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Then why does the BMA talk about contracts of employment for GPs being with the practice and not the nhs.
Because the practice will employ staff, so the practice will have contacts of employment for, say, salaried GPs.... This BMA contact model you speak of is to ensure I don't employ my staff in draconian measures!
I'm a partner. I own the practice/business. I employ a salaried GP.
The NHSE contracts tell me/us/the practice what we have to offer to the public.
I acknowledge - it's complicated!
DrP
Private GP – any thoughts ?
This is exactly what those bastards in power want people to do. In time it becomes normalised and the great sell off will be complete.
There may be a very limited "free" at the point of use NHS left but it won't be worth anything.
The current GP service contract is based on the number of registered patients at the practice, not how many they actually see
Not quite, the contract is based on a weighted patient registration, and takes into account things like deprivation and age. the contract also suggests that patients should be seen 3 times a year on average. I can look at stats that show a good percentage of my patients are coming to the practice many more times than that. The alternative - paying doctors on their activity, didn't go down well with dentists.
No offence @chrismac but I don’t think what you are describing as practice based commissioning is what I think of as practice based commissioning- back in 2007/8 all practices were being asked to get involved with it. Then consortia were a thing for a while then everything was ripped up and thrown out with the emperors new clothes that was CCGs.
There are still some GPs that do other work on top of their nhs gp contract. Eg there are a couple near us that do vasectomies this brings in more income that probably pays for locums to see their patients while they’re doing it, plus some profit, but it’s still nhs contracted work and it’s not general practice. It’s “any qualified provider” commissioned services. Running dermatology outpatient clinics is also not private general practice. GPs are often very versatile and able to fill lots of gaps in the system. One example is the “gp in a&e” that is everywhere now I’ve done these sessions myself, so much easier than the day job! Personally I’d prefer the GPs I’ve trained to be working in general practice but I don’t have control of that. Almost anything else you can do as a fully qualified gp is less stressful than being an nhs gp- so it’s no wonder that people are choosing other career options.
The wiki page for pbc refers to it in the past tense like an extinct animal…
https://en.wikipedia.org/wiki/Practice-based_commissioning
@docrobster. No offence taking. I worked I practice based commissioning and then helped set up and create the CCGs in the county I worked in. Yes the model has moved on to AQP based but it’s still fundamentally GPs doing the work hospitals did in their practice when they are contracted as a business to be seeing patients. It’s certainly how it operates round my way with the AQP patients having appointments during the normal clinic lists.
@DrP I’m a partner. I own the practice/business. I employ a salaried GP.
The NHSE contracts tell me/us/the practice what we have to offer to the public.
Agree entirely. Your company has a contract to provide GP services to the NHS in the same was say Virgin healthcare did or boots etc do. You then employ your staff, so they are no more NHS staff than those who work at a private hospital or private primary care provider.
the contract also suggests that patients should be seen 3 times a year on average
Off topic, but does it specify mean or median? A small number of very regular visitors means they're more likely to hit 3 visits per year as a mean, but my gut feeling is that the median would be much lower. (Perhaps I should see a GP about these strange feelings in my gut 😀 )
@nickc I believe it’s more than 6 a year now isn’t it? And the ones that come a lot more than that are the really medically complex ones- multiple conditions, in their 80s etc etc.
I popped on to the pricing page for that Babylon app- payg it’s £50-60 an appointment which is affordable for the archetypal t6 driving £6k bike riding IT professional on here, but more interesting is the subscription service which is £249 a year but limited to 6 appointments a year as this is the traditional average use. Average nhs spend in England is £140 a year per person so either Babylon are making huge profits or the nhs needs to spend more. Or both. Babylon’s patients are also likely to be a self selecting group of healthy working age adults who just want a convenient service for minor quick problems or things that the nhs doesn’t provide. Cherrypicking the simple patients is a good idea if you just want to make profits.
I think the contract still says 3, but I'd have to search it and it's 288 pages long so that ain't happening 🤣
Is Babylon the one that still tells you you to go to a proper GP if they can't sort you out either over the phone or video?
mean or median
Fairly sure it’s mean. The only stats I’ve seen are total number of appointments in general practice per year- so just divided by population to give “average”. It’s an underestimate of work done anyway as so many patient interactions phone calls letters etc aren’t recorded as appointments. NHSEngland has really no idea what we do!
Not sure it matters though. You can’t compare an appointment with an 85 year old with heart failure diabetes copd chronic kidney disease arthritis and dementia who needs to be seen 20 times a year with someone who gets a bad back or urine infection twice a year and just needs it sorting.
For what it’s worth what I think we will see is more segregation between “urgent/convention/minor” delivered by anyone who can diagnose and treat a simple common condition and “complex/chronic/severe” service delivered by named gps with continuity as a more important factor than speed of access. How a system like that picks up patients that need to move between the two types of access is hard to predict. How many minor illnesses before someone starts to look for the hidden cancer?
sadly another example of the people who 'run' my GP practice on a day to day basis letting down the GP's who do a good job.
My wife has fairly textbook symptoms of whooping cough; I'm attuned to this because I had it 10 or so years ago. Mild cold symptoms 10 days ago has quickly deteriorated into a hoarse cough that goes onandonandonandonandon.........until she goes red faced, retches, gasps for breath. Worse at night.
It's not urgent as in must be seen today, so she requested a call back from the GP via the online system, firstly because she can reduce infectiousness if they deem it worthwhile with AB's. Second, because it's a notifiable disease and needs tracking. One for a GP to read and action at an appropriate time.
Didn't get a call back. Got an secure message* back from CN team telling her to get cough medicine to reduce the symptoms - something that is specifically told NOT to do in the NHS advice - and if not better in a couple of days to call back. They have completely missed the important content of the request, and it's only because of my past history and ability to read the internet that we are going to have to escalate by getting in the appointment queue tomorrow.
* which you can't even respond to.
Employer provides Aviva Healthcare, it comes with an online GP through app service. I’ve only used it once, when my daughter needed physio and aviva’s own policy is not to allow under 16s to self refer. My experience of that was so mediocre that I don’t perceive it as a solution to the problem the OP thinks he has. It fulfilled my need but anything which would require physical examination, blood pressure, stethoscopes, blood tests, x-rays etc looked like it would be referred back to the NHS GP! That said my employer believe it is helping people who don’t work from home to access GPs and so helping the business.
In terms of getting an appointment have you tried walking into the GP either during the day or at the 8am rush to see if the reception staff can help get you what you need? Often they can be quite helpful if you approach them the right way.
<span style="font-size: 0.8rem;">Pharmacist route is fine in theory… ours used to be good (crazy busy) at dealing with things when people couldn’t get to see a GP… but has now left. Over worked/stressed? Don’t know.</span>
This is the problem - people (including some pharmacists!) perceive asking the pharmacist as doing the GPs job for them. Let’s be clear, pharmacists are highly trained medical professionals, who are (should) be competent and experienced at doing this. They mostly (all?) should even have a private consultation area. It’s not a favour to customers or the GP - it’s their job. If they can’t deal with it they will tell you to see GP but if you say, pharmacist said I need to see the Dr to the receptionist it might just carry a bit more weight.
I think whilst WhatsApping pics of a rash is clearly not the right solution; and a telephone appointment is unlikely to solve it you might be surprised if you engage with the system they’ve provided how it does work. “Thanks I’ve looked at your pics, nothing there is concerning me, the pharmacy should be able to provide a topical cream that will clear it up in 7-10 days, come back if that doesn’t work” or “From your description I am happy to refer you to Detmatology” or “OK that doesn’t sound good can you come down to the surgery this afternoon so I can take a look”.
GPs are over worked and under resourced. But we seem to have a culture where patients are happy to use google for diagnosis but unwilling to do anything other than visit a GP face to face.
@nickc Disclaimer: I’m a PM at a GP practice. I use these sorts of threads as research
Interesting Nick. I wonder if you see what I see. This is my experience (and that I have had with my children):
- Google symptoms, already suspect I know whats wrong, certainly know the things the Dr is likely trying to rule in/out
- Call Surgery get appointment (with minimum description of condition)
- Dr discusses the issue, and says "OK we will need (pick from) Blood / Urine / Stool / X-ray". [Which was probably obvious before google but certainly after].
- Phlebotomist appointment / x-ray referral or sent home and return with sample bottle
- Follow up Dr appointment to discuss conclusions of the tests (or in some cases the results have nothing remarkable on them so the patient doesn't get a follow up and then has to refer themselves back to the start of the process to begin another cycle of investigations).
Assuming that pattern is common (and I'm guessing that patients fall in 3 broad groups: 1. People with an ongoing / chronic problem having follow up; 2. People with some symptoms that require investigation like above; 3. People who genuinely need seen today - for treatment etc to start today.). Is it feasible that a very quick telephone or online screening process (it could be half a dozen questions in an online "wizard") identify the tests the Dr is likely to order, and miss the first appointment completely freeing up slots for people in group 3.
that's what E consult SHOULD be doing, TBH..
DrP
The real problem is not training enough doctors. The reason is lack of proper funding . The restriction is demonstrated in the ridiculously high entry requirements for medical schools. Obviously required grades should be of sufficient merit, but they are actually set so high that only the very top academics can be considered. Will an elite level academic perform better than a very good academic? That along with other barriers to entry such as having related experience means the UK has a shortage of doctors and has to import many qualified doctors from overseas.
Actually, the big issue is no one want to work in the NHS as a doctor any more. Especially general practice. There's lots of doctors..they're all over my facebook feed galavanting around NZ or Oz. The 2 facebook GP groups I'm part of are FULL of people asking about emigrating to Canada/NZ/Oz.. why... becuase, simply put, the current atmosphere towards GPs is S H I T.
I'm lucky that I enjoy my job and my patients are mostly nice.
But the nation is angry. The service is dying. And GPs really are mostly the messenger being well and truley shot.
You don't get threads about "I rang up for a table at the fat duck and they can't see me for months" or "I wanted to book a taxi for ten minutes past midnight on 31st dec and there's WEREN'T ANY RANT RANTRANT" do we.... but yet everyone assumes the right to see a GP at any time (24hrs a day now) for any reason (i don't want to pay for sun cream...genuinely) is unfaltering and infallable.
Genuine question. If my apointmetns for teh day (which is based on number of staff, and a safe amount of workload, coupled with all the OTHER work I have to do, coupled with the fact I like to eat, and piss, and shite etc)..when they are all full, what SHOULD I do when the N+1 person rings in wanting to be seen?
DrP
and I’m guessing that patients fall in 3 broad groups
Pretty much, we have a triage that goes;
Emergency: seen today
Urgent: 24-48 hours
Routine: everything else (in effect pts are normally offered "something this week" or "something next week" )
Add to that mix is people telephoning in, and people coming in off the street. folks with LTC that need reviews, check ups, regular check ups, groups of folks that our contract says we need to manage a particular way, and so on. Add to that the fact that most patients see the GP as dealing with them and their prescriptions, when our list of daily things includes (but not limited to)
Reports,
Flu jabs
covid jabs
home visits
nursing home rounds
revalidation
daily weekly monthly CQC requirements
policy updates
revalidations
mandatory training
Learning disability reviews
chronic health reviews
recruitment (constant)
ICB assurance reporting
safeguarding
combatting health scares in the press
GP training
managing local targets
out of hours
etc etc etc....
Now, every GP practice is it's own thing. We have a KPI that says the reception team will answer 95% of calls within 1.30mins. I've known some GPs that just don't answer the phone at all, others that won't allow on-line consultations, and everything in between. The reason that happens is that every GP practice has a capacity limit of how many pats they can see in one day, and that's generally about 1% of the pt. population (that's a pretty much SOP for any well functioning GP practice), how they reach that limit....I've met GPs that will send every urgent case to A&E and I've met GP who fill their sessions with on the day bookings, there's no rule book
generally about 1% of the pt. population
Blimey.. I think we see about 2 and a bit % daily..oof!
DrP
Sucka!
🤣
The restriction is demonstrated in the ridiculously high entry requirements for medical schools
The restriction is also the Government limiting funding to medical schools to restrict number of students coming through the system. Unbelievably, the Gov is limiting supply of new Doctors.
https://www.theguardian.com/education/2023/jan/14/ministers-refuse-fund-medical-school-uk-doctor-shortage
Sucka!
ha!!!
Our PCN released appointmetn data recently..we weren't even the highest...will check...
DrP
It's a tricky one. I think most people are just trying to do what's best in a system that's basically broken, but it's not clear what actually is best.
I certainly feel the OP's pain. I'm sure it is possible to get an appointment at our local (Aberdeenshire) GP but I've never had the time to work out how. In theory you can phone during some small window around 8am but the line is permanently engaged. There is now an eConsult service, which I have used but there are at least 3 big issues with it i) even that is only available for a short window each day ii) you can't just put in a free text description of the issue but have to go through a long list of seemingly irrelevant questions, which takes ages iii) if you put the "wrong" answer to any of those questions it just says it can't help you. No idea of where you should go next, just sorry we can't help! Fortunately you can go back and just change the answer though, which makes the whole exercise pointless.
So, what to do? I could afford to pay for an appointment, but haven't done so as it just feels wrong to buy my way to the front of the queue for something as essential as a GP appointment. But the reason I have that cash is that I'm time-poor, which is why I can't work out how to "play the system" to get an appointment. If my cash goes to subsidise the visit of Elsie who doesn't have the cash but has the time to try and get through the system is that so bad? Probably, which is why I haven't done it.
But I do something similar in other areas. I managed to damage something in my leg on a run and haven't been able to walk without pain for the past three weeks. So I paid to see a local physio who I know is good at sports injuries. That's not really any different. If I was being consistent I should have waited to see an NHS physio, but somehow that seems different.
The physio did say that I should really see a GP to rule out a few things, but as I said to her I'd need to be in pain for a bit longer before I was ready to face the misery of trying to get an appointment 🙂
The real problem is not training enough doctors. The reason is lack of proper funding . The restriction is demonstrated in the ridiculously high entry requirements for medical schools.
That does seem to be getting addressed, at least in Scotland. Our medical school has seen a big increase in students this year with more increases planned (mandated by the government in Holyrood). For the first time ever they are having to consider trying to actively recruit students rather than the usual "selection" approach and I think the entrance tariff has dropped a bit. There is quite a bit of good work being done around widening access too although obviously still a way to go.
we weren’t even the highest
I'm being a bit loose with the stats, that's just GP appoints and it's a little over 1%, it doesn't include the 25-30 triage (from the online system) I give them every morning, and doesn't include the nurses or the HCA (doing a blood clinic that we won' get paid for...)
even that is only available for a short window each day
We do the same, It's a capacity issue. I imagine every GP practice does. You know that everybody recognises that adding a lane to an already busy motorway ultimately does nothing for congestion? Allowing online requests for consultations is exactly the same thing.
We do the same, It’s a capacity issue. I imagine every GP practice does. You know that everybody recognises that adding a lane to an already busy motorway ultimately does nothing for congestion? Allowing online requests for consultations is exactly the same thing.
I kind-of understand this but as a patient one advantage of an online system should be that I can use it to report symptoms that aren't urgent. It's not about adding extra capacity, it's about giving patients who are short on time a convenient way to say "I've got these symptoms, do you think we need to do anything about them". As it stands it just seems to be another version of the "phone for an appointment" system and doesn't offer any advantages so what's the point?
I think what frustrates a lot of people with the current system is that we know our GP is busy and we're happy to make allowances but they don't seem to understand that the rest of us might be busy too.
Going back to the original question it seems to me that we all think it's wrong for those who are cash-rich but time-poor to use their cash to get an appointment with a GP, but we don't think it's wrong for those who are cash-poor and time-rich to use their time for the same purpose.
I kind-of understand this but as a patient one advantage of an online system should be that I can use it to report symptoms that aren’t urgent. It’s not about adding extra capacity, it’s about giving patients who are short on time a convenient way to say “I’ve got these symptoms, do you think we need to do anything about them”. As it stands it just seems to be another version of the “phone for an appointment” system and doesn’t offer any advantages so what’s the point?
So the ideal would be that I cancel 6 face to face appointments per day, in order to deal with, say, 18 eConsults (in reality, my practice doesn't have numbers that high).
But if we do that, we'll be berated for cancelling 6 appointments.
'people' (BBC, mail, patients, hospital staff) don't understand the complexity of running a GP practice. Time and time again we've tried letting people know.
DrP
You don’t get threads about “I rang up for a table at the fat duck and they can’t see me for months”
If a proportion of my earnings were given to The Fat Duck every month I'd be disappointed if I struggled to book a table. 😀
If you have the money and can go private pay I'd say so you can get on with life.
It would be nice if GP practices did late night opening for people who are employed so we don't have to cancel/take time off work though I appreciate this would make being a GP even less appealing.
pats they can see in one day, and that’s generally about 1% of the pt. population (that’s a pretty much SOP for any well functioning GP practice),
If the business cant see enough patients in a day then surely it should either hire the staff to do so or be honest and stop taking the revenue for work it knows it can’t deliver.
I agree we need to train more doctors but the professions representatives , mainly the GMC and BMA, do all they can to restrict entry to the profession to keep salaries high for those already in it
https://bmj.altmetric.com/details/5571179/twitter
it’s about giving patients who are short on time a convenient way to say
I understand your frustration, I really do. If I could trust patients to use these systems like that, I'd happily open them for longer. I know that other practices they've had to close on line appointment requests because patients abuse it. Plus at the end of the day, it's still a triage that ultimately I have to give to a clinician to sort out, and annoyingly they get upset with me if I don't let them out their chains to go home occasionally
If the business cant see enough patients in a day then surely it should either hire the staff to do so or be honest and stop taking the revenue for work it knows it can’t deliver.
How many patients is enough patients? I do have to abide by laws that tell me I can't actually work my GPs until they drop dead from exhaustion. I know, it's frustrating, but what can you do? NHS GPs see something like 95% of ALL NHS activity, as the population ages, the need for GPs is only going to increase. There is a finite supply of trained GPs and while I have enough I know that other GPs practices struggle. You cant remove patients from your list just because you can't recruit to fill a vacancy.
Interesting responses. Thanks. It does sound as though the eConsult patients are viewed as an extra set of patients somehow different to the ones coming through the traditional route (hence comments about having to cancel other appointments to deal with these “new ones”) rather than just a different way for the same patients to interact with the service.
note “” denotes my interpretation here rather than a literal quote.
i think what they're getting at is that if you open up an extra method for patients to contact you. it doesn't mean that the previous number of enquiries simply gets spread across two communication methods making it easier for patients to reach the practice.
Because the service is so stretched, the second method of contact just brings an "extra" set of contact requests that need to be dealt with/ triaged by a GP so it creates "extra" work.
Maybe im wrong but i think that's they mean.
Also as noted, (IANAGP but i know quite a few) it doesnt matter how many new Dr's you train if they dont want to become GP's or even work in this country. Further driving down GP pay / increasing work related stress/ responsibility/ burn out will not help this.
Recruitment to rural areas is a huge issue for lots of GP practices even to reach previous staffing levels.
Remember that these are all hardworking intelligent ethical people who could have worked hard at any career and achieved a high level in that field. They mostly chose healthcare because they want to help people. If the career falls behind other similar "high" level jobs in management/ law/ finance etc from a life work balance/ quality of life point of view' those poeple will (are) choosing other careers.
rather than just a different way for the same patients to interact with the service.
Counter intuitively; the number of phone calls coming into my practice to secure an appointment does not vary if I open e-Consult longer. Many patients seem to see on line consultation requests as "in addition to" as opposed to "instead of" For some things (repeat scripts) online services can be really useful and save time, as a way of getting an appointment I'm not sure it helps.
Counter intuitively; the number of phone calls coming into my practice to secure an appointment does not vary if I open e-Consult longer.
A GP friend of mine said the same recently, except he included the word 'timewasters' a few times. 😀
I've just, a few minutes ago, had a conversation with my wife which has some relevance to this thread, so I shall report it with no judgement. 😀
This morning, my 19 yo daughter did an AskMyGP request for the urine sample results she gave last week. A short while later my wife received a call from the surgery re those results. She gave my daughter's number who then missed the call but rang back and left her number. A few minutes later my wife had another call from the surgery re urine results. She gave the correct number again and my daughter managed to get her results a few minutes later.
The surgery tends to be decent, most of the time, but they did refer me to a COPD surgery a year or so ago, which is a surprise as I don't even have asthma. (My wife has serious, properly nasty asthma!) 😀
I will bet money that your wife and daughter (and probs you) are a "family group" on the patient system and they have your wife's mobile as the listed contact phone number, hence she gets the call.
God, I'm such a nerd.
Private GP – any thoughts ?
This is exactly what those bastards in power want people to do. In time it becomes normalised and the great sell off will be complete.
There may be a very limited “free” at the point of use NHS left but it won’t be worth anything.
In the far east the private GP is much more reliable than the government provision for minor health problems. Not cheap but not expensive as well. Say per visit the bill is minimum £50(conversion rate) to no upper limit, which need to be added on top of the prescription (yes, they prescribe medication too). If people go private for serious problems they will need to sell their house to pay for the bill if they are average earner. Either that or slow torturing death. For the poor they will have no choice but to go to the government hospital and to be "experimented" on by junior doctors. No guarantee of end result but at least they get some treatment whatever.
I will bet money that your wife and daughter (and probs you) are a “family group” on the patient system and they have your wife’s mobile as the listed contact phone number, hence she gets the call.
Yes, it's obvious what's going on, but it really shouldn't happen that my adult daughter goes to the GP and we get a call about it. I'm surprised that I need to point it out, but maybe she has things which she wouldn't want her parents to know.
Equally, if I go to the GP about my STD, I wouldn't want my wife to know.
My comment at the time was that if they can't even get a phone number right then it makes you wonder at their competence for the rest of the job.
(To be clear, I haven't got an STD... 😀 )
Equally, if I go to the GP about my STD, I wouldn’t want my wife to know.
We digress but there are some fascinating ethical questions in this type of scenario. What if your GP is also looking after your wife and knows your STD could be placing her at significant medical risk? I find these sorts of things fascinating (luckily I do not have to deal with anything as tough as that in my everyday mundane job)
We digress but there are some fascinating ethical questions in this type of scenario. What if your GP is also looking after your wife and knows your STD could be placing her at significant medical risk?
Should my GP also be telling the other 30 people that I slept with in the last few weeks?
(Once again, this really hasn't happened! 😀 )
but it really shouldn’t happen that my adult daughter goes to the GP and we get a call about it.
Who's job do you think it is, to update those sorts of details?
Equally, if I go to the GP about my STD, I wouldn’t want my wife to know.
We're starting to tell patients about a new online consultation system that we're (the whole ICB) is going to use. You need a unique email address for each registration. You won't be at all surprised to hear that couples are calling to complain that because they share an email address for lots of other things, that they should be able to register two people using the same email. The idea that it's confidential information seems not to be relevant
Also it’s surprisingly common for patients to change their contact details and forget to inform people like their GP, dentist etc. Apparently the surgeries are supposed to magically know these new details……
but it really shouldn’t happen that my adult daughter goes to the GP and we get a call about it.
Who’s job do you think it is, to update those sorts of details?
Yeah, fine, but they'd been given the correct phone number that morning. Twice.
It’s almost as if the whole staff are run off their feet and stressed so mistakes get made.
“People” underestimate/ don’t realise the amount of frantic “ducks leg paddling” that’s going on underneath the waterline every day in practices…..
Yeah, fine, but they’d been given the correct phone number that morning. Twice.
By who? Number changes on the day are tricksy. If a pt. calls and says "I'm the mum of miss X can you call back with results on this other/different number than the one you have listed". That's a pretty much a red(ish) flag that will set antennas twitching. It's the same reason that lots of practices won't leave phone messages on phones that are shared on a family group. It's bad practice confidentiality-wise. Some practices will even not speak with dad about children unless they've confirmed ID with marriage/ or sight of his name of the birth cert, and will only talk to mum otherwise.
I know it's frustrating, but GPs aren't doing this stuff to deliberately wind you up, I promise.
By who? Number changes on the day are tricksy. If a pt. calls and says “I’m the mum of miss X can you call back with results on this other/different number than the one you have listed”. That’s a pretty much a red(ish) flag that will set antennas twitching. It’s the same reason that lots of practices won’t leave phone messages on phones that are shared on a family group. It’s bad practice confidentiality-wise. Some practices will even not speak with dad about children unless they’ve confirmed ID with marriage/ or sight of his name of the birth cert, and will only talk to mum otherwise.
Is this any different from security questions when you ring your insurance company/energy company/any financial organisation? They manage to cope with changing phone numbers.
mark&janet@yahoomail.com are just the WORST people!!!!
DrP