To think that the screwed up NHS is partly the gps doing...

[seriouslygardening]

Please read before you roast me, sorry it's long and possibly complicated…

Brief timeline
Well before covid hit - gp surgery brilliant
Couple of years before covid, gp merged with large GP group which now covers 3 cities and many many surgeries. - appointments much, much harder to get.
Covid hit- GPs formed a private limited company making themselves directors and running all the vaccinations in the city. Appointments at all surgery’s like hens teeth- scarce- understandable.

Covid, now “over” and the surgery’s haven’t gone back to normal, they have closed smaller practices and outsourcing their work to the Private limited company where all the GPs are still directors and appear to be working. Patients have to wait 3-8 weeks (usually the latter) to get a phone call from their practice GP.

Excuse for closing down smaller surgeries "no receptionists to deal with abusive patients" in reality, all the receptionists moved to the private company, and they advertised for new positions at below national living wage (£9.50ph).

They have outsourced their online and telephone triage system to another company about 200 miles away, so some outsourced GP(?) decides whether you get an appointment or not.

In our city, patients are finding no alternative but to use A&E, Urgent care, Out of hours, Minor injuries (all based at the hospital) after getting frustrated at the lack of service and phoning 111. The hospital are all aware that the increase in patients through their door are from this one GP group, yet they aren’t able to do anything.

So in effect, the gps get paid by the NHS for the (lack of ) service they provide at the nhs surgery, the NHS pay the private company(plc) to run, the GPs then get paid as GPs of the plc and as directors of the plc, they are also shareholders so get dividends all whilst the patients aren’t being physically seen and costing the NHS hospital to see the patients and treat them.
Looked on companies house website and this company has nearly £1.5M in the shareholder (GPs) fund, their creditors and assets equal out and they have £3M in cash in the bank. All whilst putting more pressure and using more resources at the hospitals. Now this amount of money is small compared to the overall cost of the NHS but if you multiply it over the whole country, it would add up especially for one patient the nhs can end up paying 3 times as much than if same patient had just managed to see GP in own surgery.
So am I being unreasonable to think that GPs are partially to blame?

IR35 has also stopped a lot of newly "retired" GPs from working as locums to cover sickness, holidays, etc. My own doctor "retired" but was a regular at our surgery for a couple of years after working through his own limited company. He stopped doing it when IR35 came in, and was open in telling me that was the reason - i.e. very high tax/nic which meant is wasn't worth his while doing it.

I am not a GP but a doctor. 10 years ago when I was a junior trainee rotating I did GP and A&E.
Back then I thought GP was hard work- the days are really long- but at least then there was a lull or an end point. My colleagues now are just firefighting for 12 hours a day- they don’t work ‘part-time’ in terms of hours but there is no way to do a 9-5 day. It is intense and everywhere are haemorrhaging doctors because of burnout.
A&E similarly there was a lull at 3-5am so the 12 hours was more bearable- now you start and know there are more people in the waiting room who will still be waiting at the end of the shift.
It is multifactorial- increasingly complicated illness, higher demand, fund squeezing, mismanagement.
10 years ago there would be more managers than doctors in the handover room…

To address some previous points-

• spreading GPs 24/7 would mean even fewer GPS because you would be spreading them even thinner- not the solution at all.
• the limits on training doctors have been campaigned for because training needs to be adequate- there are only so many resources and time to enable clinical training
• I agree some GP’s will be looking to monetise but also a I can empathise a little with them really about trying to create something that is sustainable- the old cliche of the family doctor for the village has been chased out

Yanbu.

I have been involved in some negotiations with GP practices and NHS through work and am frankly dumbfounded at the profiteering

Another factor, they are often very dismissive of people. And women in particular. I think I had about 10 appointments because I knew something was wrong and they wouldn't listen. Then an optician spotted my (very visible) ptosis and wrote to the GP to tell them to refer me to neurology. That was 9 appointments that shouldn't have had to happen if they had listened to me, and looked at me!

I have heard similar stories from other friends who have later been diagnosed with similarly serious conditions

Recently went on a medical leadership day and they were talking about being visionaries and compassionate etc…
Sadly in the break out rooms we agreed that actually the people who get promoted and into management in the NHS seem to be those who are the most ruthless and domineering

The outsourcing to private companies is happening in pretty much all areas of the NHS now. It’s certainly happening in our hospitals /mental health/learning disabilities. My dh is a consultant and it seriously angers him the money that the hospital spends on private companies to do work that costs far more than the NHS staff would do it for. They also make mistakes and employ companies that can’t actually do the work that needs doing! Oh and even mention quality assurance or safeguarding! And never any consultation with the clinical staff who might be able advise, or even do the extra work themselves for a bit of overtime money (no let’s pay 2 or 3 times that to randoms who might be spectacularly useless instead!)

Dh has been a victim of this himself when his brain MRI scan showed an important change, but the private company reporting on the scan didn’t pick up on the change, and therefore didn’t communicate it to anyone. 😡

I think this is a great idea. Also, how about having prescribing nurse but with actual prescribing power or a person between a nurse and GP who can see the majority of people, and can refer to GP if needed, but basically prescribe antibiotics, antivirals, and other lotions and potions.

It sounds awful seriouslygardening.
We have one GP but he covers 3 surgeries and it's not too bad getting in. He does have a couple of Advanced Nurse practitioners, and a few practise nurses and specialty nurses making things run smoothly. I think you are right about your GP service trying for most money for least amount of effort there. I'd look to see if there is another practise to move to that isn't covered by them.

Because home BP readings are more accurate. We can sit doing BP checks all day long, but then you'll wait much longer for your smear or your child to be vaccinated.

I could work all today, but then will need my time off in the week in lieu when it's busier.
Statistically there are far more patient no shows at weekends. Plus no supportive services available such as child health, specimen transport.

Ours has done this.

Luckily for us the nearest practice is still a short walk away, but the service is just not what it was.

Back in 2007, I was at university. There was a huge, single GP centre that served all students. You could book and manage appointments online and everything synchronised back with your home GP for the holidays. Other appointments all showed on my central record.

What the hell went wrong?

I'm pregnant. I have the badger notes app. I can view but not manage practice appointments. Midwife appointments are in my NHS app. The hospital scans are managed by letter and phonecall. One of the appointments in the app doesn't have a location in it. My first scan had three nurses - the sonographer, one who took my blood and one who made the appointments.

Got six months more of this bullshit before I give birth at one of the three poorly rated hospitals.

Seeing as pharmacists are consistently over worked and under staffed just doing their basic bread and butter work(and medicines management is a crucial part of healthcare in itself ) this isn’t going to work either. Putting other professions forward to try and paper over deficits in gp provision isn’t an effective solution.

My little GP surgery was great. I'd see the same GP and could usually get an appointment within 48 hours.

During COVID it was merged/bought out by a huge practice down the road. It's now impossible to get an appointment within 2 weeks, never with the same GP twice and have recently had such gems as "Yes you can tell me, but only if you're quick', "How should I know", "Well it's hard to say".

No idea what to do other than go private.

They are now asking patients to buy their own blood pressure machine and tell them the readings instead of running a clinic.

Because it’s more accurate to get an average home blood pressure reading. And BP machines are now more widely available an relative inexpensive

Also there has been changes made to the way pharmacists are trained, the idea being that from 2026 all newly registered pharmacists will also be independent prescribers.

@cptartapp the smears are already outsourced. Not everyone can afford a home bp machine.

The NHS is "screwed up" because:
1 - It is a model designed in the 1940s, which just doesn't work in the 21st century, especially with all the advances in medical science.
2 - The British public abuse and misuse it, because they think it is "free".
3 - Politicians of all parties are too scared to tell the truth and say that we need to move to some kind of insurance system, in which the public take at least some responsibility.

Neighbour borrowed ours to check his BP against our machine because his was reading what he thought was too low. 2 different machines 2 concerningly different BP taken minutes apart. So are the both accurate?
Not everyone can afford them.

Not everyone.
But if 3/4 can and do, (like most patients I see), it saves hundreds of nursing hours over the year which means people get seen more timely for their cancer injection, their newborn's vaccinations or their recall smear.
I'd be quite happy to sit and BP's, but when there's not enough appointments and not enough nurses, it's prudent to follow national guidance and try and make the best use of our time.
No one wants repeated appointments to keep having a raised BP checked to confirm a diagnosis. The cost of petrol or bus fares back and forth over a few weeks would more than cover the cost of a basic sphygmomanometer. Not to mention the ongoing prescription costs to them of antihypertensives which may not even be necessary.

Ours merged into a group and everything went down the hill very fast, suddenly it was impossible to talk to someone on the phone or trying to get an appointment without having to call every single morning and staying in the queue for hours before the call finished with the message to try again tomorrow.

Having said that, I think it it was the Tories policies and massive budget cutting that forced surgeries to merge. They also cut funding for nursing and medical education with the result that there are less of these professionals around… then Brexit, if we cannot recruit health professionals from abroad and we are not subsidising the training of those in the country no wonder everything is going down the hill.

So old style Gp partnership is not limited meaning that if the practice went under (as small businesses can do) then the GP will loose their own money/house etc. Since as a GP partnership you have only one choice with whom to have your major client - the nhs - then there is considerable risk taking on a non limited partnership when the nhs can change the contact unilaterally whenever they want meaning that if the government changes the amount or way they pay and the partnership fails the GPs family looses their home. The government keeps on saying it’s going to reform general practice , no one knows what that means but I sure don’t want my family home as collateral in whatever reorganisation occurs. e.g labour wants to make everyone salaried employees - if your a current or potential GP partner with a mortgage on the surgery or other debts in the partnership and the government decides to scrap all that - your left with a load of debt and no business. This means that GPs are looking for non traditional models such as PLCs etc because no one wants to end up homeless because the government change the rules again. That’s not to say that some of the big conglomerates are not out for profit at the expense of care - these aren’t your run of the mill GPs though, these are businesspeople first and GPs second - this is the privatisation of primary care that everyone is warning about

the small old style family GP with one of two partners has already been priced out and stressed out. All the people posting about their little small surgery being taken over by a big one - that’s probably because the small one went bust. Single or two partner practices don’t work anymore as the funding is poor and the risk and workload huge. These big business setting up don’t represent individual GPs selling out patients for more money, they represent small GP practices collapsing and the big firm swooping in to make profit.

the traditional model of Gp is financially, practically and emotionally unsustainable. Yet patients blame the individual GP who has been forced out of the market rather than the system that drove them out.

There are certainly problems with privatisation, but the key reason that services are now so poor, access so difficult and so on, is because there is a huge shortage of GPs. This has been an issue for over a decade but accelerated since covid. Government has known it’s a problem and failed to do anything about it.

This is far from normal, in my experience (within the NHS).

I’m a practice manager.

The main issue is, there are not enough GP’s. The reason they are outsourcing and using ARR staff is for this reason. You can’t recruit GP’s anymore. They are all locums, very expensive and don’t do any admin, so all your partner GP’s are doing the admin and not seeing as many patients.

I don’t know of any surgeries operating in this way, are you talking about a PCN (primary care network?) as yes that makes profit, but it has to go back into the business, or back to the practices in the PCN. The PCN’s are winning local contracts via their ICB in competition with other NHS Trusts. This system came into play many years ago when they (Tories) abolished PCT’s and separated all services into 2 categories - commissioning and providing. The commissioning has all the money and awards contracts to whoever is seen to deliver the best value.

The partners themselves do make profit via their GP partnership. They have always done this, they do this via QOF and other contracts. Some practices do not make profit, or a small one. This is not a big conspiracy, it’s not new, it is the structure. GP’s are independent contractors who hold a GMS contract which generates funding from the NHS.

Also for anyone who isn’t aware from 15th May the new contract dictates that no patient can be ‘told to phone back another day’. This means all patients need to be placed somewhere, for something. This doesn’t increase capacity it is dictating how they manage demand. So not enough GP’s and now we have the contract change. It will be interesting

There needs to be an excess payable for everything to deter people from missing appts or making unnecessary visits to the GP. £20 for a GP appt. £50 for a hospital appt. Nor refund under any circumstances. Reduce NI accordingly.