Monthly Archives: July 2014

It’s make your mind up time: what do you want GPs to do?

Originally published at http://www.drcosgrove.net/2014/07/GProle.html on 20 July 2014.

Workload in general practice has become unmanageable. GPs work long into the evening and at weekends making referrals, writing reports, checking letters and test results, issuing prescriptions and managing their practice. General practice has been working beyond capacity for years. This was tolerable to a degree when pay was reasonable. However, the demand from society for GPs to do ever more work for ever less pay (and even less understanding) has brought the profession almost to its knees. Furthermore, there has been no investment in premises for a decade, so that many GPs are now working in wholly inadequate accommodation.

It should come as no surprise, therefore, that the existing shortage of GPs is due to become extreme. Many already close to retirement age are deciding to retire early. Others are emigrating, for example to the Middle East and Australia. Saddest of all, practices are closing altogether as they become unviable.

Clearly, significant investment in general practice is urgently needed simply to keep the service going. However, if the service is to be fit for the medical needs of the 21st century – such as improved access and longer consultations – society must choose what it wants GPs to provide.

Most of a GP’s work can be divided into four groups.

1. Management of those who need, or who believe themselves to need, medical treatment

This is central to general practice. GPs are contracted for “management of [those] who are, or believe themselves to be, ill … [where] ‘management’ includes … such treatment … as is necessary and appropriate” (Standard General Medical Services Contract para 8.1.2-3).

What we must treat and how has changed immeasurably since the inception of the NHS. The range of conditions we can treat and the complexity of the treatments delivered within primary care now is extraordinary. Tragically, resources have not kept pace.

On the other hand, our healthier population is, happily, less likely to succumb to bacterial infections and their complications. The tools of evidence-based medicine (including the ability to compare the value of different treatments using cost per QALYs (quality-adjusted life years) have helped to expose many treatments as either unnecessary or inappropriate.

Paid to care for a population of patients, it has been in the interests of responsible GPs to reassure their patients about which symptoms and conditions do not require medical treatment. Unfortunately, GPs have now been completely robbed of this ability. The ability of stories of health misfortune and non evidence-based miracle treatments to sell newspapers by the million has been irresistible to journalists. They care nothing for the ill health in the form of anxiety that they provoke, and there is no shortage of special interest groups to ensure that such stories reach the press.

Consequently, appropriate reassurance and the traditional low cost (low financial cost to NHS and low risk of harm to the patient from medical tests and treatments) wait and see stock-in-trade of general practice is becoming increasingly less acceptable.

2. Treatments of limited value

The cost per QALY mentioned above provides a helpful tool here. Particularly if GP time is factored in, the cost per QALY for providing treatments for self-limiting conditions (such as the vast majority of acute respiratory infections [Cosgrove, 2014], gastroenteritis, viral skin infections and even muscular injuries) would be exorbitant. Not only that, but the urgency to see a doctor before the condition resolves puts the system under immense pressure. Where drug treatments have a role, they should be equally readily available to all patients. Perverse incentives to consult GPs such as free prescriptions for medication available over the counter should be very carefully examined.

Cosmetic treatments – from minor surgery, to treating fungal nail infections and arguably even acne vulgaris – are also associated with high cost per QALYs. Most CCGs prohibit hospitals from even seeing patients seeking cosmetic treatment but GPs do not have that luxury. Indeed, although we are discouraged from treating such conditions, it can be next to impossible not to whilst maintaining an effective doctor-patient relationship.

As it is so very difficult for GPs to just say no, and increasingly so in this age of inflationary demand, society must choose between allowing the NHS to pick up this enormous bill and finding new ways to fund it. Given that GPs no longer have any influence on demand, they should be paid according to a tariff for the work they undertake like just about any other service provider. To what degree patients pick up this tab and how is a matter for government.

3. Non-medical interventions

No-one understands better than GPs that social factors (affluence, living and working conditions, exercise, diet, relationships, religious group, hobbies, weather) influence health infinitely more than medical interventions (Marmot, 2009). Indeed, as +Bastiaan Kole explained in his piece “GP or social worker? (2014)”, such an understanding is vital and comes to GPs as second nature. However, influencing social factors is, in all honesty, beyond the gift of GPs. Not only that, but a GP has neither the training nor the perspective to judge the needs of their patient relative to those of another in social need.

Patients have become accustomed to consulting their GP when distressed in relation to difficulties at home or at work. Of course, for a minority, prompt medical treatment for mental illness will be the very best option. For many others, however, one has to ask whether assigning them a medical diagnostic label and offering them a shoulder to cry on in 10 minute instalments is really the best way to meet their needs.

As a society, we have immense questions to answer to understand why our most vulnerable see no alternative but to turn to doctors in such circumstances.

4. Managing risk factors

Another massive change has been the drive to identify, manage and treat medically not disease itself but risk factors for disease, such as raised blood pressure, cholesterol and cardiovascular risk, low bone density, obesity, pre-diabetes and smoking to name but a few. No-one can deny the benefits of reducing such risks. However, the lifestyle advice given to those with these risk factors is no different to the advice applicable to anyone else.

For all of the risk factors listed above, there is now drug treatment available. Some may see this as a breakthrough in medical science. Some may worry that this absolves individuals of responsibility to live healthily. Others may suggest that architects, town planners and government have a far greater potential for impact by influencing living conditions.

What is not in doubt for a growing number of these conditions is that drug treatment, as analysed by cost per QALY, is cost-effective. Indeed, the National Institute for Health and Care Excellence (NICE) has just decided that an additional 4 million people should take cholesterol-lowering medication (2014). As +RCGP headquarters have pointed out, significant additional investment in general practice would be required (Baker, 2014) to deliver this objective.

Such a recommendation obliges large numbers of people with no physical illness to consult their GP regularly as if they already had a chronic disease. The only illness these people have is the fear of illness manufactured by drug companies, special interest groups, journalists, health economists and politicians who fail to make available to general practice the resources needed to undertake this massive extra work.

Project Management Triangle

Conclusion

There is little doubt that GPs have the skills and position within their communities to fulfil a variety of different functions. As costs rise, society must consider how it wants to use and pay for such a scarce resource. Remember the three parameters of the Project Management Triangle (en.wikipedia.org/w/index.php?title=Project_management_triangle&oldid=613535125, 2014) or Weale’s Inconsistent Triad of Healthcare (1998): if the price of healthcare is to be controlled, society must choose between speed/access/convenience and scope/quality; we cannot have all three!

Refusing to make choices will result in the ill (group 1 above) having to compete for resources – the so-called Patient Paradox (McCartney, 2012). For the options presented above, serious consideration should be given to whether 9 years of medical training is really needed in every case, or whether individuals and communities could reasonably be expected to shoulder more risk and responsibility.

Time to give up the daily marathon?

I wanted to become a doctor from a very young age and pursued that dream and qualified in 1978.
I worked in the NHS as a junior doctor back in the days of over 100 hour weeks and gained so much experience but was constantly exhausted from going to work 9.00 am Friday and getting home again late Monday evening with disturbed periods sleep for short times during these long shifts and paid 1/3 rd normal time rates for most of it. It was deemed par for course then and I coped but I was many years younger of course so had more more energy and resilience.
I emigrated to South Africa in 1981 having married a South African and worked as GP over there util I returned to the UK in 1997. As I had been out of the NHS for so long, I had to retrain to be GP in the UK and spent 3 years in a vocational training scheme – hard work in my forties. Most colleagues were half my age! Such was my committment to GP, I battled on and got my certificate of completion in GP in 2000.
Since then, I have been working either as salaried GP, locum, or, since 2009, my current job as Partner in practice in North Wales. I have seen many changes, some good, some not so good and some downright ridiculous. I have always got on with job I love best, ie caring for my patients and offering best care I can. Such a privileged role and, despite all, always trying my very best to provide the level of care my patients deserve.
However, with all this continued denigration of our profession and lack of manpower and investment into Primary Care, expecting us to do more and more with fewer and fewer resources, I have had to think to myself- why am I doing this now at ripe old age 61?
We are portrayed as greedy, lazy, overpaid people who care nothing for our patients just as much profit we can make for doing as little as possible. We are blamed for all NHS failures from increased A&E attendances to not diagnosing cancer timeously and now Hunt wants to name and shame us for that. We face uncertainty during every consultation and make clinical decisions every 10 minutes over 50 times a day yet nobody seems to acknowledge the pressures we work under nor the stress involved in that decision making process. Our referrals to secondary care are scrutinised by clerks and we are chastised if we make too many, yet if we miss something then we are castigated even more.
I really love the art of medicine and being a GP but retirement now beckons, as I’m not sure how much longer I can continue with the present demands placed upon the service and myself and maintain my own sanity. The sad fact is that I can’t always provide care that my patients deserve through no fault of my own but because the system is in disarray.
My retirement will just add to problems recruitment and retention, severe where I work in North Wales, so I stay for my patients and no other reason. All very sad as NHS may well lose another well qualified and experienced GP, giving up due to an inability to the provide service I would like to.
It saddens me to read all the negative press we are continually subjected to and the ignorance of those in charge who really have no concept of what our job entails and how the expectation to ‘go the extra mile’ for every patient has become a daily marathon, and one I may have to step down from.

Letter to Jeremy Hunt regarding his “name and shame” policy

Dear Mr Hunt,

The Mail on Sunday and Sunday Telegraph reported on 29th June 2014 that you had indicated that GPs who inadvertently fail to refer a person with cancer early enough would be “named and shamed” on the internet by the Department of Health.

You may have been aware that as a result of this there was a robust response from GPs and, to a lesser extent, the general public. In the space of 48 hours over 650 signatures were collected in support of a letter to the relevant newspapers. We include an excerpt from the letter below.

Despite the reports of the newspapers, which one could attribute to exuberant spin, you have recently been quoted as saying:

I don’t believe in naming and shaming GPs, I believe in using data to identify outliers … I believe if GPs are outliers on cancer diagnosis they would want to know this information.

We would make 2 comments on this:

  1. We believe GPs deserve to have a written press release explaining exactly what you mean about the identification of outliers, including the evidence for effectiveness, the mechanism, the organisation, the cost and the implications. This should be negotiated properly with the GPC prior to any further announcements.
  2. We are concerned that identifying outliers will invariably lead to “naming and shaming”. If you are determined to collect this details of outliers, we would want reassurances to prevent identifying information being published or leaked to the media.

At the RCGP conference in Harrogate, October 2013, you asked GPs to judge you on your actions and not your words. Putting aside the rise in workload, drop in income in real terms, drastic fall in junior doctors applying for GP training and introduction of schemes without evidence of effectiveness, we would like to point out that your words have already had devastating consequences and have been twisted and amplified by certain sections of the press.

GPs need to be supported, not bullied; they are doing an excellent job – politicians and some journalists need to stop attacking them. We look forward to clarity in this matter.

Yours sincerely,
Resilient General Practice

Samir Dawlatly
John Cosgrove
Siobhan Stapleton
Rachel Blackman
Lesley Long
Freda Bhatti
Michelle Sinclair
Toby Helliwell
Milan Mehta
Juhi Saltzstein
Michael Simmons
Afsheen Tanveer
Melvin Xavier
Andy Shum
Amy small
Rhianna McClymont
Manzur Haque
Gregory Tyson
Hussain Gandhi
Anjana Mahadevan
Emily Leadbeater
Nadia Sohail
Mairéad McMahon
Yasasthrie Athapattu
Aditya Narkar
Katie Bramall-Stainer
Olayemi Kekere-Ekun Olubajo
Sam D’Lattlee
Lorna Macgregor
Sophie Galloway
Mamta Suresh
Surangi Mendis
Upeka Ranasinghe
Deborah Webb
Rachael Morris
Kailash Chand Malhotra
Val Hudson
Sue Wallis
Suneel Saini
Natalia Lomatschinsky
Matt Varrier
Jeff Foster
Gemma Greenacre
Helen Walker
Kosala  Perera
Mohammed Salim
Charlie Moody
Alan Woodall
Louise Whereat
Arjuna Singanayagam
Danielle Rahman
O Adedayo
Ngawang Sherpa
Joy Godding
Alistair Jones
Iram Rizvi
Desiree Dr Bergmann
Nicola Ashley
Shalini Urs
Liza Osagie
Alexis Park ✯
William Gordon-Wright
Thirza Deboo
Kulsum Ansari
Naomi Taylor
VIj Kud
Sarah Akram
Evon Leung
Marwa Hilmi
Seimone Potter
Chris Reid
David McLees
Koustubh Gupte
Hemali Parekh
Charley-Vic Walshe
Zafar Ullah
Helen Phillips
Ruchika Gupta
Magdalena Kostka
Carmel Malone
Beth McCarron-Nash
Ruth Moloney
Sarah Worboys
Peter Martin
Ellen Sibly
Cemile Jones
Ruth Marchant
Kathryn Hogg
Indrani Mitra
Pamela Jordan-Byrne
Ellen Dean
Simon Dent
Sarah  Beer
Richard Woollett
Amina Shamtally
Sophie Moss
Vipul Parbat
Fran Ferner
Haroon Butt
shashidhar khandavalli
W EY
Munawar Nabil Choudhuri
Aisha Bhaiyat
Amisha Patel
Kirsten Kassyk
Girish Malde
Becky Moylan
Gillian  Kyei
Mike Cumby
Sarit Ghosh
Stephen O’Hanlon
Siobhan Brennan
Karen Poynton
Priya Jay
Joe Hawkins
Angela Foster-Raynor
Annabel Fountain
Ashley Southall
Atif Hasan
Mark folman
Ankur Khandelwal
Karl Samson
Alison Lawton
Alexandrina Braithwaite
Sophia Lomatschinsky
Hasan Mallick
Latha Kestur
Lynn Frost
Clare Tanner
Rachel Lawton
Hugh Robinson
Alexandra Oliver
Arun Thiyagarajan
Shivani Rai
Chris Earnshaw
Dave Jones
Aysha Butt
Nitika Arya
amy banks
Sim Dehal
Grahame Morris
Cat Chatfield
Lesley Hedli
Declan Nugent
Kate Adkin
Hannah Bowles
Alexandra Baker
Collette Ifill-Kennedy
Saijit Shetty
Maria Jones
Ambu Shrivastava
Sandhya Tyagi
Fahad Zulfiqar
Kirsten Riemer
Pamini Ledchumykanthan
Kim Morgan
Tara Breslin
Joanna Baker
Yvonne Cleland
Seraj Anwer
Fatima S Latif
Susie Power
Laura Pollington
Andy Whiles
Suzy Franklin
Amit Varma
Shirin Khan
Mili Gupta
Wendy Hakeem-Habeeb
Louisa Dove
Ben Brown
Seaneen McGouran
Udeka Senaratne-Niland
Sarah Perry
Mel Piper
Kirsty Challen
Aislinn Macklin-Doherty
Vicky Marchant
Faisal Awan
John Eric Shillabeer
Helen Eckley
Tiz Tizzard
Linda Perry
Dawn Baker
Shamaila Masood-husain
Rosie Freedman
Rosie Jones
Indy Chakraborti
Kavita Kumari
Simon Monty Gomery
Mat Owen
Clare Holmes
janani bodhinayake
Maria Papaioannou-Moran
Hilary Marmot
Bushra Chaudhry
Toyin Sanwoolu
Kevin Treweeks
Clare Fisher
Yousaf Iqbal
Mark McCartney
Kate McGuinness
Lucy Weeks
Helena Young
Sophie Carpinteiro
Grant Quinn
Karen Ogg
Emma McKinney
Sarah Hazell
Daniel Mackay
Robert Thornton
Georgi Georgiev
Zoe Olliver
Pete Bodenham
Julie Christine Packer
Sue Ainsworth
Ali Ben-Mussa
Eleanor Ranson
Marie Diesel-Dyer
Eóġan Robert
Zaid Al-Najjar
Danny Garrett
Danielle Smith
Elizabeth Spary
Jenna Bardsley
Mateusz Pucek
Karen Ainscough
Sarah Porter
Lesley Anne Gregory-Clark
Lucy Smith
Jessica Pope
Shama Shaid
Claire Brocklehurst
Usman Ahmed
Russell Donald
Dave Robinson
Abs Munshi
Robert Jack
Hamad Ashraf
Elizabeth Donnelly
Natalie Settle
Lisa Stilwell
Pete Hedges
Mark Adams
Sharon Bell
Gerard Hart
Lynette Saunders
Lesley Jane Ginever
Jaime Hyde-Wyatt
Katy Lindfield-Butler
Chris Geden
Mike Gough
Deb Das
Shahram Shirazi
Keith Reeves
Chris Doyle
Natalie Miller
Mollie Rowley
Natasha Westbury
Megan Leigh Robertson
Andy Macrow
Paul Wood
Michael Forrest
Lizzy Sharpe
Ruth Harris
Phil K Taylor
Rachel Hamblin
Sophie Archard
Daniella Fairhead
Rajiv Kalia
Chris Atwill
Nicola Crowther
Asma Khalid
Sophie Hollands
Sarah Wiley Wiles
Jack Burnham
Rachel Ali
Jo Szram-Bliss
Hannah Bufton
Sharon  White
Craig Ballantyne
Emma Douglas
Sara Colclough
Jennifer Singh
Helen Blacow
Andie Siggers
Sukhdip Jhaj
Meghana Pai
Gillian Williams
Ria Clarke
Stuart Setterfield
Robert James George
Jo Williams
Emily Van De Pol
Jamie Asher
Steve Fitchett
Ian Singer
Heidi Bennett
Alixe Thiagarasah
Nadim Azar
Tom Cummin
Jyoti Lalwani Rawat
Zoe Watson
Ann Williams
Catherine Louise Ward
Janet Renn
Mark Orrell
Lucy Gaden
Jessie Ahmed
Kirsty Ormond
Sandyra Feeney
Claudio Sancese
Yen Khor
Laura McCarron
Luke Baldock
Emma Simmons
Alex Stimson
Susan Lennon
Andrew Wright
Gemma Atkins
Mark Brewer
Graham Crippin
Kay Go
Charlotte Openshaw
Amanda Church
J G
Shaun Millson
Salina Ahmad
Claire Kelly
Julia Ward
Bipin Champaneri
Hannah Thould
Hilda Nasho
Jackie Street
Nidhi Lakhi
David Scrafton
Elliott Ralph
Therese Burgess
Craig Evans
Matt O’Brien
Lisa Williams
Jacky Stenner
Neilbob McBob
May Hagerty
Hannah Lloyd-King
Tammy Towers
bornali roy
Ansar Hayat
Kelly Jackson
Lorraine Ricketts
Rebecca Bird
Sally Edey
Clare Bates
Neil Bailie
Sian Phillips
Laura Beardwood
Scott Dougherty
Matthew Sephton
Stu Amison
Joanne Cuthbertson
Carys Greenway
Vivienne Birch
Marie Anna Docherty
raj kanwar
Vanessa Louise Ingram Jafrato
Durrat Bharmal
Lindsey Beldon
Oscar Croysdale
Jemma Rennocks
Ryan Kerstein
Emma Claire Heap
Matthew Prendergast
Tony Matheson
Louise Turner
Marcus Heap
Matt Malone-lee
Mark Mellor
Abhishek Chauhan
Ana Rita Borges
Helen Parry
Sarah Johnston
Jayne Birkett
Frances Osis
Anthony W Grayson
Rhys MORGAN
Sue Clark
Sarah Bowers
James Rowlupo
Melanie Yorke
Peter May
Alison Clark
Sarah Thomas
Aamir Khawaja
Nick Woznitza
Jim McCaul
Ben Burrows
Claire McGonagle
Keera Rowland
Karen Pears
Sue Grant
Sarah Fischer
Muhammad Khalid Razzaq
Lorraine A Brooks
Roz King
Helen Cole
Alec Jones
Sanjeev Dhall
Ken Atkinson
Alistair Calder
Susie Gawler
Ranjit Sagoo
Anton Raymond Borg
Fiona Dogan
Richard James Claydon
Sarah Cambridge
Karen Swanscott
Simon Wright
Lucy Taylor
Karen Gallant
Geeta Tyagi
Robert Davidson
Kapil  Lad
Arvind Kamath
Ted Curtis
Natalie Johnson
Jim Weems
Barry Naylor
Victoria McMaster
Chaminda Dooldeniya
Natalie Hutchins
Suzanne Hurst
Karen Reissmann
Sarah Morris
Sarah Lowes
Joe Jones
Billy Nichols
Kirrili Taylor
Rob Mawdsley
Rosemary Smith
Danielle Grindley
Pim Dhahan
Rose Wilton
Hammad Mustafa
Claire Gordon
Angela Musso
Dastan Ali
Mariana Abdelsaid
Sumit Virmani
Alex Hamilton
David Logan
Al Watson
Adam Winstanley
Kaz Walker
Debbie Suen
Karen North
Ben Banerjee
Clara Lee
Sue Pickford
James Read
Jacqui Abington
Tim Wright
James Mackenzie
Diana Forero
Lesley Cox
Heather Macdiarmid
Evin Winters
Alistair Burns
Robert Parkin
sobana anandarajah
Simrit Welkhu
Alan Johnson
Mary Catherine Spence
Caroline Garside
Emily Sherley
Kat Banks
Jadzia Weedon
Clare Cooper
Jane Campbell
Carolyn Black
Indra Panditaratne
Erika Oby
Mark Thornton
Ivan Beavis
Iain Jamieson
Reggy Smith
Martyn Chambers
Tim Webster
Sheonad Macfarlane
Steve McKenna
Ayisha Khan-Kheil
Neil Moody-Jones
Louise Hopkins
Vic Sivanesan
Tracy Foley
Clare Cassell
Susan Taheri
Meilyr Gwynfryn Dixey
Jim Green
Kathryn Le Grice
Natalie Williams
Ros Miller
Kiran A Qureshi
Eileen Fox
Ardnas Nedyah
Jane Ward
Aimee Sullivan
Mina Goyal
Amy Caskey
Natalie Morris
Claire Corlett
Katie Palmer
Anna Marie Malone
Janice Hodgson
Becci Bookie Smith
Gwilym Sion
Deano Brassington
Alex Hart
Pauline Tickle
Thomas Hardy
Leigh Martin
James Burns
Richard Horsley
Sonia Chester
Naila  Aslam
Vonalina Cake
Kiran Kunwar
Joyce Braaksma
Elaine Elding
Rebecca Rogers
Rebecca Poole
Sam Fowler
Alka Mishra
Matthew Farrand
Victor Fakeye
Jane Pang
Durga Sivasathiaseelan
Roddy Neilson
Rebekah Grayson-Richardson
Janine Flatters
Sampath Kumari Narasimhamurthy
Lisa White
Merwen Dartash
Joe Burt
Laura Paterson McCombie
James Sutton
Lauren Harris
Matthew Whitehouse
Mili Shah
Sean Sproule
Stuart Collett
Lyndel Taylor
Susan Gorman
Neal Stote
Ajmal Hussain
Alvin Chan
Jenny Atkinson
Maggie Naskalski
Elise Tamsett
Earim Chaudry
Freyja Page
Adrian Antony Abbott
Shilpa Chegu
Devan Patel
Asha Pillai
Doug Wright
Marcus Cope
Simon Roberts
Laura Castle
Claire Lowe
Barbara Anne Thomson
Lucinda Wakefield
Eleanor Cairns
Joanne Owen
Pamela Ann Mckirdy
Jon Moorcroft
Chris Lam
Andy Finucane
Kathryn Cowen
Garry Gazzajanimal Pursell
Vio Salmon
Maggie Hazlehurst
Andrew Roberts
John Murphy
Paulo Wrightio
Domine McConnell
Natalie Flood
Janette Keeling
Catherine Beanland
Minh Lam
Andrea Shenton
Fleur England
Barbara Icke
Phani Sirigiri
Gillian Breese
Christian Allen
Debby Ferguson
Carmen Ricketts
Holly Ysabelle Wilson
Penny Corrin
David Manns
Ed Ccr
Dan Noble
Karen Blair
Ian Kerslake
Annabel Olojede
Louise Townsend
Maya Clemence
Judith Sandiford
Susan Scott
Rachel Harrison
David A Millar
Sally Wood
Paul Nash
Rhys Jon
Salma Akhter
Neera Jaitly
Deborah Iwenofu
Chloe Orton
David Jaberoo
Sudesh Nagvekar
Kanchan Imrapur
Rachel Kearns
Mark Boothroyd
Tom Hughes
Clare Reynolds
Ray Harney
Naila Rabbani
Lisa McCartney
Benish Shoaib
Janet Green
Brenda Maureen Taylor
Simone A Smith
Jon Upton
William Fordyce
Catriona Toplis
Selina Gill
Julia Somerhalder
Oliver Galgut
Amira Lemsatef
Jack Blake
Hazel Macrow
Adam Abraham
Caroline Forwood
Kaishy Tariq
Ashley Kumar
Andrew Taylor
Emma Carrington
Nicole Gough
Kal Cave
a tiwari
Janet Jones
Sue Park
Thomas Jones
Cecilia Parsons
Dave McCartney
Vivek Vivek
Debbie George
Laura Dudbridge
Ben Passmore-Webb
Daniel Pheasey
Mark Ashton
Rhonda Crawford
Geoff Morrison
Catherine Cooper
Silpa Kalidindi
John Meikle
Brian Towell
Marina Casagrande Rohr
Janette Nash
Khizer Mehmood
Neil Ball
Liam White
Suzanne Pickup
Nina Wood-Ford
Declan Harte
Mark Torres
Thomas Back
Jeremy Goad
Tom Nichols
Pauline Blake
Jayne Lemon
Caroline Rose
John Caswell
Sue Bagley
Sahra Kay
Beth Brown
Satveer Singh Poonian
Christopher McGonigall
Karen Wilton
Tony Ng Woo
Waqas Malik
Pam Mcgrath
Marie Mccartney
Sagar S Kulkarni
Rosemary Jones
Chidozie Adiele
Linda Stapleton
Mary Clare Bancewicz
Roy Williams
Hayley Magill
Matt Ira Chapman
Tony Mulcahy
Elaine Hamilton
Princess Mada
Nicola Anderson
Tim Wheeldon
swarna narla
Melody Sleggs
Aidan Hammel
Rose Shaw
Chloe Tunnicliffe
Isobel Mccrossan
Anne Connaughton
Arpana Patel
Poulami Datta
Jack Boyle
Chris Uto Marston
Andrew James Boyack
Rohhss Chapman
Vicki Rae
Ravi Canhye
Hannah Morris
Jim Halliday
Jan Jones
Anne Proudlock
Margaret Gallant
Claire Neilands
Tony Gu
Warwick Bell
Clare Ashcroft
Brownbear Adam Hussain
Shiyam Nizar
Roushan Ara
Nicola Brown
Andy Kermode
Sophie Rock
Chris Villiers
Chris Villiers
Afsaneh Ramez
Liz Waite
David Hunt
Paul Reed
Louisa Johnston
Julie Worth
Bethea Jenner
Elaine Franks
Paul Groves
Susan Wallace
Junaid Campwala
Pete Cavanagh
Claire Hill-Smith
Julia Reissmann
Adam Wrigley
Cara AlKhayaliOLeary
Jenny Liddell
Isha Lowe
Jemma Ross
Claire Feenan
Graham Neill
Sahana Sridhar
Rajiv Mansingh
Emma Hilton
Novin Manshani
James Murphy
Aamir Iqbal
Ananda Krishnappa
Nalini Balakumaran
Ritu Agarwal
Cathy Black
Catherine Ellis
Sudha Dhall
Krishan Bhanot
Jessica Price
Thomas Round
Lorraine Barrett
Ramamoorthy Raguram
Adnan Ali
Dr Sagar
Anjali B Chandra
Ed Farrell
Paul Murphy
Sabeen ghause
Sakthikumar  Vedasalam
Mark Nankervis
Helen Howells
Jeenita  Mohanty
Aisha Truchet
Brian Semmens
Jeremy Newman
Constance Kerali
Anna Giddings
Teresa Tang
Marilyn Monkhouse
Shabina Petkar
Catherine Papadopoulos
Joe Rahman
Rebecca Jardine
Caroline Moss
Sarah Gawler
Tabassum Ahmed
Rebecca Gidley
Zenobia Sheikh
Rashmi Mane
Fatima Agha
Kathy  Tedcastle
Nadia Dullaghan
Dawn Brittain
Helen Hanson
Diane  Biondini
Helen Lewarne
Angela McGinness
Paul Searle
Tina Straker
Faisal Chowdhury
Chris Threapleton
Gareth Powell
Arma Yaqoob
Mehul Lakhani
Elaine Edwards
Pipir Khan
Nicola Sedgwick
Anna Crawford
Michaela Janks
Giriraj Varshney
Jane Nolan
Andy Teo
Lou Cullen
Graham Hartland
Dave Allen
Sharif Hossain
Jash Mutucumarana
Balvinder Singh Chahil
Darren Jamieson
Samantha Jade Collings
Vicky Jones
Shirin Lakhani
Adam Konstanciak
Vidya Kanthi
El Morris
Rae Moore
Farah  Jameel
Jayne Kennedy
Chris Sampson
Helen Parsons
Maria Vanezis
Jan Weetch
Frosini Alexandra Konstanciak
Geoff Brown
Jane Houlden
Peter Vanezis
Sheila France
Ruth Freedman
Azubuike Chile
Samrin AaHMED
Emma Gayton
Peter Dawson
Christopher De Rycke
Anna Down
Aparna Sanyal
Rebecca Ullah