As a doctor, I say it’s time to nationalise GP surgeries

Practices refuse to take on work that benefits patients because it isn’t in their business interest. Let’s bring them into the NHS writes Dr Paul Williams, a GP and the Labour MP for Stockton South, in the Guardian

  

‘Public satisfaction with general practice remains relatively high, but not all practices work as well as they should for their patients.’ A receptionist at a GP surgery. Photograph: Anthony Devlin/PA


General practices support patients through every stage of their life. They are the heart of their communities and the gateway to our NHS. Every day, around a million GP consultations take place in English practices. We should rightly be very proud of our system of primary care.

But it isn’t perfect. As data published this week shows, patient demand for general practice services is increasing while the number of GPs is actually falling – according to the survey, one in 10 GPs are in contact with 60 or more patients a day, which is double the safe limit. At a time when people are living longer, and health problems are becoming more complex, the government has spectacularly failed to deliver its promise of an extra 5,000 GPs. Not enough medics want to be GPs, and too many doctors leave general practice too early.

Simple changes might make things better for staff working in primary care, and for patients. When the NHS was founded in 1948, hospitals were brought into public ownership and general practice was left in the private sector, where, mostly, it has remained. Most of the time your GP doesn’t get a salary. They have contracts with the NHS and local authority for a variety of services and they take home the “profit” that they make.

While some think the partnership model is more productive than being employed like hospital colleagues, it is not right for everyone. Increasingly, GPs do not want to become partners because of the levels of responsibility and financial risk involved. Evidence suggests that many GPs would be open to moving to a salaried model. At the same time, there are many other staff who work in primary care who would like more influence over the organisation they work for.

Public satisfaction with general practice remains relatively high, but not all practices work as well as they should for their patients. In many practices you can see a doctor on the same day, but in the area I represent as an MP, in March 4,437 people had to wait more than 28 days between making an appointment and having a consultation. In some parts of my constituency, poor access to a GP is the biggest issue that people contact me about.

 ‘Evidence suggests that many GPs would be open to moving to a salaried model.’ Photograph: Alamy Stock Photo

As a health service leader, I was astounded by the number of times practices wouldn’t take on work that was clearly beneficial to their patients, because it wasn’t in their business interest. I have battled with GPs who told me that they weren’t paid enough to do annual health checks for adults with learning disabilities (they get more than £100 per check), wouldn’t take student nurses on placement because the profits weren’t large enough, and wouldn’t offer appointments in early mornings or evenings because it was “optional”. That clearly isn’t right or fair to their patients.

Our health services should be designed around need. The places with the oldest people and the highest levels of deprivation should get the greatest resources. The inverse care law tells us that in the real world the opposite happens. Practices emerge where doctors want them to be, rather than where public health needs assessment tells us they should be.

Culture and leadership are always more important than organisational structure, but a new ownership model for primary care would create an environment that facilitates happy staff and healthier patients.

Employee-led mutuals should be created within the NHS with nurses, doctors, pharmacists, therapists, managers and patients all having a say in how the organisation is run. These new organisations – instilled with a progressive and innovative culture – would be much better working environments for staff, with improved career pathways for nurses and more incentives to invest in people. As they would be within the NHS, there would be no profit motive. Crucially, they wouldn’t be able to pick and choose which services to offer to their patients. Struggling practices could receive investment to bring them up to the level of the best.

This model would enable a strategic shift from reactive and hospital-based care to preventive community care – without the NHS having to pay a premium price that includes GP profit. All existing GPs should be offered salaried employment within these organisations. Those that wish to retain their existing contractual arrangements should be allowed to do so. This is likely to be particularly important in rural communities.

Groups of general practices are already coming together into primary care networks. This is a step in the right direction. Why not give them the option to go one step further, become NHS primary and community care organisations, and complete Nye Bevan’s NHS?

Is this the loneliest generation?

The Government is trying to quantify social isolation amid health fears

Brian Brady

Sunday, 13 January 2013

Government officials have been ordered to find out exactly how lonely Britain's population is, amid concerns that "the most isolated generation ever" will overwhelm the NHS.

The Department of Health is attempting to measure the extent of "social isolation" in the UK, after warnings that it has sparked spiralling levels of illnesses including heart disease, high blood pressure, dementia and depression.

Research has revealed that loneliness is a growing problem in the UK – particularly among the elderly – with one in three admitting that they sometimes feel lonely. Among older people, more than half live alone, 17 per cent are in contact with family, friends and neighbours less than once a week, and almost five million say the television is their main form of company.

However, the trend is expected to worsen in the coming years. The Office for National Statistics disclosed last year that the number of Britons living alone has risen to a record 7.6 million – one million more than in 1996 and amounting to almost one in three households.

But beyond the personal problems the "loneliness epidemic" presents, ministers have been put on alert over its wider impact – and financial costs. Loneliness is blamed for piling more pressure on to health and social care services, because it can increase the risk of complaints including heart disease and blood clots. Experts also believe it encourages people to exercise less and drink more – and ultimately go to hospital more often and move into residential care at an earlier stage.

The Government's attempts to measure social isolation among people using health and social care will increase the pressure on the NHS and councils to tackle the problem now – to slash millions from their spending on the effects of loneliness in the future.

The care and support minister, Norman Lamb, said: "For the first time, we will be aiming to define the extent of the problem by introducing a national measure for loneliness. We will be encouraging local authorities, NHS organisations and others to get better at measuring the issue in their communities. Once they have this information, they can then come up with the right solutions to address loneliness and isolation."

It is the latest in a number of attempts to gauge, and change, the national mood: Tony Blair appointed the LSE academic Lord Layard as his "happiness tsar", while David Cameron has previously tried to measure people's well-being. In each case, the driving aim was to cut health and social welfare costs by making people feel better about their lot.

An official guide on combating isolation, issued to local authorities by the organisation Campaign to End Loneliness, says: "Tackling loneliness will reduce the demand for costly health care and, by reconnecting individuals to their communities, it will give renewed access to older people's economic and social capital." The guide points out that a scheme in Essex where lonely people were "befriended" by volunteers cost £80 per person but produced annual savings of £300 per person. Another project directing older people to local services cost £480 but realised savings of £900 per person.

Anne Hayden, a Dorset GP, saved more than £80,000 in costs for six patients who were "high users of NHS services" with a befriending scheme to boost their emotional well-being. David McCullough, chief executive of the WRVS (formerly the Women's Royal Voluntary Service), said: "It's to the benefit of not only the patient, but also the NHS as a whole, that GPs spot the early warning signs of isolation and refer patients to services such as befriending or community centres."

Case study

Win Noble was a nurse who had to give up work to care for her husband after he had a stroke and heart attack.

"It's not until you're on your own that you feel miserable. My husband died in 2001. I had nursed him for 20 years.

"In 2005, my next-to-oldest daughter died and then so did my youngest daughter. I was on my own because the rest of the family don't live in the area and I'm partially disabled, so I can't really socialise. One of my other daughters is housebound, one lives in Rhyl and one in Skegness and my only son is in Sleaford. I hadn't seen my son for five years but he rings me and came down this week.
"I don't see the others. I used to read a lot of books, from the mobile library, and I do a lot of puzzles just to keep occupied.

"Age Concern contacted me and suggested a craft class. After a few weeks they started to get a group together to play games like Scrabble and have quizzes. I got really involved and really enjoyed it. I became a volunteer and people needed me again."

Rachael Bentham

Detox for the soul

Famous? Done something you regret? Not sure how to salvage your reputation? Just check into rehab, says Zoe Williams

Wednesday January 31, 2007
The Guardian

Jade Goody has gone into rehab, admitted for "depression and stress". "Jade has struggled since leaving the [Big Brother] house a week ago and learning that she has become the most hated figure in Britain," a friend told the Sun. I wish I had a friend who formed such succinct sentences. It makes you realise how much your own friends blether on. Here's the sequence of events, as I understand it: Jade calls Shilpa Shetty "Shilpa Poppadom" and "Shilpa Fuckawallah" and tells her she should spend time in "the slums"; she exits house; defends own reputation; realises she's on a sticky wicket; "collapses" with stress; is "told by GP that he was going to refer her to the Priory", but seems to have entered said institution under her own steam; is "now being monitored by doctors, while they decide what treatment to give her".This is a funny old business, isn't it? The stress-induced collapse is always so fishy. It's such an unusual response, when most people, under stress, just absent-mindedly eat ginger biscuits. In cases of rehab for addiction, where a person has got themselves into a fix from which they must, for their own wellbeing, be rescued and rehabilitated, doctors pretty much know what to do. "A heroin addict, you say? Let's monitor her while we decide whether or not to take away her heroin . . . Oh, depressive? You watch her pacing up and down, I'll just go and Google Prozac, see if that might work."
I hate to call anyone a fraud. It seems such a petty accusation, set against existing tabloid charges of "racist", "bully" and "fat". Celebrity stress is not exactly the most serious of medical conditions. It doesn't even sound that medical. You might just as well refer yourself to a creche.
I do not, however, think this is self-indulgence on Jade's part. Rehab, in this instance, is being used as a one-stop redemption shop. It's a neat mea culpa previously used by Mel Gibson, after his antisemitic outburst last August, when he asked a police officer if he was a "fucking Jew" and shouted "the Jews are responsible for all the wars in the world". Mel, of course, wasn't the first star ever to enter rehab - indeed, going into rehab on the advice of a doctor, or a judge, with handcuffs on is as old as the Hollywood hills - but Gibson illustrates neatly the more modern variant of self-referral. It is a way of atoning that you can do really very fast, and of course, it's not that much of a hardship either. You were never medically referred, so when you get there, doctors don't know what to do with you except watch you. And a lot of these people are actors. They are used to being watched. Mel said, after his curious explosion, "I am not a bigot; hatred of any kind goes against my faith." But naturally, this was not sufficient - words have never been quite vast enough to convey atonement, which is why in the olden days they used to make up Songs of Atonement.
It seems to be particularly in misdemeanours of bigotry that only residential self-flagellation will do - to complete the prejudice triptych, along with Jade's racism and Mel's antisemitism, Isaiah Washington, star of Grey's Anatomy, rehabbed himself for his anti-gay remarks (he called one of his fellow actors a "faggot".) He said, "I regard this as a necessary step toward understanding why I did what I did and making sure it never happens again."
The only thing that comes close to (actually, thinking about it, probably surpasses) bigotry for hot social shame is sexual harassment, for which Mark Foley institutionalised himself last year. The Republican congressman, who sent sexually inappropriate emails and messages to teenage boys, explained: "I strongly believe that I am an alcoholic and have accepted the need for immediate treatment for alcoholism and other behavioural problems." It's rather American, isn't it, blaming alcohol for the fact that he couldn't stop badgering his staff for sex? In England, one might be tempted to respond, "Matey, we all like a drink, but I certainly don't employ 16-year-olds and then spend the day sexy-mailing them, even when I've had an absolute skinful."
So where did this come from, this self- disciplining (in the most literal sense)? I've seen the seeds of it in children; a friend of mine's kid will do a running commentary on his own naughtiness, finishing off with suggestions for an appropriate punishment, so that when he has really pushed it, and upset everyone, and ruined everybody's day, he'll shout, "Now I've been really bad! Oh, lock me in the car!" I don't, however, think Mel Gibson got the idea from my friend's naughty kid; on the contrary, it comes from the judicial system, in which - far more frequently in America, it must be said - stars are exempted from custodial sentencing by agreeing to a spell in Betty Ford.
There's a distinctly different tang to that kind of offence, though: Winona Ryder did rehab instead of prison for her shoplifting. She would never have had to redeem herself with us, her public, for such an offence, since a) nobody really minds a shoplifter - it feels like a nice, of-the-people crime, and b) she had already redeemed herself with her lovely Marc Jacobs court outfits.
Andy Dick (you know Andy Dick! You will find him in the not-very-famous-but-makes-lists-of-famous-people-with-addiction-problems-look-longer section of the library), Charlie Sheen, Nicole Richie . . . oh, there are tons of them. They were mainly addicted to painkillers. What this really rams home to me is how much better American painkillers are than ours.
The question remains: how much of an atonement is it when you admit yourself and you're not even really addicted to anything? What happens when you get to the Priory? Do they still go through your luggage and make you go to the group therapy, or are you allowed to just sit about looking glum? Doesn't that drive the proper addicts crazy? Is it like AA - do you still have to go round all your family and friends when you get out, apologising for the time you arrived at their wedding/ bar mitzvah [not that] drunk, [really not at all] whacked out on drugs, [no more] unreliable and flaky [than the next man]? And if it is rehab lite, must one go residential? Couldn't Jade have said sorry with a detox? Couldn't she just have given up wheat, then put out a press release? "I may be guilty of racism, but I've eschewed doughnuts in penitence and, by the by, beaten my bloat!" ·

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