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.’