, managers who would fit this description; not ‘yes men’, of course). These ‘experts’ would then send in their honest assessment and suggestions. The DOH people wouldthen go back to the drawing board, redraft the project proposal. They might decide that, actually, while it is an interesting idea it  will be impractical to implement (too costly, unacceptable unintended costs…), or that there are problems that need to be further hammered out, or that it all looks promising, with just a few tweaks to be made. They then present their findings to the minister, and decide on next steps. If they decide to go ahead with this, they then make the feasibility study document public: with the aims, objectives, benefits, possible risks, implementation plans etc; they would also make clear how they are going to evaluate the results of this policy. The minister would then sign the document, and so would at least one named DOH human being, with an email address for feedback. They would then implement the policy (maybe as a pilot); then they would evaluate the policy using a sound methodology which gave an honest answer and not necessarily ‘the answer they would like’. And they would publish the results of the evaluation, together with their conclusions.

This, I would submit, is a sound methodology. It is very different from the unsound methodology.


With reference to the ‘Choose Your GP’ issue, the evidence that we have available reveals a totally unsound methodology. In September 2009, the then Secretary for Health, said in a speech, ‘In this day and age I can see no reason why patients should not be able to choose the GP practice they want.’ He could see no reason, no problem with this policy. In March 2010 the Labour government, still with Andy Burnham, published an online ‘consultation’ on this issue. There was a 54 page document, a patient booklet, a patient leaflet outlining the proposed policy. Everything was slanted towards the benefits of being able to choose your GP anywhere in England. The 54 page document is full of half truths, distortions, misunderstandings of how the system actually works. It is a soothing bit of propaganda whose main message seems to be: ‘we want you to have choice, your choice, because you’re worth it….aren’t we wonderful, vote for us, your choice’ . The document mentions a few ‘challenges’, ‘but nothing unsuperable’, but leaves out numerous risks and costs. This document is truly a ‘dodgy dossier’. The questionnaire accompanying with the consultation was not designed to identify the problems, just to reinforce the message that ‘your choice is paramount’, ‘tells us what your choice is’.

I strongly recommend that you read the Royal College of General Practitioners’ response to the ‘consultation’.


What about Andrew Lansley’s methodology? I tried to find this out, and am happy to publish the result on this blog. In March 2010 I emailed Andrew Lansley. If you read the email exchanges you will see that Andrew Lansley and his team had no evidence to present that they had done a risk assessment on this policy, that they had thought it through. His chief of staff, in one of the emails, offers to ask Andrew to do a ‘feasibility study’. Well, that pretty much sums it up. A year before he was giving speeches extolling the virtues of this idea and castigating Alan Johnson for not driving it forward, and yet he has not yet done a ‘feasibility study’.

This is what I mean by poor methodology.


 To politicians I would ask: don’t pass this part of the bill until Andrew Lansley can present a properly worked out risk assessment, which shows in concrete terms how all this is going to work, in the real world. And the proposal needs to include the criticisms from those who have to implement the policy. Then if you are persuaded that this will lead to better patient care at an affordable price, then pass the bill.

Don’t be content with just lofty words like ‘Liberate’. Remember a previous occasion when Parliament agreed on a plan to do some Liberating without making sure of the facts and the complexity. There were a lot of unintended consequences.