PUT UP OR SHUT UP………..

So, apparently we need to stop moaning and whingeing about General Practice, or we won’t attract the new recruits; that’s the latest arrow winging from Westminster.

No recognition of the fact that we are all struggling at the moment, just that we need to shut up about it.

No mention that to move forward with mute acceptance and obsequience would be like bringing the next round of GP lambs to the slaughterhouse, completely unequipped and unaware of the trials to come.

Okay, so rather than let our emotions get the better of us, let us look at this problem in the form of an employee appraisal (though of course we aren’t employees and perhaps therein lies the problem for the government).

Occupation: GP

Duties & Responsibilities:

• To be the main point of healthcare contact for the whole population within the UK
• To manage both scheduled and unscheduled care both within and outside normal working hours
• To keep updated in all areas of medical knowledge and skill to ensure that care provided by other organisations is of an appropriate standard
• To manage co-morbidity, co-ordinate care, manage acute and chronic illness, health promotion and disease prevention
• To be the patient’s advocate and maintain an holistic approach
• To prescribe not only safely, but in line with this year’s local and national guidelines and in the most economical way possible
• To run not only a business budget of £9bn, but be responsible for the commissioning of the majority of NHS services
• To be involved in the continuing development of the healthcare system

Achievements in Past Year:

• Number 1 in latest Commonwealth Fund Report despite increasing consultation rates and decreasing resources
• Took over commissioning NHS services
• Coped with increasing demand whilst maintaining quality

What do you find Interesting:

• Intellectually stimulating and rewarding
• Challenging
• Still most trusted profession
• Degree of autonomy and flexibility especially with career path as generalist but with ability to sub-specialise
• Satisfying and ‘Every day is different’
• Tremendous variety of medical and other issues to manage
• Holistic approach empowering Patients to manage their own health
• Opportunities for a great variety of different roles to suit any time commitment, pocket or interest: out of hours GP, salaried GP, GP partner, commissioning, politics, journalism, sexual health, family planning and numerous other clinical roles, occupational health, developing information technology, property investment, entrepreneurship, management, service design, teaching medical students and training junior doctors.

Challenges in the Past Year:

• Annual contract changes
• Increasing climate of abuse from government, media and patients
• Problems with retention & recruitment due to career uncertainty, increased retirement and emigration, and falling income
• Constant inspection by multiple agencies
• Increase in spurious complaints
• Increase in bureaucracy and mindless box ticking exercises
• Decrease in autonomy
• Increased threat of litigation though exhaustion doesn’t preclude prosecution
• Spiralling workload and unreasonable demand
• Reduced respect for clinical judgement; as the alternative is testing and referral, this threatens the financial viability of the NHS
• Annual appraisal & revalidation process
• Lack of support for business/commissioning processes
• Yearly reduction in pay and resources
• Reduction in pension and increase in retirement age (incidentally is it really wise to push a clinician with potentially declining mental faculties to play Russian roulette with people’s health?)
• No occupational health service
• Rising divorce, alcoholism, mental health, suicide & drug misuse rates

What Have Been Your Goals for the Past Year:

• Survival

What Are Your Goals for Next year:

• Foster resilience within Primary Care
• To engage secondary care so that we can work together
• Engage the public to take control of their own health. (That Holy Grail of self-care)
• Redress the wants versus needs culture

So Whitehall, we’ve completed our appraisal document, over to you.

Somehow you need to create a workforce of enthusiastic, willing doctors who are prepared to keep polishing the jewel in the NHS crown, not a bunch of beleaguered, vilified, despondent scapegoats who are looking for the closest exit.

It’s about time we all stood together as a workforce to say “enough is enough”.

You can’t ignore the elephant in the room any longer. We ARE exhausted, drowning and furious, but we haven’t given up yet because for most of us, being a doctor is vocational.

We are proud of General Practice and of looking after our patients to the best of our ability.

We want to see Primary Care survive, not thrown to private providers to tear it limb from limb, leaving a rotting carcass behind.

It would be a betrayal of our professionalism if we did not make this clear to everyone - politicians, the public, and potential future GPs.

So, stop hiding behind the rhetoric and unfulfilled promises, we say again, what ARE you going to do about it?

Response to David Cameron 8-8 7/7 GP access pledge

Mr Cameron,

I listened with interest this morning to your political sound biting on your General Practice vision for 8-8 working, 7 days a week.

To be honest, we had been expecting this baloney for some months as your pilots for the scheme draw to a close. What's more interesting, is that having pump primed these pilots with £50m (half of what you are offering to roll it out across the country), they have failed to deliver the reductions in A&E attendance or quality as promised. More importantly, these beleaguered services actually struggled to find any GPs to provide the service, despite having big money to play with. Not surprisingly you brushed over the lack of evidence to show that these ill advised, vote winning policies actually brought benefit to a system that tries to match cost effectiveness against consumerist demand.

In your closing speech, you pledged more funds for the NHS. Let us remember, before the last election the Conservative party promised no reorganisation of the NHS. They failed to keep that promise. How can we be asked to believe that current election promises will be kept and where are all these GPs going to come from, to deliver this 24/7 service?

However, rather than try and argue those old chestnuts, perhaps we should just stick to the facts, although I appreciate politicians are not great fans of fact over fiction.
- The NHS costs £113bn per year
- Primary Care currently uses 8% of the budget - remember here please that we are constantly being slated for being unable to provide an effective and timely service, even with this percentage and we are consistently pressing for at least 10% of the budget to sustain current levels of service.
- However, using 8%, the Primary Care budget is in the order of £9bn per year
- GP practices currently open 8-6.30 5 days a week or 52.5hrs
- If practices opened 8-8 7 days a week this would be 84 hrs or a 60% increase in hours per week

You have pledged an extra £100m for this increase in hours. This equates to 1.1% increase in Primary Care funding for a 60% increase in workload.

Do the maths, as your advisors obviously can't! Forget the rhetoric and the arguments about doctor salaries, this fairy tale is simply not deliverable.

Resilient GP

Dr Michelle Sinclair, GP Partner, Fleet, GU52 7US
Dr M Suresh, GP Principal, Woodsetton Medical Centre, B13 8QJ
Alexis Manning, Sessional GP, CF11 0SF
Nitika Silhi, Salaried GP, Lynwood Medical Centre, RM5 3QL
Mark McCartney, Locum GP, SE Cornwall, PL12 6UR
Dr M Suresh, GP Principal, Woodsetton Medical Centre, B13 8QJ
Dr Freda Bhatti, GP, The Hollies Surgery, The Green, Gt. Bentley, Colchester, Essex, CO78PJ
Dr David Shore, General Practitioner, Rugby, CV230LU
Iain Hotchkies, GP, Merseybank Surgery, M21 7NN
Siobhan Brennan, GP Partner, ordsall health, m5 3ph
RANJAN Pruthi, gp, phc mawney road, RM78NX
Dr O'Reilly, GP, Essex, Co78pj
Christopher Earnshaw, GP, Lever Chambers Centre for Health, BL11sq
Dr Hannah Gibbs, GP, St Paul's Surgery, Winchester, SO22 5DD
Hala Atkin, GP, Green lane, Cv3 6ea
Hussain Gandhi, GP, Wellspring Surgery, Nottingham, ng2 7ep
Alexis Manning, Sessional GP, CF11 0SF
Dr Noim Amin, G.P, BR1 3DR
Prit Buttar, GP, Abingdon Surgery, OX14 3LB
Rachel Blackman, GP, Hartley Corner Surgery, Blackwater, GU46 7TJ
Rajesh Mahadevaiah, GP, Aylesham, CT3 3BB
Dr Howard Sunderland, GP Partner, Marple, Stockport, SK66AB
Dr Alan Woodall, GP Principal, Machynlleth, SY208EQ
Lorna Macgregor, GP, NHS Highland, PA318AE
Dr James Higgin, GP Principal, Downlands Medical Centre, BN26 6AE
Bastiaan Kole, Free Lance GP, Fulham, SW6 4HS
Dr Pamini Ledchumykanthan, Sessional GP, Shepherds Bush, W12
Vic Sivanesan, GP, Mansell Road Practice, UB69EN
Dr Natasha Collins, GP Partner, St Lukes Surgery, np11 5GX
Dr Alasdair Gallagher, GP, Oakley Medical Practice, Leeds, LS11 5HT
Shivani Vinayak, Gp, Ne31 1nu
Nicola Waldman, Gp principal, Merton medical Practice, London, SW19 1DG
Rhianna McClymont, GP, London, NW62HJ
Dr R Adam, GP, Hounslow, Tw135jg
Lynette Saunders, Salaried GP, Wantage, Oxfordshire, Ox12
Dr Rachel Ali, GP Registrar, Plymouth, pl4 6px
Catherine Jones, GP, Lighthouse Practice, Eastbourne, Bn21 4hy
Sukhdip Jhaj, GP, Silsden and Steeton Medical Practice, BD20 0DG
Dr Lynette Saunders, Salaries GP, Wantage, Oxfordshire, OX12
Sagar dhanani, GP HILLINGDON, Ub77dp
Ross wentworth, GP, Poplars medical centre swinton, m27 0na
Alixe Thiagarasah, GP, N211rn
Dr Murali Nair
Samir Dawlatly, GP, Jiggins Lane Medical Centre, B32 3LE
Dave Jones, GP, locum, M32 9AE
Alison Lawton, Salaried GP, Park View Medical Centre, Long Eaton, NG10 3RJ
Rob Mawdsley, Dr, Bridge of Earn, PH2 0PQ
Thirza Deboo, GP, Marlborough, Sn8 4by
Rebecca Gidley, Salaried GP, E1 0LS
Alexandra Taylor, GP, Chatfield healthcare, Sw113uj
Dr Ashley Southall, GP Partner, Larksfield Surgery, SG5 4HB
Dr Tom Hodges-Hoyland, GP Partner, Ashgrove Surgery, CF37 2DR
Dr Sophia Galloway, GP, Steyning Health Centre, West Sussex, BN3 5ND
Katherine Robertson, GP, Colinton surgery, Eh13 0LB
Lenin Vellaturi, ST4 4QF
Dr Helen Phillips, GP, Burney Street Practice, SE10 8EX
Yusuf Rajbee, GP partner, Portland Medical Centre, Se25 4qb
Mei-Ling Lancashire, GP, Surrey, GU15
Clare Dyer, GP, Baldwins lane, WD3 3LG
Naylea Choudry, GP partner, Darwen health centre, Bb3 1py
Robert Hegedus, GP Partner, Builth Wells, SA200YW
Dr Tabassum Ahmed, GP, Arnos Grove Medical Centre, N11 1BD
AMIT TIWARI, GP, MERSEA ISLAND SURGERY, CO5 8RA
Dr Nikki Prasad, GP, Ch medical, fields new road, West Didsbury, M202ED
Dr Shama Shaid, General Practitioner, Hemel Hempstead, Hp12ld
A.Butt, GP, Sw4
Dr Tom Caldwell, GP Partner, Thorneloe Lodge Surgery, WR1 1RU
Seema Haider, GP, Haiderian Medical Centre, Rm142yn
Anna Morris, GP, Orchard Medical Practice, LE9 6RG
Monah Mansoori, GP, TW1 2JU
Dr Dax Tennant, GP Partner, Polegate, BN245FH
Jonathan Ferdinand, General Practitioner, Wickhambrook Surgery, Suffolk, CB8 8XU
Sarah Worboys, GP, Nw52be
Dr Donagh O'Riordan, Consultant Physician, Colchester General Hospital, Colchester, Essex, CO4
Rajeev Kanwar, gp, kineton, cv47 2qa
Yogasakaran Arjuna, GP Principle, The Woodberry Practice, N21 3LE
Dr Victoria Ingham, Salaried Gp, Hawthorn medical centre, Swindon, Sn2 1uu
Dr Asha Pillai, GP Partner, Surrey, KT12 4HT
Dr Ben Williams, GP, Poplars Medical Centre Swinton, M270NA
Jeremy Goad, GP Partner, Victoria Practice, Aldershot, GU11 1AY
Russell Brown, GP, Manor Park Medical Centre, BN26 5DJ
Anna Martin, GP, Queens Walk, W10 6HT
Graham hoggard, Pharmacist, Barnsley, S71 3qw
Dr David Barrett, GP Partner, The Old School Surgery, LE9 4LJ
Dr Alistair Richardson, GP, The village practice, N7 5JJ
Nadim Azar, GP, The Glebe Practice, LN1 2NU
Dr John G Hughes, GP, M25 9GD
Dr Nasir Nabi, GP Trainer, Walker Medical Group, NE6 3BS
Damian Fogarty, Consultant Nephrologist, Belfast Health & Social Care Trust, BT9 7AB
Alison Johnston, GP, Ulverston Health Centre, LA12 7BT
Jonathan Harte, GP, Aspley Medical Centre, NG8 5RU
Kamal Sidhu, GP, Durham, TS27 4LQ
Danielle Hann, GP partner, BD12 9NG
SIMIONESCU OZANA MARIA, THE POPLARS MEDICAL CENTRE, M27 0NA
David McLees, GP, Wallace House, SG14 1HZ
C Patel, GP, London, sw66hx
Zoe Neill, GP (soon to be ex) principal, Gibson Lane Practice, HG2 9PE
Stewart Rutherfurd, General Practitioner, Morrab Surgery, Penzance, TR18 4EL
Ruth Spencer, GP, 55 Hunter St, G4 0UP
Dr Amy Banks, GP, N1
Colin Brunt, gp, poplars medical centre, m27 0na
Dr Paul Evans, GP Locum, North East England, DH1 4BE
Ian Davis, GP, Cirencester, gl77ey
Dr Michael Weymar, GP, Overseas
Leena Menon, GP partner, Courthouse Medical Centre Caerphilly, CF83 8 NJ
Teresa Tang, Villa Street Medical Centre, SE17 2EL
Deborah Webb, GP, The Old School Surgery, Le9 4lh
Lisa Griffiths-Brown, GP, South Wigston, LE18 4SE
Catherine Lewis, GP Registrar, Hounslow, TW1 2AU
Dr Kirsty Shepherd, GP, Thw Wychwood Surgery, Shipton under Wychwood, GL7 3PH
Ruth Marchant, GP, manorbrook medical center, SE3 0EN
Dr.Brenda Moran, Salaried GP, Herne Hill Group Practice, SE24 9QP
Dr RJ Pinto-Wright, GP Partner, Ambrose Avenue Group Practice, CO3 4LN
Karuna Sharma, GP, Richmond Surgery, Richmond Close, Fleet, GU52 7US
William Gordon-Wright, GP, Horsham, DT6 6DA
Dr Sharif Hossain, GP Principal, Highcliffe Medical Practice, Higham, ME3 7DB
Dr P Bradbury, GP, Walkley House medical centre, S8 0BY
Justin Ilott, gp partner, courthouse carphilly, cf83 3gh
Dr Bunmi Adeniji, GP, Windhill Green Medical Centre, Shipley, West Yorkshire, BD18 1QB
Dr Robert J White, GP, Westfield Surgery, TN35 4QE
Dr Tom Caldwell, WR37JW
Dr Paul Fitzgerald, GP, Minster Medical Practice, LN2 2JP
Tesan Hadzikadunic, Cv34 6fs, United Kingdom
Stephanie De Giorgio, GP Principal, Cedars Surgery, Deal, CT14 7DN, United Kingdom
Carol Millington, M276HG, United Kingdom
Eilish Davoren, DT6 5FD, United Kingdom
Ian Bruce, G41 2AF, United Kingdom
Nick Beedie, M47aj, United Kingdom
Siobhan Stapleton, GP Partner, Mansell Road Practice, UB6 9EN
Sharon Swallow, Post Grad Law student, Former Hospital senior manager, UB8 3DS

To add your name, please "sign" using our online form.

Dinner time.

So my lovely wife is cooking my dinner. We usually do that together. Why am I not with her in the kitchen?

Because, Mr Cameron, after yet another 12 hour day, I am now at home sorting out paperwork, by remotely accessing the surgery computer system. Don't worry, it is all secure and conforms to the NHS Information Governance arrangements. I'm doing that from home so that I could actually see my kids before they went to bed.

If you think that people will be able to see their GP, or a GP (and incidentally I wish you'd make your mind up because you seem to say the first one when you start, then change tack in the middle of each sentence) from 8-8, 7 days a week, you are frankly deluded.

There are not enough GPs. So that means that patients will NOT be seeing GPs, but other health professionals, nurse, physicians assistants or whoever.

I can't see how you are going to train enough GPs, given that takes as an absolute minimum 5 years from graduation from medical school. There is a looming crisis, over and above the one already happening. Did you know that something like 40% of GPs are over 50? How long do you think they will hang around for? And that thousands of young doctors are emigrating rather than staying here to work in the NHS? Can you think why that may be?

340 MILLION consultations a year in General Practice. Compare that to 40 million in A&E and it kind of puts it in perspective. You want us to do more and more. Fine we can do it, or at least arrange for it to be done, but not without resourcing. The proportion of the NHS budget going into Primary Care has gone from about 10% to less than 8.5% in the last four years. That 1.5% reduction is the equivalent of about £1.5 BILLION quid, very roughly. So how are we to pay for all of this extra stuff? It is certainly doable. But it doesn't come cheap.

And what about premises? If you want us to do these things, provide a new model of out of hospital care, closer to peoples' homes, what are we going to do it in? There has been a de facto moratorium on the revenue needed to fund the extra space that General Practice needs, never mind all this extra stuff. So where are you going to fund that from?

And as for GPs now being in charge of the NHS, local groups making decisions for local health economies... Have you actually seen what is going on? There are so many financial constraints that there is very little flexibility in the system almost everywhere to allow for sensible redesign of systems and services. Yes, yes, I know there are places doing bits and pieces but, and I appreciate you are not of a scientific bent like me, anecdote does not make evidence.

The Commonwealth fund report this year showed we had not only the most efficient but THE BEST health service in the world. About the only thing we could do better is speed up access. Guess what? That requires resources.

Demand is going up and up, inexorably. You can't blame the patients, they expect what you promise them. The problem is, you keep talking about an NHS based on wants, but you then barely fund it enough to cater for the populations needs.

We need as a nation to decide what we want from the NHS. That may be the status quo, which is still going to need more resources given the ageing population etc. It may be that it provides less. Or it may need wholesale change of models of provision but that takes resources and is not without risk.

You need to start engaging with the issues honestly. Except I have no expectation that you or any of your political allies or enemies will do so, as there is an election in a few months and unless you are elected, your promises mean nothing at all.

My dinner is ready now. When I've eaten, I'm going to come back and finish off my paperwork.

Have a pleasant evening.

Russell Brown
GP, Polegate, East Sussex

Like

Classifieds

Wanted

Graduate status candidates.

40 - 50 meetings a day, number to be decided by clientele.

Wage non-negotiable depending on profit/expenses accounts with income decided by government and expenses by market forces.

Additional hours non negotiable.

Quality and outcomes must be recorded.

Regular personal inspection annually and five yearly revalidation.

Failure ends career.

Business inspection annually and possibly by 3 different agencies.

Personal/professional indemnity not provided, available for 7-8k a year from various agencies.

No holiday cover.

Pension relief now 0%.

Pension payment 23.5% of salary rising to 29% soon.

Lump sum pension now reduced, subject to further change with notice but without agreement.

Retirement age to be changed at will by government.

Package for level of seniority and experience now not included. 100k+ will be quoted by agencies and media but rarely received; no car, no personal expenses.

Hours will match workload but is exempt from working time directive but an error made through tiredness is not exempt from prosecution.

Applicants expected to have high divorce, alcoholism, suicide, drug misuse and mental illness rates within post with no help from occupational services.

This attractive opportunity is usually filled by the top 5% of school achievers.

Other careers are available.

Originally posted by +Simon Ruffle as a comment to an article on +Pulse Today.

Reproduced by kind permission of Dr Ruffle. 

Channel 4 Dispatches: Are You Addicted to Your Doctor?

+Channel 4 Dispatches explains clearly the demands placed upon GPs and the rest of the NHS.

Are you in despair for your future in General Practice?

Interim Results of Survey for GPs and Practice Managers across England

Originally published on 29 July 2014. Copied from BBOLMC.co.uk on 14 August 2014.

Aim

The purpose of this survey is to highlight an imminent crisis in General Practice. It is intended to provide information for policy makers to ensure that General Practice, the backbone of the NHS, is sustainable in the short, medium and long term. It is not about making the case for increasing pay for GPs

Introduction

In 2013, my practice advertised in the British Medical Journal, on two occasions, for a salaried GP with a view to partnership. This recruitment process resulted in only one credible candidate. At the time my surgery constructed a narrative to explain our failure to recruit. During the year and early in 2014 we spoke with other surgeries in Oxfordshire and realised that we were not alone in being unable to recruit.

In April 2014 we ran a Survey Monkey questionnaire across GP practices in Oxfordshire. We received 167 replies in the space of a few days. This convinced us that there was a serious situation developing that could affect the future of General Practice. At the end of June 2014, at the request of a group of concerned GPs from North and North-East Oxfordshire the survey was amended to include additional questions in order to assess whether the perception of a developing crisis in General Practice was real and, if so, to provide evidence to policy makers to address the developing crisis as a matter of urgency. The questionnaire was circulated as widely as possible.

The survey appeared to touch a nerve in general practice. It was first circulated on 30 June 2014 and as of today 24th July2014 had received over 2750 responses from across England, with the majority of responses from GPs including partners, salaried, sessional and locums.

The results are unmistakable. General Practice is facing an imminent crisis. Workload in General Practice is unsustainable. A significant number of GPs are ‘burnt-out’. This is leading to GPs taking early retirement, a career break or seriously considering emigration. Newly qualified doctors are not coming into General Practice in sufficient numbers. This crisis in recruitment and retention is increasing the pressure on those GPs that remain.

Results

The headline results of the survey are:

• 73% report that one or more GPs in their practice is suffering ‘burnout’ due to increasing and unsustainable pressure of work.
• 58% of GPs indicate that they will either retire or take a career break within the next five years with a mode age band of 45 – 54.
• 11% of GPs indicate that they intend to emigrate within the next five years with a mode age band of 35 – 44.
• 96% feel their practice is experiencing an ever-increasing and unsustainable workload
• 54% of respondents are not confident their practice will exist in five years’ time.
• 19% of respondents are confident their practice will exist in 10 years’ time.
• 66% of GPs indicate that, in the event of the devise the partnership model of General Practice, they would be unwilling to work for a private provider will stop
• 72% feel that General Practice needs to attract more doctors willing and able to work fulltime.
• 50% feel that the partnership model of General Practice is becoming unsustainable for the future
• 56% report that it is not easy to recruit new GP partners whilst only 9% of respondents report that it is easy to recruit new GP partners.
• 48% report that it is not easy to recruit new salaried GPs whereas only 14% report that it is easy to recruit new salaried GPs.
• 51% report that it is not easy to recruit locum GPs whilst only 18% report that it is easy to recruit locum GPs.
• 64% feel that their referral rate is likely to increase in order to accommodate the increased workload from secondary care
• 42% would feel comfortable rejecting work from secondary and community care in the event of being unable to recruit sufficient doctors and practice nurses to replace those retiring. 40% report would feel uncomfortable with this proposition.
• 75% of respondents would support asking the Secretary of State to suspend contract management on the Avoidable Admissions Directed Enhanced Service.

In addition to the raw but compelling quantitative data obtained from the questionnaire, there is a significant amount of free text that has yet to be fully analysed. The penultimate question asking for respondents to identify issues not addressed by the questionnaire has yielded 26,000 words. Each response now needs to be analysed and themes assigned. Initial analysis identifies several recurrent themes. These include:

• Low morale due to constant denigration of General Practice by Government and the press.
• Unsustainable Workload
• Compromising of family relationships due to demands of General Practice
• Unrealistic expectations of population fuelled by Government and media.

Discussion

The results of the questionnaire are compelling. Assuming there are roughly 32000 GPs in England, this questionnaire has been answered by 8.5%. It is possible that the those responding were a selfselecting, disaffected cohort but we believe this is doubtful.

The results indicate a crisis in General Practice. There is a crisis in recruitment in that it appears that young doctors do not want to go into General Practice. There is a crisis in retention in that significant numbers of GPs in the age group 35 – 44 are now considering emigrating or leaving General Practice.

This could leave a demographic hole in General Practice that could last for a generation.

Furthermore those approaching the end of their career - the 55-60 age group - are looking to leave General Practice prematurely. A number of respondents report ‘looking for an escape strategy’.

There is a crisis of morale as those GPs that remain in General Practice struggle to cope with a patient population that is aging, with decreased mortality but increased morbidity in conditions such as coronary heart disease (Patient.co.uk, 2014). In addition these GPs are trying to cope with a workload that is expanding with the shift of work from Secondary to Primary Care as outlined in the Government

policy document “Transforming Primary Care”.

This questionnaire only sought to address the problems associated with General Practice. The crisis identified in General Practice however is also developing in other areas of primary care, specifically community nursing. It was beyond the scope of this investigation to investigate the issues with community nursing but it is believed these require urgent attention as well as General Practice.

Conclusions

The main conclusion to be drawn from the interim results of this questionnaire is that General Practice is facing a crisis and that this crisis, unless addressed urgently, will leave General Practice so depleted as to be unable to deliver the government’s strategy for primary care – shifting work from Secondary to Primary Care - as outlined in the Department of Health document “Transforming Primary Care”.

In survey, it was only been possible to identify what are the problems facing General Practice. It wasbeyond the scope of this questionnaire to identify the root causes of these problems and to offer solutions as to how these problems might be addressed.

This study has identified a crisis in General Practice. It is now a matter of urgency that the rootcauses of the crisis are identified and addressed. It is recommended that an independent commission into the state of not just General Practice but the whole of primary care, including community nursing, is established as a matter of urgency.

With specific reference to General Practice, the commission should investigate:

• Why young doctors are not entering general practice?
• Why mid-career and senior GPs are considering leaving general practice?
• What can be done to make general practice once more an attractive career for dedicated and talented doctors?

Andrew McHugh

Medical Practice Director & Principal Author

Horsefair Surgery, Banbury, Oxfordshire

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.

Dr +Gillian Breese

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

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. Dr Geraldine Vaughan, GP, Quayside Medical Practice, Newhaven. Dinesh Vekeria, Kenya Prad Velayuthan Dr Risha Verma, GP, Downing Drive Surgery, Leicester. Shivani Vinayak Dr Jaisun Vivekanandaraja, GP, Greenwich, London. Dr Hema Vora, Locum GP, Locum GP, Brent. Dr Simon Wade, Freelance GP, Northants. Nicki Waldman Catherine Walker Lizzie Wall Amy Wallace Toby Wallace, GP, Field House Surgery Kim Ware Philippa Watkins Dr Zoe Watson, GP, North London. Susan Webb Linda Welford Linda Welford rosanna wellesley Ross Wentworth Christina Whalley Paul White Liz Wilbraham Dr Dianne Wilkins, GP, Warwickshire. Simone Wilkins Nicky Wilson Lorna Wilson Nicola Winder Anja Wilton, Rushey Green Medical Practice George Winder, Rushey Green Medical Practice Dr Dilanee Wirasinghe, GP, Cassidy Medical Practice, London. Dr Nishan Wiratunga, GP. Maria Wood Gareth Wood Dr Alan Woodall, GP, Machynlleth Surgery, Powys. Patrick Woodburn Tony Woodward Katya Woollett Richard Woollett Oscar Woollett Justin Woolley Dr Sarah Worboys, GP, James Wigg Practice, Kentish Town. David Wrigley Arjuna Yogasakaran Ahila Yogendra, Locum GP Dr Saher Zakai, GP Principal, Boney Hay Surgery, Staffordshire. Kathryn Zelaskowski Sampath Kumari Narasimhamurthy Chris Conan Trenning Ehab Said Abdel Aziz Monica Saksena Joye Kailash Chand Malhotra Amrit K Baura Matt 'Leeroy' Jenkins Gillian Mountney Rae Mark A J Wilson Munawar Nabil Choudhuri Ghazalah Shafi- Azar Angela Mariella Pascale Kirsten Cavendish Weston Smith, United States Karyn Theresa Haggerty Richard P Miller Meg Burns Rose Tracy McLean Packman Desiree Dr Bergmann M Motahar Hossain, Bangladesh Matt Ira Chapman Alan William Martin Steven Carl Martin Charlotte E Farmer Ann Sutton Glass Tushan De Almeida Mary Jane Watson Julie Claire Gildie Dave Teddie Peddie