A day in the life of a salaried GP

I am no longer a salaried GP, but I thought that you'd enjoy this article I wrote for Pulse magazine - it shows a day in my (old) life.



I could tell you about a normal day in the life of a salaried GP but it would be really rather dull.

This Monday, however, was a rather unusual day - the first day in our new building. The partners had been sweating bullets over it for the past few months and the big day was finally here. We had a sneak peek on the day before to find our way around and marvel at the nice new desks, smooth floors and curious locking mechanism on the doors. Keys are a thing of the past, instead we have a new little key fob that you wave at the handle and the door unlocks. The fob looks alarmingly rather like a shiny black suppository.

0800 I arrive half an hour early to set-up, and find out whats going on. I have the pleasure of doing our rapid access clinic on the first day. It’s a clinic with 5min slots designed to see all the minor complaints – like sore throats, colds, earache – so the complex stuff goes to the normal clinics. There is not much room for pausing or having chat, it’s a fast clinic and if one patient takes too long it very quickly over-runs. I predict problems, it’s in a new building that’s a bit maze-like and a doctor that doesn’t know where anything is.

0805 The trays we use to store our sick notes, forms and such like have quadrupled in size. I don’t have one or a name plate. Sadly I still have to work.

0810 First things first, time to check the most important room in the building. The tea point. So far so good.

0820 Receptionist informs me toilets are not flushing as the water hasn’t been switched on yet. Wish they had told me before I had a sit down session. Feel sorry for whomever uses it after me…

0830 Clinic starts! Patient is told they are my first patient in the new building, the patient doesn’t seem impressed and just wants their sick note.

0845 Hear the water has been switched back on. Run back to loo and flush the evidence.

0915 Need to weigh a patient. New scales not calibrated yet. Only one set of scales working, on other side of building. In a nurses room.

0950 First patient to complain about the car park being too small.

1000 Patient who doesn’t speak English tries to do consult with relative translating via mobile phone. No mobile reception in the new building. Oops.

1026 Notice that we have soft-close bins. Very nice. Patient feedback about new building generally positive

1030 Emergency case turns up needing my help and eventually an ambulance. Clinic running behind now.

1100 Total of 1 hour of urgent extras to see. Most are not urgent.

1215 1 home visit hasn’t been taken. Down to me to argue with doctors to see who is going to do it. Phone patient but they have gone out, informed they will be back from the shops soon.
Politely inform family that we will not be doing a home visit for them. Total of 24 visits today, split between 13 Doctors. Notice that a Partner did an early morning pre-booked clinic between 7-8am. Not a single patient turned up.

1250 On the phone and it starts ringing – it has more than 1 line! No idea how to swap calls so ignore ringing.

1256 Rapid access clinic finally finished. Just a mountain of paperwork to do now and script signing. Room is freezing so wear my coat.

1325 Paperwork finished. Should have been in a meeting that started at 1300. Turn up late, not missed much. Jealously spy the fancy new coffee machine in the corner of the meeting room. Can’t use it though as one of the Partners said it costs a small fortune to use. (Last week one of the Partners did get a coffee out of the machine. Shortly afterwards a sign appeared on it saying Out of Order – awaiting connection to water supply. To discourage anyone else from using it? Who knows.)

1400 Meeting finished. Got 30mins before afternoon clinic starts. Decide to walk to shops for sandwich as not sure I’ll get a parking space on my return.

1430 Afternoon clinic starts

1600 Angry email from reception manager moaning about the new tea point being dirty and no-one is washing their own mugs

1630 Feeling generous and see 2 patients who are both 20mins late each. Would normally ask them to rebook but as it’s the first day in the new building I let them off.

1700 Informed that last patient has gone to the old building. See them 10mins later

1715 Done. Leave after washing up my mug. Race across town to pick up daughter before nursery shuts at 6pm.

All in all the day went well, apart from the workload. Might try and get a cup of coffee out of the machine upstairs next week when no-one is looking.

Free at last!

By the time you read this I will be a free man. Free from the shackles of being a salaried GP! I will have stepped out into the big wide world and blinked at the bright sunshine. Much like the old chap, Brooks Hatlen, did in The Shawshank Redemption, (hopefully I won’t end up the same way he did). I will join the ranks of locum GPs and pimp my skills to any practice that wants me.

I think I have become a bit institutionalised at my current practice having been there since I gained my GP qualifications. It was actually a big shock to go to other practices to see how other doctors work. I was actually shocked to see that in some practices the doctors meet up regularly and talk, divide up visits fairly and seem happy. I forgot that there are better jobs out there. It is not as scary as you think. Being a locum gives you a lot of freedom and a set workload (a novelty indeed).

It also made me realise how hugely dependent some practices have become by relying on salaried GPs to do the bulk of the work. If more salarieds say no and get up and leave, or become locums then perhaps things will change as some Partners don’t seem to listen to our concerns unless it affects them where it hurts, in their pockets.

I’d like to claim that I got so fed up of being dumped on and taken advantage of, that I stormed into the practice managers office and slapped down my resignation letter on the desk and bellowed a few choice words at him. Sadly the somewhat unglamourous truth is that I was too cowardly to do the above. My fellow salaried colleague did actually do something similar to the above and I don’t think any of the partners forgave him and didn’t speak to him after that. I hid behind my wife’s career. We have to move so she can complete her training so that was my excuse for leaving. I didn’t want to make waves and I need decent references (my colleague didn’t as he became a Partner at another practice). Things have got quite strained at work – 4 salaried GPs leaving over the next few months – and I didn’t want to add to the shitstorm

Medication pic n mix?

(taken from Pulse magazine blog)

We have a number of non-English speaking patients and I’m not sure I’m really getting through to them about concordance with their medication. I’ve had several patients who happily take a prescription for their illness, then travel abroad and see a ‘doctor’ who gives them a variety of potentially dangerous treatments. They then pop back a month or two later and see me and complain they are not better, having stopped the original treatment and tried something else entirely. I’ve seen patients who have been given methotrexate, psoralins, roaccutane and a wide variety of topical super potent steroids without any supervision or monitoring whatsoever.

Do I decline to see them again until they do as they are told? What if they continue taking these treatments without any monitoring? Worse still, what if they give these treatments to their friends or children? I’ve had patients accuse me of being tight-fisted for not giving them the incorrect and dangerous treatment they have got from abroad. Warnings about potential serious side-effects fall on deaf ears.

It does make me wonder why they bothered seeing me in the first place if they won’t use what I gave them, but try some dodgy pills from a person with dubious qualifications. It is quite frightening what odd treatments patients can get hold off via a variety of means. Any time a patient sees me claiming a ‘special cream’ has cured them of their eczema or psoriasis I can be fairly confident the mystery ingredient is dermovate.

It’d be interesting to know how many patients use their medication for something other than what it’s prescribed for. I know of some elderly patients who have been sharing their medication, god knows what sort of interactions have been going on. I wonder if it’s a bit like pic 'n' mix?

What makes a perfect patient?

A quick bit on GP funding before we begin so you know what I am talking about in the future - QOF stands for Quality Outcomes Framework - its a points based system for GP funding. You get points for managing certain conditions, managerial activities and other things. For example for a patient with heart disease you would get points for checking they are not depressed, on certain medication, blood pressure is below a certain value etc... Its designed to increase the level of care a patient receives by ensuring certain targets are met. It does mean that there is a tendency to concentrate on getting the points and nothing else however. Also some points are based on dubious targets or near impossible to get (the recent biased and poorly designed patient questionnaire released by the government was a good example). We have a few nurses who's sole job is to go chasing QOF targets to make sure we score as many points as possible

In exchange for not doing out-of-hours care anymore GPs had a paycut of about £6000, QOF targets were also introduced. At the time there was a recruitment crisis in General Practice so the government hoped getting rid of Out-of-hours care for GPs would make it more family friendly and changing the funding would raise pay a bit. When the QOF targets first appeared the government assumed most GP practices would reach about 70-80% of the total. Infact most Practices got 100% so received a bumper amount of funding. This is why Partners salary went shooting up. It wasn't that they were greedy it was that they were doing their job well!

The government ever since has been trying to claw back some of this funding ever since by changing targets on a yearly basis or forcing GPs to do extended hours again without giving them back the original money they took from them. There has also been a smear campaign against GPs as the government was more than a little embarrassed at cocking up the GP contract negotiations and giving too much funding to General Practice. QOF targets have had negative and positive impacts on General Practice, I'll talk about them more in the coming months but that was just a brief run through to bring you up to speed. Any questions send me a tweet via @GPforhire on twitter.

(below is taken from my blog on Pulse)

Its fairly easy to find out what makes a good GP – for example the GMC has some good information on it, as does the RCGP. But what about patients? What makes a good, or even a perfect patient?
I guess it depends on you want out of them, at its most basic could the perfect patient be the one who is registered but never turns up and lives a happy healthy lifestyle with no need for a GPs input? Perhaps but with my QOF chasing hat on you can’t score that many points from them. Maybe a few points as they are a non-smoker, non-drinker and normotensive. But not many.
Perhaps if they had a few chronic diseases that would be better, could get a few more points out of them. What about if they are a depressed obese asthmatic with epilepsy, diabetes and heart disease? Could score a lot of points there! But to be a good patient they would, of course, have to turn up for regular review and take all the medication you throw at them. Ideally you want to be able to score as many points for as little work as possible I suppose. Maybe patients could be trained to chase their own QOF points? What if a cohort of diabetic patients touted their QOF point potential to low-scoring practices? Could they hire themselves out by registering with a different practice each year?
You could have some sort of QOF über-patient but it’s just a tad dehumanising to only view them for their QOF scoring potential. For me personally I like patients who turn up on time, don’t stink of fags, booze or sweat, don’t have a vast list for me to try and sort out in 10mins, do what they are told, and most importantly send me cards saying thank you so I can put them in my appraisal portfolio to show what a wonderful doctor I am as it seems nowadays if its not written down it doesn’t count.

Medicine by numbers?

I’ve noticed something with the GP Registrars I sometimes get to supervise. They almost always forget to chase the QOF points. Its not even on their radar. When I’ve asked them it almost invariably “too busy chatting to the patient”. They aren’t taught about ticking the boxes, or if they are then they willfully forget. Compare that to a salaried GP – QOF chasing has now become our raison d'être. But lets be honest, who doesn’t hate chasing all the QOF Points? Perhaps someone should make the equivalent of a Photo-me booth? We could call it a QOF-me Booth? I reckon it could score most of the clinical QOF points. Pee in here, put your arm in here, blow here. QOF-me booth could do it all. Hmm, hang on a sec, that will do me out of a job! Forget I ever told you…

Are we getting to the point where we are practicing Medicine by numbers? It does make me wonder what is a GPs role in the future? If all chronic diseases can be managed by nurse-led clinics, acute problems can go to the drop-in clinics what’s left for us? Insurance reports and cremation forms I guess.

Show salaried GPs some respect

Below is a reproduction of my new blog which is appearing in Pulse magazine. I will be posting other stuff on this blog aswell. The Pulse magazine blog is aimed at GPs so it might use the odd big of jargon that you might not understand. QOF points are the major way General Practice is funded. Essentially you get points for asking or doing certain things - eg asking someone who has diabetes if they are depressed, getting a blood pressure below 150/90, asking ex-smokers if they are still ex-smokers etc... Its meant that most consultations have now become QOF chasing exercises because if you don't get the points, the Practice doesn't get the cash. The GP partners get the cash, they decide where it goes and how much they get to keep, salaried GPs work for the partners - we cost 1/2 to 2/3's as much as a partner but do all the clinical work and none (usually) of the business side of things.

Simple really. Well it would be if the QOF points made sense - which they don't always, and a percentage of them change every year. So now you understand a bit about how General Practice is funded hopefully the rant below will make some sense!

What’s it like to be a salaried GP? Not much fun that’s what. I came into general practice with the rather foolish idea that I would eventually end up a Partner, help think up some innovative changes, improve patient care and be my own boss. I mistakenly thought that I’d be a Salaried GP for a year before finding a partnership. Now nearly 5 yrs later I’m still a Salaried and partnerships remain as rare as rocking horse droppings.

I’m getting really fed up with the barrage of emails reminding us of all the QOF points we have missed, a big chunk of which could be done by the receptionists but for whatever reason they can’t bring themselves to do it. Extra work to do? Down on the QOF points? Extra vists to see? Bounce it to the Salaried GPs! It’s the attitude of the partners that I find disrespectful. If it’s a choice between getting a Partner to do something or a Salaried it almost always gets bounced to the Salaried GP – after all you have to make sure you get your moneys worth out of them.

I know lots of Salaried GPs are sick to death of getting flogged by the Partners. The Partners can cancel clinics at the drop of a hat, go on courses, meetings, anything that takes their fancy. Salarieds? No such luck. If it doesn’t bring money into the ‘practice pot’ (partners pockets) they are not interested.

Work is meant to be distributed fairly but it’s laughable when the partners claim they do the same as the Salarieds. They don’t. Don’t kid yourself.

I know some salaried GPs have been given permission to pursue some management activity (QOF chasing) but with no extra pay or time to do it in. Why bother? It’s getting like that now at work. Why bother? – I’m paid to do my clinics, fill in some forms and do visits. If it is anything else then I am not interested. It is terribly sad that it’s getting this way. The goodwill of the salaried GPs is evaporating fast. Partners need to treat us with respect and have a radical rethink about how they use the increasing salaried GP workforce. That Darzi clinic down the road is starting to look quite appealing…

Choose and Book. What a massive waste of money.

Title says it all really. I'll explain why in a mo,

First apologies for not updating this blog sooner. 3 reasons
1) Been on holiday - very nice it was too
2) Couldn't decide on a topic
3) I'm lazy (main reason)

So much has happened since I last blogged. From Tamiflu being declared rubbish (we knew that already), CRB checks for all (we're all paedophiles til proven otherwise apparently), and the government keen to get rid of GP boundaries (did they actually talk to any GPs about this idea or did they, as a colleague suggested, simply run it past a Question Time audience to see if they clapped?). Thats just a start, there are other things but, er, I've forgotten.

Anyway, to the subject at hand, Choose and Book (CAB). Have you seen your GP and been referred to secondary care (hospital etc..)? What should happen is the GP asks you where you would like to go and then books the appointment for you. A short wait and then you are seen in the hospital of your choice. Sounds like a neat idea, you could pick a hospital near work for example rather than the run down portacabin round the corner. The idea ( I think) was to create a sort of marketplace where hospitals compete for your 'custom' which in turn drives up standards and improves care.

A nice idea you might think but the NHS being what it is its a complete and utter shambles. What used to happen before all this was you'd see the GP, (s)he would recommend referral, sort out a letter, it'd get sent and a few weeks (or more) later you'd get an appointment. The GP could even refer you to a specific consultant so you wouldn't have to see the dodgy crap one that every knows is shit but too scared to say anything about.

Simple. Doc ->letter->Consultant. Job done.

Now what happens is you see the GP and they recommend referral. Where I work the doc does the next step but I know in other areas its handled by a dedicated team. The doc explains to you that you now have a choice of where you go. In fact they mention the word choice several times. This is because the powers-that-be occasionally monitor patients to see if GPs have offered them choice. Next step is logging onto the Choose and Book website. (How much did that cost??). Whats been happening recently is that the screen freezes and the entire thing crashes so the GP mutters under their breath and sends a referral the old fashioned way (sort of).

Assuming the website works the GP types in what service they want to refer you to and then the computer returns a list of available hospitals and such like that offer this service. This list used to be 5-6 local services, its been changed now so it shows every place in the UK that offers the service. Quite why anyone would want to go somewhere that is hundreds of miles away is beyond me but you have that choice so the Government is happy. Rather cheekily it also lists at least 1 private provider. It also lists waiting times - where I work this is woefully inaccurate and out by weeks.

You ask to see a specific consultant but the GP tells you that you don't have that choice. (Infact if truth be known you'll probably end up with the dodgy shit consultant as they have the shortest list.) You pick a place, GP confirms, prints out a form with a password, reference number and telephone number (assuming the printer works). You then phone this number a few days later (to let the referral letter reach them first, otherwise they can't do anything) and confirm who you are with the password etc and you are given a date for your clinic. You have to phone them fairly soon, if you leave it more than a week or two the referral is returned back to the GP. Finally you get to see the consultant, only its not a consultant, its a nurse practitioner.

So the new pathway is GP->Choose and book website->patient phones booking system->booking system liase with hospital->appointment booked->seen in clinic (might not be the one the GP wanted though)

Ok problems.
1) Patients actually want to go to their local hospital and see a named consultant ->can't do that
2) Special referral pathways have been set up to triage referrals and make sure they go to the right place ->CAB overrides this so trivial stuff now takes up consultant clinics rather than more complex cases
3) GPs don't know much about all the different services on offer so can't offer advice as to whats best
4) Patients sometimes make wrong decisions about where they want to go
5)It assumes patients have a good reading level (not all do). Bit stuck if they can't read the info.
6)Some services are overrun and waiting list times have soared, other services are underbooked. No way of moving patients to these underbooked clinics which would save time
7)Try explaining CAB to elderly patients and they haven't a clue what you are talking about. Large numbers fail to attend hospital or referrals are bounced as they didn't phone to confirm
8)Try explaining CAB to patients where English isn't their first language and they haven't a clue what you are talking about. Large numbers fail to attend hospital or referrals are bounced as they didn't phone to confirm
9)Website crashes.
10)Hospital clinics are being filled inappropriately due to an inept booking centre
11)Services have got worse not better.
12)The amount of effort its taken to set up a service that, in my opinion, is actually worse than the old system is quite breath taking.

Neat huh? I have yet to meet a GP who thinks that CAB was a good idea that works well. Its a bad idea, that works badly. Genius.

Why am I not surprised?

As I am writing this Breaking News on twitter (@BreakingNews) has reported of the first few cases of Tamiflu resistant Swine Flu in the US. Seeing as we are giving Tamiflu out like smarties in UK I predict it will be a few weeks before we start seeing resistant cases in the UK too. Great.

Its debatable if Swine Flu will surge back again in the autumn/winter. Certainly all the preparations are based around a second more severe wave of infection. Will it be the same virus or will it have subtly mutated so no-one will be immune who can tell? Its all guesswork from what I have been reading.

I'm not going to rant on about Tamiflu being rubbish in children as you guys already know that. I will say that the recent study from Oxford was dismissed by the Department of Health as the research was done on Seasonal Flu, not Swine Flu. A couple of points worth considering;

1) The reason why we are giving out Tamiflu en masse is based on this study, which was done on, (you've guessed it) Seasonal Flu. So its ok to use one study done on seasonal flu to justify Tamiflu, but not another - huh?

2) Its hard to do studies on an emerging pandemic influenza as its new and not been around long! As we are no longer swabbing who knows what illness the children really have? Hopefully we'll get some decent studies coming out soon but don't hold your breath.

I've been asking people on Twitter if they would have the Swine Flu vaccine if offered. Mixed responses really but some people are now so distrustful of the Governments handling of the Pandemic they would decline. Others don't want to use an untested vaccine.

Please don't confuse the vaccine with Tamiflu. Tamiflu is rubbish. The vaccine isn't. I understand reasons why people are fearful of the vaccine but its manufactured in exactly the same way as the seasonal flu vaccine, just a couple of protein bits are altered. It will still have to meet the stringent requirements for using a vaccine on the public. The seasonal flu jab is only manufactured a couple of months before the flu season but people don't panic that its not tested properly. Seasonal flu kills 12000 people per year in the UK, it would be considerably higher if we didn't vaccinate.

There was a small outbreak of Swine Flu in the states in the 1970's. The vaccine produced then was with inferior technology and there were a number of reactions to it. Vaccine production nowadays is considerably more advanced and safer.

Swine Flu is H1N1, Spanish Flu was H1N1 too and that killed roughly 50 million people. Ok the Swine Flu virus is slightly different but it still has that potential to kill. I don't want people to be dismissive of the vaccine just because Tamiflu was a load of shit. Swine Flu so far has been a mild illness in most. It may, or may not, stay that way. Should you have the vaccine if offered? I think so. Its personal choice though so don't take my word for it. Don't base your decision on the rantings of an irate GPs blog. There may be a risk in taking the vaccine but there is a risk in everything we do in life. I suspect the risk of harm from the vaccine is considerably smaller than the risk of driving to work, using routine medicines or even just mowing the lawn. And if you smoke? Well the risk of harm from that far far outweighs any possible complication from the vaccine.

Later folks! Stay healthy!

Why not just put Tamiflu in the water..?

Hello again dear reader,

Been getting loads of feedback via twitter (@GPforhire) about my last posting. Apparently you didn't realise that Tamiflu isn't all its cracked up to be. Not surprising really as the negative side of tamiflu has had very little coverage. I could be paranoid and think that the government is suppressing reports of its lack of efficacy and side effects but is Labour capable of that?

Things are changing a little, there was this report in the Guardian today, and a previous one in May. I saw a young child last week that got a nasty rash from the drug. We've had multiple patients that couldn't tolerate the tamiflu due to vomiting and then phone us in a panic worried that they'd succumb to Swine Flu without their magic bullet drug.

Just so you know that I'm not making this up heres a few links that have looked at various bits of data.
You might have to be a BMA member to see the full articles

Tamiflu and anti-inflammatories (aspirin, ibuprofen or diclofenac) might be a nasty combo
GPs seeing lots of patients with side effects from Tamiflu
Tamiflu and neuropyschiatric side effects in teenagers - case not proven, caution recommended
Use of Tamiflu in children not supported by the evidence

So for the record, I wouldn't take Tamiflu, and neither would anyone in my family. Not for Swine flu anyway. For Avian flu I'd probably take it but resistance to it is growing.

Another worrying development:

Misdiagnosis.

I know of 3 deaths that have happened recently because they were thought to have Swine Flu but sadly had something much more serious which was missed until it was too late. This number will increase as the number of people assuming they have Swine Flu when they have something else will no doubt increase.

We run a simple problem clinic at our practice (see my earlier blog entry). Its been nearly empty this week. Summer holiday don't make that much difference to the numbers. I think its because these patients are confusing their symptoms with Swine Flu and using the Pandemic Line to get their tamiflu. These patients will probably turn up next week complaining of side effects from their treatment for their non-existent Swine Flu. I know some docs who have been swabbing patients still. Roughly 10% of the patients they thought had Swine flu actually had it on swabs. Thats experienced GPs seeing patients face to face and are still getting it wrong 90% of the time. God knows what the general public numbers would be like. Its madness frankly. Countless thousands of people taking Tamiflu (via the Pandemic line) for a mild self-limiting illness which they haven't even got!!


Quick link before I go. Heres a website run by the Medicines and Healthcare products Regulatory Agency MHRA. You can report any side effects from Tamiflu here. Tamiflu is a black triangle drug and so all side effects (even minor ones) should be reported. Its how we get to know if a drug is doing something odd. Anyone can report a side effect, doctor or patient.

Stay Healthy and see you again soon!

The Week that Was

So its the end of my first week back at work and the Swine Flu panic, er, I mean pandemic is in full swing. We are getting 30-40 patients a day worried they have it. Some do, some don't. Should we be giving them all Tamiflu? Well that depends on what guidelines you read and whether you are bothered by something called evidence-based medicine.

You're no doubt aware of the mountainous piles of Tamiflu the government has stockpiled. Let's get one thing straight. Tamiflu is an antiviral but this doesn't mean its a cure. Its not like taking an antibiotic for pneumonia. At best it will shorten the duration of symptoms by a day. The evidence so far has shown it has no impact on mortality (i.e taking it won't stop you from dying if thats your fate). Its use in a pandemic is unproven.

Lets not forget all the side effects. We are already seeing children who get quite nasty vomiting from it (1 in 10). Trouble is you tell the parents to stop the drug and they shit themselves, convinced that Tamiflu is the only thing stopping their child from knocking on heavens door. So the child vomits themself into dehydration and ends up needing admission.

Interestingly a large study of Tamiflu's potential neuropyschiatric side effects showed a possible increase in seriously abnormal behaviour (such as self-harm) in the under 19s. Its not meant to be used in Japan for this age group such is the number of cases they have had. Of course in this country we have no such qualms in giving it to our children. Tamiflu is classed as a black triangle drug in the UK- this means its a new drug, not all the side effects (or frequency of) are known, or the potential interactions.

One of the high risk groups for complications of Swine Flu is the under ones. The UK has a limited supply of liquid Tamiflu for this group. Guidelines state that all under 1's should be offered the drug. Trouble is is that it doesn't work, no evidence it works and I've been informed via a consultant Neonatologist that the under 1's lack the enzyme to activate it. Also the blood brain barrier hasn't fully formed yet meaning the drug that is known to cause hallucinations and confusion can easily pass into their developing brain. Brilliant. Is that in the press? Hell no, its not even in the Daily Mail which hates all things medical.

Now don't get me wrong. I'm not trying to scaremonger. I'm just letting you know that Tamiflu might make you quite sick, or worse. It lacks evidence of effectiveness and I'd think twice about giving it to anyone under 18.

One flu over the Swine nest

Good evening dear Reader,

I write this as I am watching Bear Grylls eat frozen squirrel brains in a Siberian forest. Still, if its a choice between that and Kendal Mint cake I know what I'll go for.

Work is vaguely interesting at the moment. We are all going to die from Swine Flu.

Or maybe not. In January of this year the RCGP published its Pandemic Flu guidelines which gave information about what do in the event of a new global flu pandemic. It was based on models from previous flu pandemics last century (that makes me feel old) with mortality rates etc... from Avian Flu. That was assumed to be the Big One. Its nasty, it kills a lot of people. Much to everyones surprise it was actually Swine Flu (H1N1) that swept the planet.

So far its killed a few hundred people and infected many tens of thousands (at least). Although these deaths are tragic, things should be put into perspective. Seasonal Flu (normal flu) kills 12000 per year in the UK. Does it get the same kind of hysterical coverage in the media? Not a chance. Mind you I can't be too tough on the media and the government (for once) as their projections were based on the far more deadly Avian flu.

How's things panning out now? Well I'm sure you are aware that Swine Flu is a lot milder than everyone was expecting. True it has killed people but the majority of these had other significant illness (not sure what exactly as no-one will tell us). One person died today of Swine Flu who was otherwise healthy. I am assuming they died from viral Pneumonia - v.nasty but rare, 40% mortality rate.

We've had a few cases through the doors where I work - despite advice to stay at home. I think currently the Staff are more scared then the patients. The difficulty is the guidance coming out from the PCT is mixed, frequent and far too wordy. I get 2-3 emails per day with 4-5 attachments. Each email supersedes the previous one - usually. Its a fucking mess. The Swine flu packs never turned up - not that they are needed now. Tamiflu guidance seems to change every few days. I'm still unsure if its for people presenting within 48hrs of symptoms, just the high risk groups, or everyone. Not that its any good. Government seems to think its a silver bullet but the evidence behind its use is not brilliant. Shortens the illness by hours, reduced viral load but its not without its side effects - including making all your skin fall off (rare but if everyone uses it we might see a case or two)!

Don't get me started on NHS Direct. Fucking waste of space that is. Masks are pointless too but good for scaring patients. I think a lot of the problems come from the original guidance which was based on Avian flu. Which is nasty and kills a lot of people. Where as Swine flu just makes you feel a bit poorly (usually). The guidance is slowly changing to take account of the fact that its not the End of humanity as we know it.

How you diagnose Swine flu? You guess. Thats right. We've been given a few symptoms that people will have but the trouble is is that the vast majority of viral infections we see in GP-land present with this. Even worse with children. Its only a matter of time before we miss a serious illness (meningitis, cancer, etc...) as we are so focused on believing everyone who is unwell has Swine Flu. And then the Daily Mail will have a field day. Whoop-de-fucking-doo.

Of course come winter the shit will hit the fan when Swine flu grows some balls and becomes the killer that we are all worried about. Oh well, such is life.

Why is hospital food so damned awful?

Apologies for the lack of blogging, I've been a bit pre-occupied when my next child made an unexpected appearance early when my wife's waters broke at 36 weeks. I won't bore you with all the details but thankfully baby Toby was born on the 29th May at 1030 weighing 5lb8oz. Mum and baby are doing well.

Anyway there were numerous things that caused problems, not least there being no beds on labour ward- a recurrent problem. You'd think with a Labour government in power they'd at least get that sorted ;)

I don't know if you've ever been to Leeds General Infirmary but its main car park is a bloody nightmare. It is, without any doubt, the worst designed car park in the UK. The angles on the approach to the ramp to go up each floor that you have to swing out wide to get around them. Newcomers to the car park regularly get it wrong and have to do a sort of 3-point turn to get up each level. The worst thing though, is the 1foot thick concrete miniwalls up each ramp. It seems they have designed these to jut out and rip up your wheel arch as you try and navigate the turn.

I've caught my car on it and so has my wife. In fact if you look at each ramp wall you can see a multi-coloured smear of car paint that is a testament to the number of cars that have had their wheel arches ruined on those damned stupid wall ramps. If you, like I did, wander about and look at the rear driver side wheel arch of most of the staff cars in the car park I would estimate approx 25-30% have been torn up by that stupid-ass designed car park. Let that be a warning to you if you ever park at the main car park in the LGI. Drive a small car.

Ok the other thing that I really don't understand is why is hospital food so bloody shit? I've been to multiple hospitals in the past and I have yet to go in one where the food they serve the patients is nutritious, edible and tasty. An adult male requires 2500 calories per day, 2000 for a female. This is higher if you are ill, recovering from surgery or breast feeding. Quite how you are meant meet these requirements on hospital food alone I do not know.

I remember doing my medicine for the elderly job and regularly we'd prescribe fortsips (calorie and protein dense milkshakes) to compensate for the utterly shit food that was served to patients. Honestly if you served this food to prisoners there would be riots. But as its a bunch of old crumblies who can't complain who gives a shit right?

Its no better on the adult wards for medicine and surgery. The portion sizes are pathetic, any salad consists of limp lettuce and a slice of anaemic tomato. Bread is hard, white and cardboard like. Butter is frozen solid. Everything is reheated and alarmingly whatever the ingredients it contains it all seems to taste and smell the same once it comes out of the reheater. Its a fact that the LGI cannot cook any fresh food on the premises for patients.

Get this, it is prepared in Wales and the transported via lorry to the hospital where it is reheated and then served. God alone knows why this is. Carbon footprint be damned I guess. If the swine flu pandemic kicks off and lorry drivers go off sick then I've no idea how they'll get the food to the LGI. I very much doubt relatives will bring it into a hospital full of swine flu patients.

One of the starters on the menu they gave to my wife was Orange Juice. Since when has a drink been a starter?! Oh yes, I remember now, when I did Home Economics when I was 13!! WTF? It that wasn't bad enough one of the main courses was Gravy. Thats right. Gravy. It can't possibly be a bowel of gravy could it? We weren't brave (or foolish?) enough to order it to find out. Needless to say my wife had all sorts of nice food bought in by me to supplement/replace the bloody awful shite the LGI had the audacity to serve to their patients.

So, if ever you have to go to the LGI for to visit a patient then make sure you come in a small car ( or park elsewhere) and for God's sake bring them some decent food (not grapes!).

MPs are greedy cheating bastards. Who is not surprised?

Well well well! What a week! MPs expenses have been exposed by the Telegraph (after all the hard work was done by this person).

Its hard to know where to start! The government has been undertaking a smear campaign against GPs for the past 2-3 years. Finally we get our own back! I would say 98% of what was written about fatcat GPs was complete bullshit. They picked out a few high earning GPs and claimed we were all the same.

Now in parallel we have a variety of MPs who have been 'creative' with their expenses. Of course not all MPs have been misbehaving but they have been tarred with the same brush - much like we have eh?

What really grinds my gears is the complete lack of guilt the MPs have been showing. Ok, so the expenses system may have had very weak rules that could be bent so you could claim for all sorts of uncessary shit. You still have a moral obligation to do the right thing, to act 'honarably'. Just because you can claim for frivolous things that doesn't mean you should. Giving back the money just won't cut it. And as for the Speaker? He is responsible for overseeing all claims, if all these dodgy claims happened under his watch then he must take responsibilty for this. After all, if his expenses committee had done their job properly then none of these claims would have been approved.

My big worry is that this puts people off voting. If we don't vote then how can we change anything? If we don't vote your saying we don't care who gets in. If we don't vote then that mad racist homophobe down the road will and he'll vote in some equally racist homophobe.

Anyway, enough politics. Work has been ok this week. More partners working so thats helped. Practice manager wants me to help do the Pandemic flu planning and looking at workload issues. Should be interesting, said I'd only do it if he gives me some time off clinical sessions. I foresee we will be arguing about workload problems. Must make sure I read the BMA salaried contract and make sure we stick to that.

Just finished series 1 of The Wire. How cool is that series? Got series 2 and will start watching it with the wife when we get some time.

Anyone see the end of Heroes series 3 on TV the other night? What a heap of shit that series is turning into. Not sure I can be bothered to watch the next series.

Enough inane ramblings. Catch you later!

Tax is taxing thank you very much Adam Hart-Davies

After all my ranting last week I was taken off RAC (Rapid Access Clinic) at the last moment. Phew. Doing it on monday though. Bollox. Honestly the rota at work is so borked its unbelievable. Its my understanding that a session of work for a salaried GP is taken to be 4hrs 10mins according to the BMA. That includes paperwork, visits etc... Well we seem to have so many urgent extras that our morning clinic now finishes at 12-1230. That leaves 10-20mins to do visits (normally 2-3 @ 20mins each at least) + any paperwork (referrals, form filling, letter reading, checking results etc).

I honestly have no idea how we are meant to do all this. Its not only me whos getting backed up on the paperwork front. Its fine for the partners to pop in on their day off or stay late and catch up as thats whats being a partner is about - hence the fat paycheck they reward themselves. I know some of the salarieds stay late to catch up and they are slowly (or not so slowly) heading towards burnout. Its really fucked up. I'm glad I am leaving in December to go to Liverpool (part of wife's PICU training). If i wan't I think I'd leave where I am working anyway. I could rant about work all day but frankly I guess its boring to read. Still it helps me get things of my chest I suppose.

When I went into General Practice there was a shortfall in the number of Drs going into GP-land. So for a double edged promotion of sorts the government offered a golden hello (£6000 I think) + GP contracts were renegioated . Funding for GP's was altered and linked to Quality Outcomes Framework (essentially points for reaching certain clinical and managerial targets), in addition GPs no longer had to do Out-of-hours (OOH) cover (for a £6000 pay cut).

So when I went in things were looking rosey. I got a golden hello, no OOH cover and pay for GPs was going up. An unforseen (perhaps) consequence of the new funding arrangement was that it was financially better for a GP partner to hire a salaried GP rather than take on another partner in the business. For example - new partner = £120k reduction in profits, salaried GP = £70k reduction in profits, remaining profit to be split between existing partners.

In addition the government did a spectacular U-turn on the OOH cover, demanding that GPs cover from 8-8pm (even though there was v.little demand from the public for this), for no extra funding.

So now I find myself stuck in a target driven GP-land with fatcat GP partners making the salaried GPs do the donkey work and potentially having to do OOH again. Brilliant. Not only this but the government seriously fucked up hospital Dr training (MTAS) with the result that hospital Drs have had their careers ruined as well.

Labour have majorly fucked up the NHS in a HUGE way. I know of no doctor anywhere who will be voting Labour in the next election.

Well thats all the ranting out of the way. Whats that got to do with the title? Absolutely nothing. Whats happened is that I have been on basic tax rate for my GP specialist work meaning I owe the tax man over £3000. Quite how this has happened I do not know as I spoke to him in Jan after getting a massive tax bill then too and he didn't spot anything. Doing Tax returns, even online is tedious and painful, especially when you get stung for a huge tax bill.

My first entry

Woohoo. So here it is, my blog. To be honest I'll be amazed if anyone reads this. I think the main reason why I am writing this is so I can offload about how shitty work is and how GPs (especially salaried ones are getting crapped on). I might do a bit on Swine Flu as well as it seems to be the topic of the moment. This is all new to me, I guess I should post links to various bits and bobs but frankly I can't be arsed and everyone knows how to use google nowadays anyway.

I've taken a peek at various other blogs - my 2 favourites are Dr Rant and NHS Blog Doctor . Hey fancy that, I've made a couple of links. Anyway, I doubt this blog will be anywhere near as good as them as I have a sneaky suspicion that work has blocked access to blogs - the bastards. Thankfully I still have access to Twitter.

Ok, lets take a peek at BBC News health section and see whats going on there...

Hmm, mild swine flu? Its quite amusing that people seem to be miffed that its not fatal like avian flu has been or like SARS. Give it time. Influenza viruses mutate at a fair rate. Who knows, come winter it might be a bad-ass and people will be dropping like flies (or should that be pigs?). Frankly I'm glad its mild (so far), people at my practice tend to turn up literally hours after a sniffle or cough starts so even if its mild the increase workload will be a real pain in the ass.

This is rather worrying . Its hard enough to get anyone to do Child Protection. Its terrible that the GP involved who referred the child twice to A+E with suspected Non-accidental injuries has been suspended by the GMC. Not sure I understand why - does anyone? Politics I guess. Lets see, Prof Southall got suspended by the GMC and then reinstated for false accusations re child abuse. This other GP gets suspended for correct accusations re child abuse. Damned if you do, damned if you don't.

Doing Rapid Access Clinic tomorrow. Brain-child of one of the partners. Originally conceived as a rapid, simple, drop-in clinic for things like coughs, sore throat, ear ache etc. The idea was that these problems only take 2-3 mins to sort out and so don't need a 10min appointment. Trouble is is that people are coming in with stuff that really doesn't need to a GP - like waking up that morning with a sore throat. As a result the clinic is full (30+) of minor crap that could be self treated or waiting for it to settle. The clinic should really be done by a nurse with appropriate training. Complete waste of bloody time but alas, as a simple salaried GP I am unable to sway the partners. I can't even get them to change the name of the clinic - its no longer rapid access (drop-in) its now pre booked appointment slots. Completely fucking stupid.

When I get a moment I'll go through whats wrong with the practice where I am working. Mainly so I have a note of what not to do if I ever become a partner (GP partner jobs are rare as rocking-horse shit). Will save that for another day.