Health problems


           The party political spat over why Accident and Emergency centres are under pressure shows Labour at their worst. They have waded in to claim it is not the fault of the GP contacts they signed, but the results of more recent action. The truth is more complex.

            There was a good case to cut GP hours to ensure doctors are in good form when working, and to give them a private life as well. There is also a good case to say a GP should take responsibility for named patients not in hospital on his or her list and be able to see them and help them as much as possible to ensure continuity of care. If the doctor seeing a patient knows that patient well the consultation can be both speedier and result in better action, than if the patient is seen each time by someone different. A new doctor for that patient  has to read a bulky file, has to  try to come to an independent judgement about the person and decide how to treat  their condition with no prior knowledge.

          The new contract also required doctor practices  to put in good out of hours services which were easily accessible and gave the patients confidence they would be well treated. They also need to be authoritiative, so they can deal with any patient who has no need of out of hours emergency advice or treatment but requests it. Again this is easier if the doctors involved know the patients and their behaviour.

           There is a danger that if people do not know their GP, or do not have confidence in the out of hours service, they will simply admit themselves directly to the A and E department of the local hospital. This can overload an A and E department with patients who do not need to be there.  Do your out of hours services work well?  Are you now more likely to go to A and E?


  1. Robert K
    May 27, 2013

    Our local GP, in Abingdon South Oxfordshire, is part of a health centre that has an out of hours surgery on the same site. It seems quite efficient and means we don’t have to slog into the A&E department at the John Radcliffe hospital in Oxford for minor scuffs.
    On a broader note, I wish there could be a grown up debate about the NHS that included a fuller involvment of the private sector. It’s hard to imagine scores of unattended customers piling up in unfunded and run-down facilities at Tesco or at a local firm of solicitors.

  2. alexmews
    May 27, 2013

    Our local medical centre is and always has been a shambles. Getting an appointment to see a GP is a challenge – with the diary open only a few minutes each day and appointments being snapped up in a flash. the turnover of GP at the centre has been such that i think, over 14 years, i have never seen the same person twice.

    the service is not open weekends.

    as a result – for anything other than a routine checkup or a simple prescription – my family and i (esp the kids – who get treated well) go straight to A&E.

    in recent years my wife as signed up to a private GP. Expensive but, like any other professional service, he is available when you need him, remembers who you are, and sorts you out in one visit.

  3. Martin
    May 27, 2013

    We have both a growing and ageing population. Both GP services and A&E are are going to under pressure.

    The system needs more cash and better spent cash.

    I’d suggest to help pay for the NHS we incorporate NI to basic rate tax so that more folk pay for it – especially those who use it most.

    The NHS like the rest of the public sector benefits from final salary pensions that are unaffordable to non state functionaries. Fix that problem and you fix a lot else in government. Of course you won’t be too popular with the state functionaries!

    Cut the supply of patients – Weekends are notorious for alcohol flooded A&E – minimum pricing or alcohol booze taxes. Longer term – start taxing hi sugar/fat foods. Again you won’t be popular with increasing number of “bulkier” electors.

    1. uanime5
      May 28, 2013

      I’d suggest to help pay for the NHS we incorporate NI to basic rate tax so that more folk pay for it – especially those who use it most.

      More people pay NI than the basic tax rate. This is because you pay NI when earning about £7,500 while you pay the basic tax rate when you earn over £10,000.

      The NHS like the rest of the public sector benefits from final salary pensions that are unaffordable to non state functionaries.

      Given that these pensions are currently producing a surplus, which goes to the treasury, it’s clear that you’ve just made this up.

  4. Javelin
    May 27, 2013

    It’s very hard to get to see a GP. They are over paid and only available to people who don’t work. The contract drawn up with Labour was a disaster for the health of the nation.

  5. Jerry
    May 27, 2013

    Slightly off tangent but I think relevant to the problem; How many of these out of hour calls or A&E visits are been caused by Hospitals discharging people to soon, has the savings made in the number of beds simply caused an even greater cost elsewhere. It is often said that Hospitals work best when there is something like 98% bed occupancy but in what way if “best” measured, patient care or accounting?

    I’m not suggesting nor asking for a money pit, just using as much of what money is available for front-line care, not swallowed up in needless Trust managements, as Nina suggested the other day, judge the NHS Trust by the 5pm rush to get out of the staff car park, not how many beds are occupied at any one time!

    On the other hand, if the problem in not being caused by Hospital policies then surely the problem is the catchment area of GP lists, in other words perhaps we need more GP Surgeries with smaller catchment areas – in that way GP’s will be able to manage their own out-of-hours service once again? Of course, smaller, fewer patients will mean that some GP Surgeries will not be big enough to manage their own finance (like their big sisters in the Trusts), take on business managers and generally act as if they are a private heath company etc. – no they will have to be content with being one of many cogs, all working together like in a Swiss watch to deliver health care. Oh and bring welfare and socail-services back into the DfH/DHSS, meaning that we once again have a joined up thinking…

  6. Mike Stallard
    May 27, 2013

    I want to ask why we are discussing this.
    We do not discuss the interior management of Tescos or Sainsbury. We do not discuss who drives the Emblings bus from Wisbech to March.
    Why is health any different?
    In Australia, the system is partly paid for by the state, partly not. Insurance covers the costs. It works.
    Why is the UK any different?

  7. lifelogic
    May 27, 2013

    The hospital could usefully learn a lot from manufacturing technology systems and production lines. It can take as little as 30 man hours to build a new luxury car.

    The hospitals could be far more efficient and make far fewer mistakes too if they did improve their systems and efficiency. Of course if A&E did this they would just get more visitors so instead they do not the put them off with 3 hour waits and similar rationing systems. The money needs to follow the patients, preferably the patients money. Free at the point of use is the problem.

    1. Bazman
      May 31, 2013

      Part of the problem is this treating the patients as if they were autonomous robots as you want them tpo be treated. Less of this is needed not more. Each patient is unique and sense tells us this. How can a 80 year old woman be treated as a fit 18 year old man and how would they have the same problems? Stupid logic that does not make sense. Even in the world of manufacturing do you think all parts are the same? As if. You be a rich man if they where this is the problem in the main. Consistency of product. If they where all bad, but the same, this would be good…

  8. A.Sedgwick
    May 27, 2013

    I know a few excellent GPs who have retired early purely because of the NHS bureaucracy.

    The current GP system is ridiculous where they are technically self emloyed but subject to the strictures and demands of a hierarchy which most would regard as overbearing and unnecessary.

    The function could be split between private GPs who are allowed to write NHS prescriptions and have full access to NHS Services and fully state employed GPs.

    There would most probably be an NHS dentist type exodus but I believe with more competition in fees on the private side. No doubt insurance schemes would emerge.
    Many would choose to find the money for a better service.

    There would be the inevitable socialist screeches about privatising the NHS and head burying in the sand but the NHS is overstretched and decaying if not in the process of collapse. The plus for the current GP contract is that it has probably kept more in the Service and in better health than if they were operating on a 24/7 basis.

  9. Acorn
    May 27, 2013

    Twenty three days for non-urgent GP appointment. GP can’t close their lists nowadays, and my group has taken on another Doctor. Increased population and increasing median age in our area, cause more appointments and more appointments per patient per year; was 3 now over 5 apparently.

    Interesting graphic at DoH, . Click on the Clinical Commissioning Groups (CCG) and follow the link in the pop-up. With a little luck and judgement you may be able to spot your new CCG. Ours in West Hants, has 80,775 registered patients (roughly 15% of CCG population) 57 GPs in 6 Practices.

    According to the budget, we are each worth £25 towards the running costs of the Care Commissioning Group.

  10. English Pensioner
    May 27, 2013

    When I went into a career in Civil Aviation, I knew that there was a high probability that I would be required to work shifts as aviation is a 24 hour a day seven days a week, bank holidays and all, business. Seemingly, Doctors seem to have forgotten that there are patients that might need attention at any time and that medicine, like aviation, simply can’t be a 9-5 business. There is one difference though, the absence of a flight to Ibiza won’t kill you, the absence of a doctor might.
    The Matt Cartoon in today’s telegraph says it all
    A couple sitting at a restaurant table and the waiter saying “Sorry Doctor, the Chef doesn’t work evenings”

    1. Tom William
      May 28, 2013

      Quite so. The police and parts of the armed forces arrange 24/7 coverage. Why can not GPs work a (publicised) rota system which provides coverage at weekends – and days off during the week?

      Another point is that those at work during the week would prefer to see a GP at weekends.

  11. ralphmalph
    May 27, 2013

    I actually think that there is a multitude of issues going on in the Health Service that is causing the issues. One that has nit been mentioned is that the last government brought in concept of the GP doing preventative medicine with the focus on hypertension, smoking and obesity. The last couple of times I went to my GP he did not care what was wrong with me I sat down and he took blood pressure, weight and asked if I smoked. When I started to talk about what was ailing me. He haughtlily said “Well you will have to boon another appointment to discuss that.”

    It is the same with my 84 year dad. He has had high blood pressure for 30 years and takes statins. The GP keeps calling him in for blood pressure checks, so he keeps taking up valuable GP time and he simply does not care that his blood pressure is slightly high.

    I would love to see these GP contracts but I can only deduce that the GP’s are paid lots of money to check BP, Weight and Smoking.

    In my view these new GP contracts basically turned a lot of doctors or the managers of doctors (via targets or personal choice by the GP’s) into (system players? ed).

    I go to the out of hours GP service at the hospital now and it is brilliant and herein lies the problems a lot of GPs’ are getting paid a lot of money for providing a rubbish service. The hospitals provide a great service do people go there.

  12. Peter Stroud
    May 27, 2013

    It certainly is time for a new contract for GPs. It seems that the last one gave them increased salaries, but for less work. Visiting patients at night was accepted as part of the vocation, and all practices ran a rota system. Now it seems that the average GP is content to work office hours. The present system where a doctor, completely unknown to the patient, can make a diagnosis on the telephone, is a dangerous practice.

  13. Lindsay McDougall
    May 27, 2013

    In January, I suffered from kidney malfunction for a third time. This time I was unlucky in that the problem occured at night. My wife called the night time number of my GP’s practice, a group of 10 doctors based in Hook and Hartley Wintney. The number was a READING number. She was advised to call an ambulance and get me admitted to hospital.

    I spent a week in Basingstoke & NE Hants hospital on an antibiotc drip followed by a kidney biopsy at Queen Alexandra Hospital, a specialist renal hospital. Worse was to follow. QAH recommended that I start immediately on a programme of invasive steroid treatment with 17 major side effects, including weight gain for a 20 stone man. Naturally I said ‘No’, pointing out that my problem was acute, not chronic. Instead, we agreed to monitoring by my GP and my creatinine level is slowly returning to normal.

    In total, I spent two weeks in two hospitals, which must have cost the NHS a lot of money. On the previous two occasions, my symptoms broke during the daytime, oral antibiotics were prescribed and the kidney malfunction cleared up.

    There are two lessons from this episode:
    (1) My GP’s practice should have one of their 10 doctors on call at night.
    (2) Hospitals are bad news, stressful and time wasting – because there is not enough doctor time and too many nursing and ancilliary staff who manage patients for their own convenience.

  14. Robert Taggart
    May 27, 2013

    Our local ‘casualty’ (has that name been dropped officially ? – on account of a certain drama ??!) – Wythenshawe – has always done just fine for us.
    That said, the ‘casualty’ in each case was a pensioner – who became a ‘bed-blocker’ – for two or three days each time !
    Methinks this age group are the main cause of difficulties – the NHS ‘keeps them going’ – only to find they come back for more !

    1. P O Pensioner
      May 28, 2013

      Robert, that is an ageist comment. You will also reach pension age one day.

  15. margaret brandreth-j
    May 27, 2013

    I am a Nurse Practitioner and there are many like me who run daily surgeries dealing with acute problems, chronic problems, decide which tests to run , diagnose , treat and refer. We, unlike the doctors also run our own physiological tests as an aid to diagnosis and deal with the problems promptly rather than refer for this and that in a trail of specialities. Of course we seek advice and refer where it is appropriate like any other in general practice. What has made the process easier in the last 10 years or so is our consultations which are almost entirely carried out with computer soft ware. We have on view tests, results, medical history ,we can document findings and each examination with details can be documented in free text . This has revolutionised general practice . We do not have bulky files; all the information is sorted and prioritised and we even get flags when some routine investigation or test is due. When a patient is transferred from one practice to another then the electronic files go along with them . This makes life a lot more organised for the general nurse practitioner and our patients are welcomed as we accommodate their life changes and demographic preferences.

  16. Pleb
    May 27, 2013

    Another reason to go to A&E is to get a free prescription.
    If you go to your GP you have to pay £7 ish for a prescription. A prescription given at an A&E clinic is dispensed immediatley and incurrs no charge. Simple mathematics.

    1. P O Pensioner
      May 28, 2013

      A&E clinics should charge the same as a GP prescription then perhaps that will reduce the numbers at A&E and raise more funds for the NHS in the process. Simples.

  17. Chris S
    May 27, 2013

    The problems of funding GP practices and out of hours services in particular are almost entirely down to the new GP contract “negotiated” by Labour in 2003 and implemented in 2004.

    The Reid contract as we should call it, was a massive error of judgement on the part of the then Secretary of State, The Rt Hon John Reid, now Baron Reid of Cardowan.

    I quote here from a BBC report in 2007, three years after implementation :

    “GPs were so stunned by the terms offered to them when negotiating their new contract that they thought it was a “bit of a laugh”, a doctor has said.

    Dr Simon Fradd, who was one of British Medical Association’s GP negotiators, said they were shocked by the approach taken by the government.

    They could not believe it when GPs were given the chance not to do evening and weekend work for a 6% pay cut, he said.

    Since the deal started in 2004, average GP pay has topped the £100,000 barrier”.

    Politicians and Civil Servants are obviously a lot less intelligent than Doctors because they predicted incomes would rise by “only” 15%. One wonders how Reid found this acceptable – it seems far too generous ).

    In fact the Doctors had realised what a gold mine the deal was going to be. During the first three years alone, average pre-tax GP incomes rose by 58% despite 95% of them giving up £6,000pa to avoid having to look after their patients at evenings and weekends.

    In 2006-7 the average earnings of GPs had risen to £103,000 and as much as £118,500 for those working in PMS practices.

    In 2007, John Reid’s successor Patricia Hewitt, criticised the pay of general practitioners (GPs) which had increased again to an average of £106,000 yet in all Labour was in power for six years after the new contract came into force yet did nothing to reign it in.

    The coalition has similarly done nothing about it and the problem is now even worse : A GP in a rural practice I know now has earnings of more £200,000 and rural GPs have far fewer patients to look after than city centre ones.

    My GP friend works a four day week.

    The additional cost of providing the poor quality out of hours service we now have is similarly enormous. Is it small wonder that people go to A and E ?

    The only solution is for Jeremy Hunt to call in the GPs and make them again responsible for supplying and funding out of hours services for their own practices.

    Give them back the £6,000, although this is hardly necessary, given that their earnings already make them the highest paid in Europe.

    A GP should have ultimate responsibility for looking after his or her patients as long as they are not in hospital or out of the area.

  18. Linda Breeze
    May 27, 2013

    We have had some Walk in Centres closed down. The aim of having Walk in Centres was to divert people away from A&E. Walk in Centres are also for people who cannot make appointments on the same day. Walk in Centres was supposed to take the burden and take caseloads off A&E and Surgeries.

  19. Chris Rickard
    May 27, 2013

    I have 6 doctors in my family – 4 GPs and 2 hospital doctors. GPs have never had it so good since the 2004 contract which they freely admit (except perhaps to politicians & patients). The trouble is patients will never see a GP outside of Monday to Friday 9-5 unless they are at deaths door. NHS 111 is a totally inadequate substitute for out of hours care and has no prospect of becoming adequate sithout the support of the medical profession, which it does not have at present. Nurses & computer algorithims are not going to be effective especially if the person at the other end of the line is not medically qualified. When I had my operation for prostate cancer the urologist told me to bypass NHS 111 if I had problems and just go straight back to the hospital. The trouble is too many GP appointments are taken up with time wasters and too many A&E cases are neither accidents nor emergencies. The only way this will ever be effectively addressed is to introduce a charging system for appointment as they do in NZ, where I lived for 2 years. Hunt was perfectly correct to attribute the cause of the problem to the 2004 contract change. Where he went wrong was in not seizing the opportunity to get the medical profession onside from the antagonism caused by Lansley’s reforms to find a way of restoring out of hours care with a hybrid solution of using NHS 111 to refer patients to an on-call GP from the surgery before A&E are involved. The whole of the medical profession is best by unnecessary administrative bureaucracy – NHS managements weapin of choice in trying to micro manage doctrs. This absorbs time and detracts from patient care. If he had worked with doctors to critically examine how to reduce this & at the same time, address the out of hors care, he would have got the support of the medical profession, tackled a difficult problem for the NHS and isolate Labour politically. Instead, he had no solutions and chose to play the blame game. Opportunity lost !

  20. Jon
    May 27, 2013

    There have a few occasions in the past when I’ve used A & E and for the purpose it is intended for. Experiencing these accidents the last thing you want is a queue of people with an upset stomach etc. I can’t give any experience of out of hours as I tend not to get sick but I would like A & E to remain and be available for what its purpose is intended for. That means the tummy upset snivelling people need to be dealt with elsewhere.

  21. Martin
    May 27, 2013

    I would have to be pretty ill to go to Royal Berks A&E at a weekend. One experience was enough.

    One way to ease the pressure on A&E would be to charge patients whose problems are self-inflicted, particularly drunks and druggies, for the treatment that they receive.

    1. Mike Wilson
      May 28, 2013

      What about the bloke who cuts his hand doing DIY? Self inflicted. And the person who drives into the back of another car and smacks their head on the windscreen surround. Self inflicted.

      Perhaps we could have another layer of administration at the hospital recording the precise details of the ‘Accident’ and allocating blame and, therefore, payment responsibility.

  22. Stephen O
    May 28, 2013

    To answer your question: The out of hours services I have used almost always involved a trip to the same site as the local A&E and involved a similar (lengthy) wait. The home visits I recall from 20 or 30 years ago are a thing of the past, but those ( together with the continuity of care and the shorter waiting times of those days) are the benchmarks I use to judge today’s services. So of course I do not feel todays out of hours services work as well. There is no reason to prefer the out of hours servies to A & E.

  23. a-tracy
    May 28, 2013

    Since 2004 our only choice was to go to the A&E at the hospital for our region, they were overwhelmed and they had to open a clinic next to A&E for these GP out of hour visits, it is 11 miles away, no evening or night bus service, restricted services out of hours at weekends. We get a very restricted service now, much less than other family members who live in wealthier areas who still seem to have some evening and weekend service, before 2004 we used to have one late night clinic, one Saturday morning clinic. GPs that still came to the house in an emergency all canned.

    The blame for this lies firmly with Dr Reid MP and Patricia Hewitt MP, it was all predicable. The GP contract could have had a compulsory Saturday morning clinic giving the GP on rota for that weekend a day off in the week instead. The local GP service could have been asked to also provide a one or two hour clinic on a Sunday. People don’t just get sick Monday to Friday. The on-call night cover is more difficult to cover with GPs working all day but the pressure on A&E and the ambulance service for the people that don’t have cars or transport with sick relatives has been a tremendous burden.

  24. David Langley
    May 28, 2013

    Unfortunately over the years and just recently I have gained considerable personal experience of the A & E service and the reasons why I have used them first in preference to the other options available.
    Complex reasons but briefly, I knew what was happening to me on each medical emergency except one, and that one nearly killed me and importantly that was the one where I acted on direct local practitioner advice (face to face). I wound up in critical care unit.
    All the others I went right to A & E, got the usual bollocking for not ringing out of hours etc etc, and then got the treatment and analysis immediately needed. Two of them required immediate hospitalisation.
    What we should be doing is having massive A & Es and closing down the useless call centres and foreign doctor mystery trips etc etc.
    Add to that as you stated the not joined up computer systems and we have chaos and new lengthy diagnosis before treatment. I am still briefing doctors on my condition, and now we decide together on my treatment using my various notes and the computer. To maintain a 24 hour system you have to have a 24 hour fully manned system. Health is not a 9 to 5 industry. Day and night has no meaning to a heart attack or kidney stone. When faced with the prospect of death or disaster you clutch at any straw. A & E is your best bet and always will be.

  25. Mike Wilson
    May 28, 2013

    Surely it is far more efficient to pay doctors to fly in to the UK from all over Europe, pay for their flights and hotels etc. – so they can do the out of hours calls. They have no knowledge whatsoever of their patients so they will not have any preconceived ideas!

    You couldn’t make it up really. Put a politician near anything and all you can guarantee is inefficiency and stupidity.

    How did we get from being able to see ‘your’ doctor when you needed to – to ‘ring at 8 o’clock on the dot and hope you get an appointment or be prepared to wait 10 days for an appointment’ – and, if you are really ill in the night – get a visit from someone who has no idea who you are or your case history and who, if you are really unlucky, has such poor English you are not sure if they understand you because you definitely know you cannot understand them.

    Time to rip the NHS up and start again. It has turned into a monster.

  26. stred
    May 28, 2013

    My friend, who is a retired GP, is amazed at the pay and conditions enjoyed by doctors today. He used to be on call nights and weekends for a modest salary. These conditions still apply in the case of my neighbour in France who works from a two doctor surgery. His pay is about half that of a British GP. This is not to say that many of them do not work long hours in a difficult job.

    A point not often remembered is that, even before Mrs Hewitt’s fit of generousity, GPs used to employ locums to do out of hours and weekends. Some of the ones we had to deal with were awful. In one case my son was mis-diagnosed for a condition and being prepared for an operation, when the French hospital doctor immediately noticed that it was an infection and cured it with tablets in a few hours. In another, I attended surgery at a weekend and waited for an hour while the locum chatted and laughed with the patient before me. When he emerged, he said he was finished for the day and I could just go home. I did and later the painful infection lead to a burst eardrum.

    It will not be possible to persuade GPs to go back to the old standards which applied 30 years ago.

  27. forthurst
    May 28, 2013

    On the principle that the money should follow the patient, perhaps A & E departments need to be paid for the non A & E work they perform and the GPs whose unavailablity has triggered that extra work should have their capitation fees docked, correspondingly?

    1. uanime5
      May 28, 2013

      How will this work when GPs control the NHS budget and have to pay these hospitals regardless of what treatments are performed?

  28. Bob
    May 28, 2013

    The NHS should convert to the French system of charging and refunding a percentage if you are entitled to it.

    This would stop the time wasters, self inflictors and health tourists.

    The current free for all is not sustainable.

  29. David Langley
    May 28, 2013

    Have I been banned John? A lot of my recent posts have been moderated out of existence. I might be wrong!!!!

  30. uanime5
    May 28, 2013

    Ignoring something won’t make it go away.

  31. outsider
    May 28, 2013

    Dear Mr Redwood, I have recently helped to shepherd an old friend with no nuclear family through a two-year saga of worsening illness, a world-class operation and a prolonged stay in intensive care, leading him eventually to be switched off. The details are not relevant here, except to say that the standard of care was generally good and sometimes excellent, depending on who was on duty.
    What struck me throughout, however, was that at no stage apart from the operation was any single doctor in charge of his case. There was no GP who owned his case and no hospital consultant, or even registrar. When the small band of relatives and those whe felt responsible for him talked to a doctor about his case, it was always a different doctor. This cannot be effective or efficient.
    I strongly agree that everyone should have a lead physician who knows that person, as was normally the case with the old single doctor practices. I see no reason why this should not also be the norm in today’s group practices. It might also help if each of us had a portable computer stick detailing our health records, updated as the records were updated.
    Group practices, far more than the old single ones, should be capable of providing their own out-of-hours services with one doctor on call each day (as Lindsay McDougall also suggests). This is a more natural way of conducting medicine and should also be more cost-effective.
    Lifelogic’s argument that the NHS needs to be run on production-line principles is only partly wise. He is right in the sense that the huge central “health factories” now favoured by health accountants make no sense at all. The “we make everything” factory is long obsolete as a business model and almost dead. Production-line methods are clearly good for “routine” operations, where productivity can be raised dramatically by using specialist units, either within or outside the NHS. Smaller units are simpler to manage and generally have less hospital acquired infections.

    Much of medicine, however, should and will will always remain a profession rather than an industry, more akin to the law than a factory. Attempts to shoehorn A&E/casualty into the industrial framework are counterproductive.
    Few people attend A&E by choice, other than for physical injury, but rather as a last resort. It is truly demand-led and should always remain so. If demand is rising excessively, that is a measure of inadequacies in primary healthcare. The need is to improve the availability of primary care so that people have a service that suits them and is fit for a society in which about 70 per cent of working age people are employed. A&E demand will then fall of its own accord.

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