Monthly Archives: June 2014

Response to Jeremy Hunt’s plans to name and shame GPs

On 29 June 2014, The Daily Mail and The Daily Telegraph reported that Jeremy Hunt plans to name and shame GPs who inadvertently miss cancer diagnoses. This would be a grave mistake and represent a very large risk to the NHS.

Our response (below) was printed and reported on the front page of The Daily Telegraph on Monday 7 July 2014.

Sir


If there is a perception of delay in cancer diagnosis, real or otherwise, it is devastating for the patient and their family but also soul-destroying for their GP.


Sinister causes (including cancer) could explain just about any symptom in the average general practice consultation. The risk of not finding that needle in the haystack is the reason why GPs must pay thousands of pounds every year for liability insurance.


The NHS performs better than any healthcare system in the western world, at a fraction of the cost of other countries [1] because British GPs hold the dual responsibility of caring for the patient in front of them and keeping the NHS alive within its monetary constraints by avoiding unnecessary investigations and referrals as well. This is balanced by avoiding delays which might adversely affect their patients’ health.


If a doctor is negligent, including causing a delay in diagnosis, there are due processes that determine whether any wrong has been done; via the General Medical Council or courts. Naming and shaming GPs who miss cancer diagnoses is a bullying tactic which lacks evidence of effectiveness and fails to acknowledge the risks outlined above. GPs will pre-empt this by referring so many patients for tests that those who do have cancer will lose out and the NHS will be bankrupted.


This attack on British general practice is not based on fact.  The article underpinning the headlines [2] reports that only 10% of cancer patients needed more than 5 appointments before being referred for a cancer diagnosis; a published response points out that no fewer than two thirds are diagnosed at the first GP consultation.


GPs need  to be supported, not bullied; they are doing an excellent job – stop attacking them.


1. http://www.bbc.co.uk/news/10375877
2. http://www.bmj.com/content/344/bmj.e3017/rr/583036


Yours Faithfully



Resilient General Practice www.ResilientGP.org

Dr Samir Dawlatly, Jiggins Lane Medical Centre, Birmingham
Zahida Adam Sheila Adams Dr Bunmi Adeniji, Salaried GP, Shipley,. Dr Kemi Adeyemi, Salaried GP, Oldham. Dr Samrina Ahmed, GP, The Village Surgery, Blackley. Dr Tabassum Ahmed, GP, Freezywater Primary Care Centre, Enfield. Dr Freeha Ahmed, GP, The Firs, Walthamstow. Dr Nasreen Ahmed, GP, Bellingham Green Surgery, Lewisham. Dr Jessie Ahmed, GP, Cardiff. Tasmia Ahmed Nadeem Akhtar Iram Akhtar Tamara Al-Jabary Clare Aldous Stuart Alexander Dr Shimaila Ali, GP, Dr Bamford and Partners, Chorley. Mohamed Ali Rachel Ali Majid Ali Dr Kayyam Altaf, GP, Australia. UK-trained GP and ex-cancer sufferer who was referred appropriately at first consultation Laura Ambrose Dr Sobana Anandarajah, GP, Mersham Medical Centre, Croydon. Caroline Andrews Clive Anggiansah Kulsum Ansari Dr Seraj Anwer, GP, Lincoln House Surgery, Hemel Hempstead. Dr Yogasakaran Arjuna, GP, The Woodberry Practice, Winchmore Hill. Dr Ram Arora, GP, Turning Point, Wiltshire. Suzanne Arron Nitika Arya Chrissie Ashdown, Salaried GP, Ashdown Forest Health Centre Dr Mufaza Asrar, GP, Locum GP, Nottingham/Derby. Rashel Asslanian Hala Atkin, Gp principal, Skyblue medical centre, coventry Dr Karen Atkinson, GP, Lister GP Walk-in Centre, Peckham. Faisal Awan Ricky Badiani Joanne Bailey Dr Funmi Bajomo, Salaried GP, Rushey Green Group Practice, Catford, London. Dr Alexandra Baker, GP, Swanscombe Health Centre. Emma Baker Lucy Baker Dr Amy Banks, GP, Statham Grove Surgery, London. Angela Bannister Liam Barker Deb Barkway Zoe Barnard Fionnuala Barton Dr Deboshree Basu-Choudhuri, GP Principal, Nuffield House Surgery, Essex. shona batchelor Liz Bates Chris Bates Dr Amrit Baura, GP, THE SURGERY, Brighton. Jeanette Baverstock Marcus Baw Dr Dana Beale, Salaried GP, Meadowell Surgery, Watford. Dr Catherine Beanland, GP Partner, Portcullis Surgery, Shropshire. Neil Beatson Gill Beckett Dr Freda Bhatti, GP, Great Bentley Surgery, Colchester. Dr Afsana Bhuiya, GP, Dr Kateb and partners, North London. Ella Bihari Andrew Blease, Deal, The Cedars Surgery Lisa Blocq Lindsey Bluett, GP registrar Dr Kerry Boardman, Academic GP, KUMEC, King’s College London, London. janani bodhinayake Ellen Boliek, United States Dr Adam Booth, Locum GP, Locum GP, Shropshire. James Booth Emily Botcher Dr Simon Braybrook, BLuetown Medical Centre, Cardiff. Siobhan Brennan Lisa Broad Angharad Brodie Dr Russell Brown, GP, Manor Park Surgery, Polegate. Ben Brown Iain Brown Dr Hannah Bryant, GP, Lyminge Surgery, Lyminge. Chloe Burges Dr Sitwat Butt, GP, ???, Harrow. Sohail Butt Dr Prit Buttar, GP, Abingdon Surgery, Abingdon. Tom Caldwell Daniel Campion, GP and OH physician, InterHealth Junaid Campwala Denise Cannadine Dr Catherine Cargill, Blackwater Medical Centre, Maldon. David Cargill Catherine Cargill Dr Daniel Carlton-Conway, GP, The Maltings Surgery, St Albans. Dr Kate Carr, Locum GP, Green Cedars Medical Centre, North London. Zara Casey Gillian Cassels Tom Cayton Rajesh Chadda Sireesha Challagalla Dr Shavi Chana, GP, The Fairfield Centre,London, London. Chris Chaplin Dr Caitlin Chasser, GP, West Street Surgery, Chipping Norton, Oxon. Earim Chaudry Emma Cheesman Shabin Chohan Dr En Min Choi, Salaried GP, Crown street surgery, West London. Moushumi Choudhury Naylea Choudry Shazeia Choudry Shazeia Choudry Mary Church Dr Natalia Ciapryna, Locum GP. Lesley Clark Stephanie Clark Anna Clayton Dr Sarah Cleverly, Salaried GP, Elizabeth Avenue Group Pracxtice, Islington. Christine Cliff Joanna Connolly Karen Cooper Maria Corretge Dr John Cosgrove, GP, Midlands Medical Partnership, Birmingham. Anna Crawford Graham Crippin Keith Cross Sarah Cubitt Josh Cullimore Alaine Cunningham Helen Cunningham Dr Laura Czech, GP, Regal Chambers Surgery, Hitchin. Dr Alessandra Dale, GP Principal, Stanley Corner Medical Centre, Wembley. Jojo Daly Dr Ranjan Dass, GP, The Alma Road Surgery, Romsey. Poulami Datta Yvonne Davey Dr Joanne Davies, GP Partner, Leach Heath Medical Centre, Birmingham. Iestyn Davies Amanda Davies Shoura Davies Debra Davis Dr Stephanie De Giorgio, The Cedars Surgery, Deal. Ellen Dean, Salaried GP, Park Lodge Medical Centre, London Dr Thirza Deboo, GP, Marlbourough Surgery, Marlborough. Sim Dehal Della Delahunty Edward Dennison Robert Depo Dr Pete Deveson, GP, Derby Medical Centre, Epsom. Avani Devkaran mhairi dewar Dr Jaz Dhillon, Freelance GP, North London. Marie Diesel-Dyer Kevin Dillon Dr Anisha Divani, GP, Oakleigh Road Clinic, London. Ross Dolan Marie Donnelly Dr Parag Doshi, Locum GP, Church End Medical Centre, North London. Kerry Douce Michelle Drage Dr Anna Draper, Salaried GP, Barnard MEdical Group, Sidcup. Sue Draper Sue Draper Dr Amrit Dugala, GP, Royal Arsenal Medical Centre, London. Steve Duke Dr Susie Earle, GP Registrar, Princess Group Practice, London. Ronnie Eaton Louise Elliott Mina Endeley, GP Ahmer Farooqi Dr Emon Farrah Malik, GP Registrar, GP Registrar, Surrey. Dr Francesca Farrell, GP, Queens Walk Surgery, Ealing. Kevin Farrington Nadim Fazlani Emma fellows Tracy Foley Mark folman Katie Foot Dr Sarah Forbes, GP, Oakwood Lane Medical Practice, Leeds. Michael Forrest Dr Caroline Forwood, Freelance GP, Freelance GP, East London. Georgina Forwood Tom Forwood, Australia Dr Jeff Foster, GP Partner, Croft Medical Centre, Leamington. Dr Elizabeth Foster, Lead GP, Hollinwood Medical Practice, Oldham. Jeff Foster Susan Foster Rosie Freedman David Freedman Alex Freeman Sophie French Lynn Frost Síona Gaffney Barbara Gaffney Dr Sophie Galloway, GP, Steyning Health Centre, Steyning. Dr Hussain Gandhi, GP, Wellspring Surgery, Nottingham. Kate Gaskell Dr Kamini Gautam, GP, KS Medical Centre, Southall. Chris Geden Diane Gerrard Hafsa Ghaffar, United States Smara Ghafoor Stephanie Giorgio, GP Principal, Cedars Surgery, Deal Amy Glossop Dr Jeremy Goad, GP, Victoria Practice, Aldershot. Jessica Gomersall Leona Gooch-Hatton, Germany Dr William Gordon-Wright, GP, Oxford Community Health Centre, New Zealand. Lisa Gorringe Dr Shikha Gosain, GP Partner, The Tudor House Med Ctre, Brent. Jonny Graham Dr Pauline . Grant, Salaried GP, St Clements Practice, Winchester. Anna Gregorowski Claire Griffiths Paula Griffiths Steve Grimshaw Wendy Grimshaw Jill Groome Carol Gubler Leah Gunatilleke Dr Srikanth Gunda, GP, Brerton Medical Practice, Rugeley. Dr Ruchika Gupta, GP, Spring Street Surgery, Epsom. Nirupam Gupta Dr Koustubh Gupte, GP, The Redhouse Surgery, Radlett. Tesan Hadzikadunic Shazia Hafeez Sarah Haines Harilal Halai Lakhsman Halai, Uganda Simon Hall Holly Halstead Elizabeth Hamblin Sian Hammond Manzur Haque Handy Harichandran Emma Harkin Stephanie Harris Robyn Harris Nigel Hart Trudi Harvey Jo Harvey Dr Zara Hasafa, GP, Studholme Medical Centre, Ashford. Sharon Heap Sherif Helmy Graham Henderson Kim Henry Dr Maria Henson, Locum GP, Locum GP, Cheltenham. Djahla Hewazy Dr James Higgin, GP, Downlands Medical Centre, Polegate. Jessica Hill Nat Hilliar Dr Emma Hilton, Salaried GP, Parkside Practice, Eastleigh. D Hipps Tom Hodson Dr Kathryn Hogg, GP, Market Lavimngton Surgery, Market Lavington. Dr Tim Hogg, GP Partner, Batheaston Medical Centre, Bath. Dr Melissa Holder, GP, Cotswold Medical Practice, Gloucestershire. Caroline Hollington Debbie Hopkins-Davies Sarah Horrocks Richard Hoskin Sharif Hossain Emma Howard Samantha Howard-Els, South Africa John Howe, GP Registrar, Presteigne Medical Centre Sue Howell Syeda Huma Kate Humphries Lisa Hunt Phil Hyde Victoria Ingham Helen Ingoe Grant Ingrams Tasneem Irshad Dr Esma Izzidien, Salaried GP, Churchill Medical Centre. Dr Lionel Jacobson, Senior Lecturer in general practice, Cardiff University. Rebecca Jacques Dr Farah Jameel, Locum GP, Locum GP, Surrey, Sussex, London. Farah Janmohamed Rebecca Jardine Lesley Jeffers Matt Jenkins Llania Jenkinson Paul Jennings Abbas Jeraj, Salaried GP, The Clapton Surgery Dr Hajane Jeyabalasingam, GP, The Orchard Practice, Kent. Dr Sukhdip Jhaj, GP, Silsden Group Practice, West Yorkshire. Fatima Jivraj Mell Johns Julie Johnson Natalie Johnston Nicola Jollie Dr Dave Jones, GP, GP Superclinic, Midland, Perth, Australia. Charlotte Jones Cemile Jones, Dr. Maden, Salaried GP Matt Jones, NHS user Evelyn Jones Vikki Jones Pamela Jordan-Byrne Poonam Jugessur Daniel Kalinowski Dr Raj Kanwar, Salaried GP, Kineton surgery, Warwickshire. Vishal Kapil Zanubia Karim Dr Krishna Kasaraneni, GP Partner, Crown Street Surgery, Rotherham. Kirsten Kassyk Mathew Kattukaran Farah Kausar Dawn Kavanagh Karen Keating Sheila Keats Annabelle Kerr Dr Latha Kestur, GP, Rowan Tree Surgery, Kent. Sara Khan, GP Principal, Abbotswood Medical Centre Meena Khan Sameer Khurjekar Farah Kidy, Salaried GP, Aylestone, Leicester Dr Bastiaan Kole, Freelance GP, Freelance GP, Fulham. Adam Konstanciak Magdalena Kostka Reena Kotecha Amisha Kothari Dr Vijay Kudari, GP, Vanbrugh Group Practice, London. Dr Jay Kuruvatti, GP, Wallace House Surgery, Hertford. Kapil Lad Reem Lammoza Brian Langshaw Rhian Last Samiah Lateef Dr Alison Lawton, Salaried GP, Park View Medical Centre, Long Eaton. Rachel Lawton Emily Layton Pamini Ledchumykanthan, Salaried GP, The Bush Doctors Audrey Lee Lauren Leishman Lynn Leishman tim leitch Dr Rob Lenart, GP, Malting Green Surgery, Colchester. Evon Leung Dr Jonathan Levy, GP, Lisbon Grove Medical Centre, London. Christian Leyland Jenny Li Craig Lintern Dr Emily Lister, GP, Spring Grove Medical Practice. Dr Kenny Livingstone, GP, Walm Lane Surgery, Willesden Green. Robert Llewelyn Dr Martyn Lobley, Senior Partner, Thamesmead Medical Associates, London. Dr Natalia Lomatschinsky, Locum GP, West Bridgford Medical Centre, Nottingham. Sophia Lomatschinsky Maria Lomatschinsky Claire Lonie David Lovell Runa Lynch Dr Mina MacDonald, Salaried GP, Spring Grove Medical Centre, Hounslow. Gillian Macgregor Alanna MacRae Tessa Madden Dr Cemile Maden, Salaried GP, Kings Langley and Bovingdon Surgeries, Kings Langley. Dr Raj Mahadevaiah, GP, Wingham and Aylesham Surgery, Kent. Dr Sahira Mahmood, Locum GP, Millway Medical Practice, London. Carla Mahmoud Dr Saman Malik, GP, Hanley Primary Care Centre, London. Emon Malik, GP Registrar, The Exchange Surgery Lizzie Mander Dr Novin Manshani, GP Principal, Lime Grove Surgery, St Helens. Dr Ruth Marchant, GP, Manorbrook Surgery, Blackheath. Peter Martin James Martin Elvis Martinez Debbie Matthews Dr Robert Mawdsley, Locum GP, Locum GP, Perth. Dr Laura Mawson, GP, Oakview Family Practice, London. Rebecca Mawson Kay Mayes Derek McAuley Beth McCarron-Nash Mary McCloskey Isabell McDowell Brian McGinty Anna McGloin Moyra Mcglynn Shaun Mcglynn Dr Kate McGuinness, GP, Stockwell Group Practice. Dr Rachel McMahon, GP, Coulby Medical Practice, Middlesbrough. Gurpinder Mehat Comaroni Melania, Romania Ruth Millican Elizabeth Mills Steph Mills, Australia Nitesh Mistry Donna Mizzi Dr Kartik Modha, GP, Friern Barnet Medical Centre, Barnet. Dr Jeenita Mohanty, GP Partner, Avenue Medical Centre, Manchester. Claire Monie Randheer Moochikkal Charlie Moody Dr Kim Morgan, GP, Tudor surgery, Nantwich. Ann Morgan Rachael Morris Gemma Morris Toni Morris-Eouzan Sally Morrison-Griffiths Ben Moule Queenie Muck Dr Madhavi Munasinghe, GP, Belmont Health Centre, Harrow. Karen Munn Sarah Murphy Mavuto Mwanache Gaile Myerscough Dr Nisha Nair, GP, Lyme Valley Practice, Stoke-on-Trent. Dr Murali Nair, GP, Carlow. Dr Gita Nair, GP, Victoria Practice, Aldershot. Arul Nambi Subha Nambi Dr Sampath Narasimhamurthy, Salaried GP, Rocester. Aditya Narkar Asim Nawaz Angie Newsome Sarah Nnadi Sarah Nnadi Mohammed Nuruzzaman Jordan Nye Dr Victoria O’Brien, GP, Farnborough. Moira O’Donnell Denise O’hara Aoife O’Riordan Itohan Odiase Dr Esther Okumo, Locum GP, Locum GP. Dr Karensa Oliveira, GP, Kent. Jessica Oliver Sola Olumoyegun Dr Ayo Onasanya, GP, Oak Tree Medical Centre, Ilford. Faith Owen, France Kara Paisley Dr.Shiv Pande Indra Panditaratne Dr Hemali Parekh, GP, St James Medical Practice, Walthamstow. James Park Dr Amisha Patel, GP, Cogges Surgery, Witney. Kajal Patel Manish Patel Ronak Patel, GP Partner, Brighton Alpa Patel, Salaried GP, Stonecot Surgery Dr Arup Paul, GP, Globe Town Surgery, London. Nav Paul Gill Peet Dr Gayan Perera, GP, Barton Hills Medical Group, Luton. Kosala Perera Christopher Peterson Kim Pettett Ashley Philip Xanthe Phillips Helen Phillips Jolyn Phillips Sue Pickford Pravina Pindoria Mel Piper Colin Pitt Barney Powell Katie Power Sam Powles Luke Powles Anupama Prasad Dr Veronica Priestley, GP, Grove Medical Centre, Egham. Jay Pryal Kerry Purdie Sheetal Purohit Laura Pye Samrina Qureshi, Salaried GP, Hillingdon Nadia Rahman Jeanette Ramejkis Abhijit Ray, GP Associate, Studholme Medical Centre Julie Reid Julie Reid Zeshan Riaz Dr Anand Rischie, GP, Pleck Health Centre, Walsall. Dr Priya Rischie, GP, Mirfield Surgery, Birmingham. Dr Nadiya Rizvi, Sessional GP, Sessional GP, East London. Dr Kath Robertson, GP, Colinton Surgery, Edinburgh. Dr Anna Romito, Salaried GP, London. Dr Trefor Roscoe, Retired GP, Retired GP. Sarah Roscoe Jennifer Rossiter Melanie Rowell Ravish Roy Leon Rozewicz Kishor Ruparelia Dr Stewart Rutherfurd, GP, Morrab Surgery, Penzance. Christiane Rutkowski Dr Gemma Rutter, Locum GP, Lakeside Medical Practice, London. Kaz Rytter Dr Afsana Safa, GP, Marleybone Health Centre. Dr Anil Sagar, GP, London Road Surgery, Reading. Kate Sager Rahul Sahay Suneel Saini Anneela Saleem Gemma Samanta Hardip Samra, Salaried GP, Bexley Medical Group Aisha Sarwar Geejo Sasikumar Naazya Sayed Rachel Scott Ruth Sealy Ramesh Seewooruthun Dr Vivek Sekhawat, GP, Torrington park group practice, Finchley. Dr Hema Selvamani, Locum GP, Birmingham. Edwina Sencer Ghias Shafi Dr Shameer Shah, GP, Enderley Road Medical Centre, Harrow Weald. Rebecca Sharma Shereen Sherazi Dr Saijit Shetty, GP, White Horse Surgery and Walk in centre, Northfleet. Andy Shum Ellen Sibly Anu Sikkaiyan Dr Nitika Silki, GP, Lynwood Medical Centre, Romford. Dr Michael Simmons, GP, Schopwick Surgery, Elstree. Emma Simmons Adam Simmons Dr Michelle Sinclair, GP, Richmond Surgery, Fleet. Dr Toyah Singh, GP, Cardiff Bay Surgery, Cardiff. Tarandeep Singh Dr Ajanthi Sivakumaran, Salaried GP, Aspri Medical Centre, Harrow. Durga Sivasathiaseelan Dr Amy Small, GP, Prestonpans Group Practice, East Lothian. Dr Caroline Smith, GP, GP Superclinic, Midland, Perth, Australia. Dr Alison Smith, GP, Ashby Health Centre, Ashby. Dr Michael Smith, GP Registrar, Queen Elizabeth Hospital, London. Chris Smith Dr Larisa Smondulak, GP Registrar, Forty Willow Surgery, London. Dinis Sousa Dr Ashley Southall, GP, Larksfield Surgery, Stotfold. Karen Spark Jason Spencer Jonathan Springett Faye Stanage Gillian Stanton Julie Stanton Dr Siobhan Stapleton, GP, Greenford. Dr Jenny Steel, GP, Blacketts Medical Practice, Darlington. Claire Stubbings-Tilley Bhuwan Subedi Dr Nadia Suleman, GP, Stanley Corner Medical Centre, London. Dr Howard Sunderland, Marple medical practice, Stockport. Dr Mamta Suresh, GP, Woodsetton Medical Centre, Dudley. Alison Sutcliffe Amanda Sutton Dr Selina Swann, GP, Orchard House Surgery, Lydd. Nick Tait Dr Rajvinder Takhar, Locum GP, Slough. Dr Juhi Tandon, GP Associate, Hampstead. Nikhil Tanna Afsheen Tanveer Soffee Tariq Angeli Tavares, London Dr Shamina Tayub, GP, Evington Medical Centre, Leicester. Alistair Teece Dr Dax Tennant, GP, Downlands Medical Centre, Polegate. Muryum Thapper Dr Alixe Thiagarash, Locum GP, Locum GP, North London. Dr Claire Thomas, GP Registrar, Mersey. Caroline Thomas Linda Thompson Andrew Thomson Laura Thomson Dawn Thwaites Dr Amit Tiwari, GP, Colchester. Neil Tiwari Karen Tredoux Lins Trussell Beverley Turnbull Dr Paul Turner, GP Partner, Karis Medical Centre. Dr Sandhya Tyagi, GP, Dedworth Medical Centre, Windsor. Suthan Ulakanathan Katie Usher Andrew Vanezis Matt Varrier Dr Geri Vaughan, GP, Quayside Medical Practice, Newhaven. 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General Practice in Australia – how does it compare with England?

General Practice in England and Australia – a comparison

Dr Mark McCartney
Introduction

General Practice in England is coming under increasing strain and comparisons have been made with how the service is run in Australia. This paper makes an informed analysis of the service in each country with suggestions for politicians, leaders, negotiators and health commissioners to learn from, with the aim of enhancing the respective service for patients and doctors
Method

The author is a General Practitioner who currently works South East Cornwall and in 2013-2014 spent 12 months working as a GP in South East Queensland. He has over 20 years of experience as a partner in NHS practice, including time as a medical manager of an Out of Hours Service, experience of GP commissioning in England and as a political representative on the GP Committee of the British Medical Association.
Comparative Data has been obtained from various sources in the English NHS and from the Australian Department of Health. This has been used in the context of personal experience of working in both systems to share strengths and weaknesses of equivalent organisations.
Background

The English NHS is founded on some basic principles – that it meets the needs of everyone, that it be free at the point of delivery and that it be based on clinical need, not the ability to pay. These principles were expanded within the NHS constitution in 2009. There is a cultural difference in Australia, where patients are generally accustomed to paying for some part of their health costs, either directly or through insurance schemes. Australia promotes similar principles to the English NHS (http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/principles-lp) but recognises the consumer element of payment. Australian culture also promotes personal and business independence – General Practices are recognised as small businesses that need to be well organised and profitable to survive and flourish.
The clinical role of the General Practitioner in the two countries is broadly similar, with responsibility for delivering primary care to individual patients and their families. However the roles have evolved in different ways due to cultural and political differences. The English GP practice will have a defined population “list” of patients (for which there is a considerable “capitation” payment), but in Australia patients are free to seek the opinion of any GP – payment for the service is broadly for consultations and workload. The systems of payment for GPs will be further explored, as it forms the key difference between the two countries.
Funding for General Practice

ENGLAND

English General Practice funding is directly from NHS England. There are two main types of contract, General Medical Services (GMS) and Personal Medical Services (PMS). The latter is a locally negotiated type of block services contract to deliver defined services to the registered practice population and forms about 40% of national contracts. More detailed analysis of PMS contracts is available at http://www.gpinfo.co.uk
NHSE is currently reviewing PMS contracts which may be phased out in favour of GMS.
GMS is funded through seven main streams –
1. Global sum & MPIG (Minimum Practice Income Guarantee)
2. Quality (QOF, Quality Outcomes Framework)
3. Enhanced Services
4. Seniority payments
5. Premises
6. Information Technology
7. Dispensing payments (applicable to dispensing GP practices) 
GMS core funding is through the Global Sum, based on the number of registered patients (capitation) and adjusted for other workload factors (eg age profile, deprivation, temporary resident numbers). MPIG (Minimum Practice Income Guarantee) was introduced in 2004 to enhance payments for practices that would have lost out significantly due to contract changes at that time: it is being phased out between 2014 and 2020.
Quality payments form a significant part of practice income (13% of total practice income in one study in Bristol www.gpinfo.co.uk) and cover various target areas including administrative and clinical achievement. Enhanced services relate to specific additional clinical services that central policy may wish practices to offer eg flu immunisation. Seniority payments are made direct to the individual doctor, based on years of service, but these too are being phased out. Premises payments are rent reimbursements towards premises costs or borrowings. There are currently no significant capital grant payments for practices to enhance their premises, although this was a significant route for investment in General Practice in the past.
NHS England provides practices with IT hardware and software through the GP Systems of Choice agreement, although practices are responsible for some of their costs, including consumables, business systems and specified enhancements to their systems.
Rural practices with dispensing rights receive additional funding to cover the costs of supplying and dispensing patient medication.

AUSTRALIA

90% of government funding for General Practice in Australia is through the Medicare Benefit Schedule (http://www.mbsonline.gov.au/). This is a payment system for providing specific clinical services in both primary and secondary care, ranging from brief GP consultations to neurosurgical services. GPs are at liberty to charge the patient more for their service, but the patient can recover the gap from Medicare (“out of pocket” expense for the patient). Sometimes the practice will choose not charge the patient, but claim the Medicare payment directly – this is known as “bulk billing”. However the Australian government has recently introduced changes to Medicare that may require a patient co-payment for GP consultations, radiology and pathology referrals and some hospital Emergency Department attendances.
The remainder of government funding in Australia is through the Practice Incentives Program (http://www.medicareaustralia.gov.au/provider/incentives/pip/) which is aimed at supporting general practice activities that encourage continuing improvements, quality care, enhance capacity, and improve access and health outcomes for patients. Administered by the Australian Government Department of Human Services (Human Services) on behalf of the Department of Health, PIP is part of a blended payment approach for general practice. The following areas are targeted under the PIP – Quality Prescribing, Diabetes, Cervical screening, Asthma, Indigenous health, eHealth, After Hours, Teaching, Rural loading, Procedural GP (eg  intrapartum obstetrics) and Aged Care access.
Comparing funding arrangements

GP practices in England thus have a relatively fixed income – there is some scope for taking on new NHS work by increasing the number of registered patients or providing additional services under a DES, but the additional income is relatively small compared to the core and quality funding streams. There is a little opportunity for private medical work; this is usually limited to private medical examinations and other peripheral services. GPs are limited in their ability to charge patients. GP practices are also responsible for meeting (or dealing with) the demands of their registered patients, who are unwell or think they are unwell. There is also a risk to the quality of patient care when demand is high. Since no funding is attached to individual consultations, there is no stimulus to increase the number of appointments. With increasing demand, pressure on appointments increases. At the same time practices will be attempting to maintain profits by controlling access.
Australian GP practices can increase their income by seeing more patients and providing more services which attract a fee or Medicare rebate. Working harder and longer will generate more income, although there may additional expenses. If there are no appointments available GPs are at liberty to turn patients away, although this may not necessarily be good business sense, or for good patient care. However patients are at liberty to visit other practices that have available appointments and are not restricted to using a practice that they may usually attend. The system ensures that GPs remain motivated and are paid for the services that they provide. It improves access for patients who feel that urgent attention is required, at the risk of reduced continuity of care and duplication of effort and investigation. Payments for individual services may encourage practices to provide more services, which may lead to supplier induced demand, or gaming, to improve practice profits.

General practice from the patient’s perspective

In England, at present, a patient may only register with one practice. For those with chronic conditions needing regular appointments they will be able to develop a relationship with one GP to maintain continuity, but there is a sense that requests for appointments on the day are more likely to be with a duty doctor or other clinician in the practice who has spare capacity. Similar issues occur in Australia, particularly with many doctors now choosing to reduce their working hours from entirely full time. The key differences in Australia are the payment for the consultation and the fact that the patient can choose to attend another practice on any particular day, subject to availability. The patient is not “registered” with the practice.
These differences perhaps improve the experience of booking an appointment better for the patient in Australia. Payment for services, including consultations, motivates the GP to improve access and availability for regular patients. The continuity improves the experience for both patient and GP; there is increased efficiency with less duplication of effort, probably fewer investigations, prescriptions and possibly fewer clinical errors. The practice may be able to offer the patient chronic disease services which are beneficial to all.
Individual GPs in Australia that are popular with patients may become overbooked with appointments, thus reducing access and availability. Neighbouring GPs may be able to manage the extra workload, but there is loss of continuity and medical records become fragmented. From the GP perspective the ability to limit the amount of work in a day is attractive, but there is balance to be struck.
Back in England GPs are faced with increasing demands for appointments, but they and patients have nowhere else to go. GPs are contracted to deal with all their registered patients. As demand and workload increases then practices are faced with managing GP access by restricting appointment availability, limiting consultations to one issue, triaging calls or undertaking more telephone consultations. Overspill can be taken up only by the patient attending minor injury units, emergency departments or walk in centres. In these situations patients may be faced with long delays in a waiting room or seeing a clinician with training or experience different to that of a GP. There is limited availability to private General Practice in England, which struggles to compete against the NHS GP service which is free to the patient.
The General Practitioner’s perspective

There are lots of things about General Practice in Australia that make it a much better experience than working as a GP in England.
1.       Patient expectations – these are high, but this is not a problem working in a well organised and funded system.  GPs are expected to “fix” things first time, which is not always possible, but makes the job challenging and interesting. There has been no media campaign criticising doctors, which has allowed a positive working environment to thrive.
2.       Doctor patient relationship – payment for consulting does alter the relationship, particularly when the patient agenda is not met. This does require some skill – for example antibiotic prescribing. However there is a benefit in that an overt financial value is placed on the consultation and other services rendered
3.       Workload – the GP is in control of his workload – appointments can be booked at whatever interval is required. Some doctors are able to consult at a faster rate and may be able to earn more for that, but GPs can choose to book patients at 10, 15 or even 20 minute intervals to allow them to work at a rate they are comfortable with
4.       Access to radiology – with Medicare rebates available to patients for most investigations, the GP can arrange ultrasound, CT and MRI at often no cost to the patient. The investigation and results can be made available at almost alarming speed. However this is great for dealing with symptomatology suggestive of cancer or other conditions which might require urgent intervention. When referrals are required the GP can arrange a full work up prior to specialist review. There is no urgent referral system for investigation of cancer as most of the tests can be undertaken in primary care.
5.       Access to pathology – my experience of pathology collection and reporting was that the service in Australia was much quicker
6.       Financial arrangements – GP pay in Australia is similar to England (http://www.hscic.gov.uk/searchcatalogue?productid=13317&q=doctors+earnings&sort=Relevance&size=10&page=1#top) , although the cost of living is higher. Medical indemnity costs are less, mainly because they are subsidised by the government. GPs can earn more by working harder and for longer hours, but the positive motivating factor is that GPs can bill for specific services and procedures as well as payments for care plans etc as part of chronic disease management payments. Most GPs working for practices in Australia are not paid a salary but a percentage of their billings.
7.       Relationship with secondary care – private specialists have good access for advice and referrals with a positive relationship with GPs. Communication between primary and secondary care is on the whole much better. There are also better relationships between GPs and junior doctors – hospital admissions are arranged on the traditional doctor to doctor basis
8.       Professional development – there is a feeling of greater flexibility and scope for professional development in Australia if the GP so wishes. There is less bureaucracy associated with licensing.
9.       There is no QOF. In fact monitoring of referrals and prescribing is of very light touch compared to England. Consultations are not dominated by the computer screen in the room.
10.   The Australian climate and lifestyle is great if you love the outdoors.
There are however some downsides to the ways of working for GPs in Australia

1.       Private General Practice – patients who pay for consultations are more likely to expect or demand a specific investigation or treatment. Establishing and agreeing what is appropriate for these patients can sometimes be a challenge. Patients may be seeing several practitioners for treatment and there is no certainty about what investigations have been undertake or medication prescribed.
2.       Easy access to investigations can lead to patients expecting a test for every condition. There is a possibility of over investigation, with follow up tests exposing patients to unnecessary risk or harm.
3.       Medical record keeping (including clinical coding) and information sharing is of poorer quality in Australia. There is no unified patient record – this can lead to duplication of effort and expenditure, including potentially invasive tests. Attempts to create a unified record, the PCEHR, appear to be faltering.
4.       Potential lack of follow up – patients who do not respond to treatment may visit another facility, so the GP will not get feedback on the success or otherwise of any treatment plan. The lack of continuity can be frustrating for all, particularly when patients come back to the original GP with an unresolved issue.
5.       Lack of a health safety net  for some patients – uninsured patients may be referred to the public hospital system where waiting lists can be very long or some treatments just not available
6.       Safeguarding for children and vulnerable adults is more difficult to deal with when there is no named responsible GP
7.       Progress to greater use of secure electronic referrals is being made in Australia, but fax machines still seem to be the most important piece of equipment in a GP surgery. This may be because specialists and secondary care are less likely to be set up to receive or transmit information in any other way.
8.       For patients to get some prescriptions on the Pharmaceutical Benefit Scheme (eg opiates, certain branded products) requires the GP to telephone a central line to get authority to issue (http://www.pbs.gov.au/pbs/home). This is a tedious distraction in a consultation, although it does provide some control on the prescribing of these medications.
9.       There is no system of payment for services provided by practice nurses (these type of payments were scrapped by a previous government in an attempt to save money). The GP literally has to oversee all their work to enable the billing process.
10.   Continuing medical education is still dominated by pharmaceutical companies and other private health providers.
What can NHS England learn from the Australian perspective?

General Practice in Australia and the UK are experiencing similar population health and demographic challenges. There are also reported shortages of GPs in both countries. Here are some suggestions for NHS England based on personal experience of working in both countries.
1.       Australian General Practice is respected as a business entity that thrives on the support and encouragement of a sustainable business model, which includes relatively stable income streams and payments based on services provided, which are on the whole clinically proven and evidence based. NHS England should reduce the perpetual change model of the annual contracting process and resist the urge to move core payments into politically motivated schemes such as extended hours and admission avoidance. NHS England also needs to seriously consider an investment programme for GP premises, which are in generally in poor condition to those in Australia. The current system of GP payments does not encourage practices to invest in their own premises, particularly when property costs are so high.
2.       Access to GPs in Australia is improved by Medicare payments for individual patient consultations and NHS England could consider introducing this element into GP pay, rather than stoking up demand and making small flat payments to practices simply for “opening their doors”.
3.       Availability and access to radiology and ultrasound investigation for GPs could be improved to the level of service in Australia. It is felt that this would have a dramatic effect on reducing demand for secondary care appointments in England.
4.       NHS GPs could be allowed to offer private services to their patients in England. This would allow practices to improve access to core NHS services and increase the resources available. However, as in Australia, there should be a defined level of service available to all patients, irrespective of their ability to pay.
5.       Barriers to communication between primary and secondary care in England include the Choose and Book service and a poor level of consultant secretarial support. Improving communication would have benefits for patient care and possibly reduce hospital admissions.
6.       Appraisal and revalidation in England has become onerous and is generally disliked by GPs. It is expensive and there is no evidence that it is more effective than the Australian system of a three yearly programme of CPD credits.
7.       There is a target led culture of management in England, exemplified by the QOF GP payment system. The system of practice incentive payments in Australia is more light touch and less intrusive in doctor patient consultations. NHS England should consider reducing the value of target payments, something that may enhance access to GPs and the patient experience
What can Australia learn from England’s NHS?

The major advantages seen in England are population based GP lists and the continuity provided by the unified GP record. However these may not be culturally acceptable in Australia, where citizens utilise their right to attend any GP that is available and willing to see them. However the Australian government could take some action to improve the current situation.
1.       Medicare rebates for patients attending the same GP practice could be increased to a higher level to encourage continuity of care. Follow up and continuity for families, particularly those with possible safeguarding concerns could be enhanced by creating a special Medicare payment to encourage patients to continue to attend the same practice. Recently proposed changes to Medicare, including the copayment for consultations and investigations, may have some unforeseen consequences on patient care. Patient consulting patterns may change in ways to undermine any perceived financial benefits of the copayment plan.
2.       The Australian GP clinical records could be improved by linking payments to clinical coding at the time of clinical consultations, with additional financial incentives for updating clinical summaries and sharing information with other GP practices. The Australian equivalent of the English Summary Care Record is the PCEHR (http://www.nehta.gov.au/our-work/pcehr), and has been dogged by similar problems. It is not the answer to improving the clinical records. Australia could look at what has happened with clinical records in England and learn from all the mistakes that have been made. Privacy and information sharing legislation in Australia could be reviewed and a higher status given for information governance in practices.
3.       The current system of monitoring GP prescribing in Australia appears haphazard and not effective. There is a high level of branded prescribing and Pharmaceutical companies continue to have a strong influence on GP prescribing habits. Drug budgets for practices are not feasible given that there is not a defined patient list. However the Authority system for prescribing could be further streamlined and the savings invested in a more rigorous data collection, monitoring and feedback scheme. The National Prescribing Service (http://www.nps.org.au/) could have a role in this, but significant investment would be required
4.       While access to radiology services for GPs appears to be excellent, there is a high cost for this service and easy access combined with high patient expectation for scans may be leading to unnecessary and potentially harmful tests. Quality could be possibly improved with additional training or other methods such as screening of requests for certain tests as part of the Medicare rebate process.
5.       Australia could improve the system of payment for services delivered by practice nurses. This would free up time for practices to focus on patient issues which require GP intervention.
6.       In Australia there is an evolving system of communication between primary and secondary care, which is diverse and led by local pioneers. However the use of practice fax machines to circumvent privacy and confidentiality issues should be discouraged, with support given to secure electronic messaging.
Summary

The GP contracting and delivery in England and Australia is explained and compared. The experience of working in two different models of General Practice has been described and used to illustrate the advantages and disadvantages of each model. The author has made some suggestions for possible enhancements that could be made by leaders, commissioners and politicians.
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The journey of a thousand miles begins with a single step

Three score and six years ago, our fathers brought forth in this country a new health service, conceived in liberty, and dedicated to the proposition that all people deserve free health care and freedom from want.

OK, excuse my crude theft from Abraham Lincoln’s Gettysburg Address, but the concept was a novel one unrecognised anywhere else in the world in a developed nation at the time. We were post-war, exhausted financially, and surviving on loans from the USA. Forgive what might seem hyperbole to some, but I feel the creation of a health service that would free a nation from illness was a milestone in history to challenge the Magna Carta in terms of historical significance.

Today, however, nearly seventy years on, the NHS, in one of the wealthiest nations on earth, is collapsing from spiralling demand. Its foot soldiers in the front line, GPs, are being decimated in a battle of attrition that seemingly government, the press and the public are colluding in that will result in the destruction of a once proud profession.

Is there any hope for us, or is the battle already lost? We believe there is. It is time for General Practice to stand up, fight back, and say “Enough is enough“. It is time to tell the government and the press to get off our backs, robustly and firmly.

We need to train new GPs to be patient-centred, but to have the freedom to know when to say “No” to act in their patients’ best interests, but equally in their own. General Practice in the UK is being consumerised, packaged and prepared for sell off, and too many of those who purport to represent us have vested interests in that outcome.

It appears our Royal College is not preparing new GPs for the workload intensity they are facing on qualification, and as a result many lack the resilience and burn out within a short space of commencing their careers. This is a sad outcome for some of our best and brightest medical graduates. So what are we going to do about it?

We are a small but committed group of GPs with a wide range of experience who know how to survive in this harsh clinical climate, how to say “Yes” and “No” with assertiveness to patients and to the powers that demand too much of us, know when to act to protect our patients, and just as importantly, know when to act to protect ourselves.

We are not a replacement union for the BMA. Nor are we a fledgling college to rival the RCGP. However, we aim to influence both and change their mindset, the better to protect our profession. We will offer our experience to train new GPs in resilient practice, offer a support network to help answer those tough challenges we all face, whether new GP or old hand. We will influence and challenge robustly the people who are supposed to represent our interests but too often get lost to the “dark side” to serve only theirs, once power is acquired.

Can we achieve it? We believe we can. Too many will write us off initially as being a small and insignificant pressure group, as “Remedy” was initially perceived by some when it formed in response to the junior doctor training fiasco. It will take a while, but as the Chinese philosopher Laozi said, “The journey of a thousand miles begins with a single step”. We are taking that first step today.

Our influence and support base will grow, as we draw in new colleagues trained in “resilient primary care.” Change will happen if we make it happen.

Don’t believe us? Have you already lost hope that we can make things better? Then think about what Margaret Mead, the anthropologist wrote: “Never underestimate the power of a few committed people to change the world. Indeed, it is the only thing that ever has.

Alan Woodall, GP
Powys, June 2014.