A shortage of GPs, but no shortage of red tape.

I am in that rare cohort of GP’s, a doctor who is returning to the UK to work. Madness I know but my wife’s job meant we ended up in Australia for a year.

At the advice of NHS England and GMC I was instructed to cancel my membership of the GP performers list and my GMC registration. This was necessary as the new rules dictate that all doctors must have an appraisal yearly (this cannot be done in another country) and you cannot be on the performers list unless you do a minimum number of GP session per year in the UK.

I was told that coming back to the UK and reapplying would be a breeze. How spectacularly wrong that was. Here is my progress so far…

1. I was able to do most of my GMC reapplication abroad – the last bit (ID check) has to be done in person. The whole process for the GMC was painless and quick. A good start.

2. The GP performers list application was another matter entirely. I was instructed at the outset that it would take up to 12 weeks to process and they wouldn’t start the process until I could prove I was living in the UK. Just to reiterate – that is 12 weeks where I would not be able to work. Three months with no pay – a quarter of the year. I’ll leave it to you to work out how much that is, if I see it in writing I might weep.

3. I tried my best to start some of the process in Australia but it was a no go. They wanted two original proofs of UK residency – a UK council tax bill and utility bill or bank account. I was going to be living with my parents for the first couple of weeks whilst we looked for somewhere to live so it would be at least that long before we had rental agreement (which didn’t count anyway). I would then have to wait for the correct forms of ID to come through the post.

4. Once I had that bit of paperwork I could start, or so I thought. They gave me the wrong form to fill in – it was for their new electronic version that doesn’t go live until September. I also need to pay £40 by cheque or postal order, cash or online payments must be too sophisticated, or something.

5. The new electronic system involves typing your answers onto an online form, which you then, er, print out and take in by hand thus saving valuable pen ink. It was obviously too difficult for them to transfer my written answers from the new form (which looks near identical) to the old form so I had to go back to their headquarters and do this. Everything I submitted has to be an original – no scans or photocopies allowed. No idea why as the first thing they do when they see my forms is photocopy them and then hand them back. Clearly they must get a large amount of forgeries to need this extra measure.

6. About mid-September, I phone up to check the forms progress, apparently my references haven’t got back to them yet (obviously too difficult for them to phone up the numbers I left on the form). I phone my references and sort that hurdle out.

7. Start of October. I have had my induction at work since that doesn’t actually involve being a GP so that’s allowed. The performers list team email me and ask can I give them a list of all my house officer jobs? God alone knows why, they are not on my CV as no employer cares about something that long ago. Thankfully I find a very old CV from years ago on my computer that has it on. They also want a certificate of proof that I am on the GP register. I politely inform them that the GMC have this information online and don’t issue certificates, any employer can simply look it up – I email them a screenshot of my GMC online GP register confirmation just in case they haven’t a clue what I am talking about.

8. Currently my application form is sat in another teams office now, its waiting for someone to re-read it and then it will be passed on to the medical director to sign, it gets passed back, emailed back to the first team and they write to me to let me know I can start work. I expect by the time I am finally approved to work this will have cost me at least £10,000 in lost earnings, more if you count the lost pension contributions etc…

It’s nice to know that GPs returning to the UK are treated so well. Hurrah! A model of NHS efficiency

Committee for Responsible and Appropriate Prescribing (CRAP)

I was going to continue my blog exploring what other gems are hidden away in the white paper but I’ve changed my mind (its my blog and I can do that). In the news today it was announced that the National Institute for Clinical Excellence is to be stripped of its power to decide on which new drugs get the nod for NHS prescribing.

Instead that dubious honour will be given to GPs. So in addition to looking after their own patients, managing the practice, juggling the budget for the NHS as a whole they will now take on this role too. NICE will be relegated to giving out advice about drugs and creating guidelines (a bit like the Drug and Therapeutics Bulletin does).

NICE was independent of government influence and made decisions based on a combination of the clinical effectiveness of a drug and its overall cost. NICE got in trouble after patient groups (more often than not funded by drug companies) and the media would criticise them for not recommending drugs that it deemed to be clinically ineffective or of marginal benefit but v.expensive. It’s a tricky thing that I don’t think the public fully appreciates. The NHS is not a bottomless pit of cash. It has a finite drug budget – once gone then that’s it. The overall NHS budget for the next year has been increased to 0.5% but taking into account the annual inflation of NHS costs that amounts to about a 5% cut. Not only that but the government expects the NHS to find £20bn in efficiency savings over the next 4 years.

NICE was created, in part, to get rid of a postcode lottery of drug prescribing. Some PCTs would approve expensive treatments, some wouldn’t. NICE created a level evidence-based playing field that everyone could stick too. Doctors like having an independent body we could turn to that offered expert opinion on new drugs (even if it was a bit slow at times). Now various GP prescribing groups up and down the country will have to take on the role of evaluating drugs and deciding what’s allowed and what’s not. Should a patient get drug X that costs £20k per year and might increase life expectancy by 4months or should 1000 patients get drug Y that costs £20 per year that reduces the risk of heart disease? What do you say to patient(s) you decline? What do GPs say to the lobby groups that will no doubt start nagging them about some new fancy experimental drug? What do GPs do when the media paints them as fat cat GPs not allowing drugs as they are penny-pinching? How will GPs feel when the government blames them for spiraling NHS budget costs?

GPs will have to form committees to decide which new drugs get the nod or not. I suggest it’s called the Committee for Responsible and Appropriate Prescribing (CRAP). Of course there wouldn’t be a national one (otherwise why get rid of NICE’s powers) so no big CRAP. Instead there will be lots of regional ones – lots of little CRAPs. Which GPs will want to be in the CRAP? Will patients understand the CRAP rulings? It feels like GPs have been given more crap then they can possibly handle. I’m trying to recall the all the health economics training I got as a GP. Oh that’s right, there isn’t any.

Perhaps I am being a tad negative. GPs could with their new powers get rid of a lot of duplication in prescribing. For example funding for one or two types of a class of drug rather than several, or cutting funding for isomerised versions of drugs. I wonder what would happen if a CRAP group wanted to allow prescribing of Heroin?

The degree of change going on the NHS is quite staggering considering the government said that they wanted a hands off approach to the NHS originally. It was a scary enough prospect considering becoming a GP partner and managing my own practice and small budget. Now being expected to sort out the NHS budget and take over the role of NICE is quite frankly terrifying. I think I’ll stick to being a locum for the time being.

Actually on second thoughts any GP involved in a CRAP will no doubt get some hefty backhanders from drug companies so its not all bad…

NHS reforms, the iceberg in the water?

I’ve heard it said before that trying to change the NHS is a bit like trying to steer the the Titanic – painfully slow. Well if the NHS is the ship then perhaps the new NHS reforms are the iceberg in the water? The British Medical Association, Unison and Royal College of Nursing have all started warning against the NHS reforms but the government is just going to ignore them.

Before I start my usual ranting I think its worth a bit of an introduction. The last government had tried their best to change the NHS from a doctor-led caring service to a patient demand driven tick-box target-driven nightmare. It was always amusing and perhaps a tad exasperating to hear the previous government talk about 18 week targets and how good everyone was at meeting them. The sad truth is that the numbers were often carefully massaged and manipulated, for example having waiting lists to get on the waiting list. Apparently these waiting lists don’t count for some arcane reason.
Choose and book was created to meet a fictional demand for such a service. Patients can book their own appointments but often referrals vanished into thin air, answerphones switched off (so no messages could be left) and patients called back when they can’t answer the phone (so are booted off the waiting list). All ingenious ways of reaching the mythical 18week target. The worst cases of creative target meeting were A&E departments (too numerous to mention here).
General Practice had a shiny new contract as there was a shortage of doctors becoming GPs. Finally GPs could work sensible hours, could opt out of out-of-hours care (for a pay cut) and would get a pay rise for meeting a variety of targets. Sadly GPs were too efficient met all the targets and they pay soared. The government then waged a bit of a hate campaign against GPs, altered targets, froze pay and forced them to do extended hours again for no extra pay when there wasn’t even a demand for it.
There was also a little thing called Medical Training Application Service (MTAS) – a new way of allocating jobs for junior doctors. Unfortunately it was an umitigated disaster causing a colossal crisis in recruitment and even caused some doctors to leave medicine all together.

And so here we are, a new government and a whole new set of reforms despite telling us at the outset there would be no such reforms. Ho hum. Control of the NHS budget is to be handed to GPs and Primary Care Trusts abolished. Primary Care Trusts previously held the purse strings and could dictate to GPs and hospitals what the money could be spent on.
So now GPs will be in control of multi-million pound budgets. This of-course assumes that they actually want take on this massive responsibility. I stupidly thought that GPs wanted to be doctors who care for their patients rather than be managers. Obviously GPs will have to hire staff to do this complex job so where will they get them from? Well, PCTs will have to make all their staff redundant and give them a hefty redundancy package. These same staff will no doubt be re-hired by GPs to do the jobs they were originally doing. I wonder how much this re-jigging of staff will cost? Not to mention all the re-branding that will be involved!
The government have said that the NHS would be ring-fenced to protect its funding but still want it to find £20bn of savings by 2014 (huh?). So GPs are expected to play a key role in finding these savings by allocating the NHS budget. This means they get the blame rather than the government for cutbacks etc… (clever!). Also GPs won’t see a penny of any savings they might create. More work, no compensation and we’ll get the blame if it goes tits up. Yes please!

I’m going to have a break now. Blogging about the politicians buggering about with the NHS is depressing, tiresome and I’m getting bored (as I’m sure you are also). More ranting after the break. Comments welcome.
p.s. If you want me to post hyperlinks to anything in this blog let me know (I’m lazy)

NHS White Paper

(For an article in Pulse Magazine)

Just read the NHS white paper and it looks like we GPs can finally stop being back seat drivers of the NHS and have a go at the wheel. Well I say we, I really mean GP Partners. Salaried GPs will still be trying to fill the whole left by the GP Partners who have gone on to become new NHS managers, play golf or sit in the staff room with their feet up. Locum GPs like me will fill the whole left by all the burnt out salaried GPs who can’t take it anymore, and the gaps left in the rota by GP Partners playing golf.

Of course I am being my usual cynical self, its not all bad. I am sure great good can be achieved over time but the level of re-organisation required for the NHS mark II (as I like to call it) is quite terrifying. It won’t be cheap so how we can save £20 billion and reorganise the NHS simultaneously is anyone’s guess. I’m hopeful that GP Partner numbers will increase fairly dramatically as I don’t think salaried GPs will want to get hands dirty without a hefty pay rise.

I’ve heard other GPs talk about it being a bit like fund-holding all over again, but this it is compulsory. All GP practices will be forced to be part of a GP consortium. There they will have to fight it out, argue, arm-wrestle or do whatever GPs are going to do to decide where the money goes to. No longer can you fob off your patients and say the PCT has pulled the funding for tummy tucks, it will all be your fault. Now when you see a patient needing an operation you’ll be thinking how much this is going to cost and how much abuse will I get at the next GP consortium meeting for referring them.

Patients are meant to have control over their medical records and can go to whomever they want, wherever they want for an opinion. Practice boundaries are to be abolished - its nice to see the government listened carefully to all the objections to this problem, then ignored them, screwed up the bit of paper it was written on and then burnt it.

You’ll be over-joyed to hear patients will have choice, choice and a bit more choice with added choice on the sides and sprinkled on top. Apparently patients like to choose. It doesn’t matter that all that choice is expensive, unnecessary and a bureaucratic nightmare. Almost always when I’ve asked patients about where they would like to go to its wherever is nearest. Regardless of the fact that the nearest place doubles as a butchers shop at the weekend and offers a 2 for 1 special on MRSA and C.dif infections

Of course there will be some GPs who will be positively tumescent at getting their hands on a big pot of cash to play with. I wonder how quickly their tumescence will shrivel when they realise they’ll get the blame if it all goes breasts skyward.

However, GPs are well known for agreeing on everything, their lack of financial motivation and running multi-billion pound budgets. I honestly can’t see anything that could go wrong.

NHS or RHS?

I have realised that we don’t have a National Health Service. We have a regional one. Its only since I’ve been a locum and worked in 3 different counties that I’ve realised this. What do I mean? Well let’s take admitting a patient into hospital for a start. Each hospital has its own rules for admitting a patient. Some have a GP hotline, some have a switchboard may or may not answer and when they do they can’t find the doctor you are looking for, and some have their own team who negotiate on your behalf with the admitting doctor. I don’t get it. How hard can it be to have a common admission pathway to hospital? Very hard it seems. In the end you get fed up trying to work out what’s going on and the patient gets bounced to A+E with a letter.
What about paperwork? Each hospital has its own paperwork to be filled in, different colour schemes and boxes to be ticked. Is it too much to ask to have one set of universal notes? They would look the same for every hospital and could be easily read through, filled in and relevant section found? Far too sensible. Each hospital has to have its own identity so someone somewhere in an office can justify their salary. Universal notes would save on stationary costs, improve patient care (as everyone knows where everything is) and you could even audit things easier if you were so inclined. Hell, if every hospital stuck to this you could even begin to attempt to computerise it. There could even be a standardised admission letter that GPs could use so the admitting doctor could read our ineligible scrawls.
Mind you I can’t be too critical of different hospital records seeing as I have had to train in 5 different electronic record systems to be a GP locum. Some of the systems I’ve used a truly rubbish, God only knows why the GPs use them.
I could rant about postcode lotteries for health care but everyone knows about those. I’m talking about what goes on behind the scenes. Nurses needing to retrain when they move hospitals because one hospitals certificate aren’t valid in another hospital. New doctors not having the faintest idea how to fill in requests for tests as every hospital does it differently. TTO forms that vary from place to place with varying information filled in. Getting everyone to agree on all this would be a nightmare. But then that’s where politicians come in, so we can blame them if it all goes wrong.
I read that it’s the ambition of Labour and Conservative that every hospital becomes a Foundation trust (worked well for Mid Staffordshire?). With this of course it would mean a rebranding of each hospital. New signs, new letterheads, new everything. That will not be cheap, and surely some of that money could be better spent ensuring the smooth running of the hospitals and the staff that work there. You might even improve patient care, but that’s not my main concern, I just want an easy life.

Shit Life Syndrome

I think I have discovered a new syndrome, well I say new but really its been around for as long as politicians have lied. I had a patient see me the other day who was feeling down in the dumps. Being a kind & caring GP I patiently sat and listened to her tell me her life story of how she has no money, no job, an abusive boyfriend, a young baby to feed and how its all making her feel a bit, well, shit. Believe it or not but I don’t have a magic pill that can fix this, I asked her why she came to the GPs but she wasn’t sure, she didn’t know what else to do. She has a syndrome that I am seeing more and more nowadays. It consists of low mood caused by adverse life circumstances. Otherwise known as “Shit-life Syndrome”.
Depending on where you work you’ll probably see a few of these cases. They are easy to recognise. About 5minutes into their history you mind will start to wander, perhaps thinking about what you are going to have for lunch or how that bid for an ivory back scratcher is going on ebay. Several minutes later your mind will wander back the patient who will still be telling you about all the terrible things that are going on in their life. There isn’t really much you can do, you ponder that if your life was going as shit as theirs you’d feel pretty depressed too. What about counselling? “Nah, tried that before doc and it was rubbish” (Waiting list is vast anyway). Ok then, what about antidepressants? Won’t change a thing but will make the drug companies happy.
I know! Exercise, going for nice walks, going out with your friends? Gyms too expensive, have you seen where I live doctor, and I’ve not got money to go out are the 3 rapid replies. This patient has “shit life syndrome”, nothing you can do for them other than listen. Maybe sign the odd ‘fit-note’ so they can get a bit of extra cash to help pay for the 50 inch flat screen telly every feels they have to own.

What’s the solution? Perhaps society needs to concentrate less on accumulating wealth and more on accumulating happiness? But we live in a consumer-drive society with an economy in nosedive so this isn’t going to happen anytime soon. Oh well, lets just cut benefits, raise taxes and penalise anyone else who happens to have shit-life syndrome (aka the Daily Mail solution)

NHS cuts or efficiency savings..?

As we rapidly approach the General Election the main political parties seem to be trying to out do each other with their spending plans (or non-spending plans to be more accurate). I read that the NHS is expected to save £4bn in the next couple of years and up to £20bn by 2014.

Thats a lot of pennies. Of course the politicians hate to talk in terms of cuts to spending so its called 'efficiency savings'. Surely this then implies that they have been throwing money at the NHS without bothering to check if its spend efficiently? Curiously this seems to happen all the time at the Ministry of Defence. They always seem to pay far too much, get the items (planes/helicopters) far too late and then their not even fit for purpose. I must confess I don't understand funding billions for the killing industry but then cutting funding for the life-saving one?
Anyway, I'm not a politician - thank God. I don't have to worry about balancing the books. But what if they decided to make the NHS independent of political control, like the Bank of England (fat chance)?

If you had to cut the NHS budget by £4bn what would you target?

Choose and Book? Where most patients want to choose their local hospital and the booking process is unnecessarily complex? Well that’s £200million, of course you have to replace it with something - which will have its own costs. What about the entire National Programme for IT? That’s meant to have cost £2.3bn over 3 years, now £12+bn and its still not finished. I don't think you can get a refund sadly so it may not actually save that much by scrapping it.
Homeopathy on the NHS - clearly a waste of money but would only save £4m. Independent Sector Treatment centres - ah, now that scrapping area might save a fair few quid seeing as they seem to get paid regardless of whether they do the work or not. What about the Private Finance Initiative scheme which is funding over 100 hospitals? That’s a whopping £10.9billion but by the time the final payments are made in 2048 that will be £62.6bn - again, can't get a refund and can't pull out of existing schemes but stopping wasting money on future schemes would seem sensible. How about restricting prescribing to a limited list of cheap and cheerful generics? Or is that a step too far?

Of course you could go to all this trouble by shafting the NHS and then bankers waste billions on some hair-brained-get-rich-quick scheme, need another bailout and then we are back to square one again.

Ultimately I know what will happen. GPs will get it in the neck. Funding will be reduced, we'll be berated in the press for being greedy bastards and its only a matter of time before our pensions are plundered. None of this will fix the problems but it takes the heat of the MPs and we are an easy target as we never seem to do anything about it.

Death becomes her

As a locum GP I think I am getting better at spotting money making opportunities when they turn up. I note that the public seems to be changing its opinion on assisted suicide, or active euthanasia to give it its proper term. No doubt this will eventually be made law as politicians have an annoying habit of passing populist laws based on opinion rather than fact or worst still hiring experts and then firing when they don’t agree with them. It does seem a curious vote winner but we live in curious times I guess.

Anyway, back to my first point, how can you (or the NHS) make money out of assisted suicide? It seems clear that this will eventually become law so I suggest brushing up on ways to kill your patients. No doubt the Shipman Guidelines will need to be drawn up to decide what drugs are best at bumping patients off. I’ll hazard a guess and say that not every doctor is entirely keen on the idea of euthanasia or variants of it. Well, its no time to be displaying a backbone or relying on your moral guidance.

As a large number of doctors will not want to take part in the selective reduction of vulnerable patients it could mean a big cash bonus for those of willing to wield the scythe. I’m sure you can think of a number of your elderly patients who don’t want to be seen as a burden or make a fuss, well now you could finally have the opportunity to help them shuffle off this mortal coil. You no longer have to worry about such trivialities as palliative care and all those fiddly drugs. A quick consent form, needle in the arm or pills in a cup and hey presto, one assisted suicide cash bonus and perhaps even a cremation form fee if you are lucky.

Its only a matter of time before it becomes part of the QOF targets. Just think of all the money it could save the NHS! ICU bed numbers could be slashed, hospices could close and we’d have another treatment option for our severely depressed or heartsink patients. Hopefully the money saved will be reinvested in other areas of the NHS but don’t hold your breath. The Government is pretty short of cash at the moment and needs every penny.

If you became a Specialist in Regulated Euthanasia Assisting the Passage to Everlasting Rest (R.E.A.P.E.R) you can forget about the need for basic life support skills (unless you ‘assist’ the wrong patient!). I would expect that it would be unlikely the patient complains but its possible that the family might if their dear relative didn’t die peacefully or if you declined to ‘assist’ their granny who lives in mansion that’s far too big for her.

Seems like a win-win situation to me, what could possibly go wrong?

To jab or not to jab?

A patient came to see me the other week and asked me about the swine flu jab for her children. Should she get her children vaccinated?

She had two healthy children under five with no pre-existing illnesses. The media had helpfully pointed out that the children who had died from swine flu had pre-existing illnesses, although rather more unhelpfully no one was saying what these illnesses were.

Being a locum, I thought I had missed the official information to give to parents about the jab. I checked in with Dr Google but couldn’t find a thing. A few papers here and there, but nothing that had meaningful numbers in it. I was surprised as there is a wealth of very good information for parents about other vaccines but nothing that I could find for swine flu.

Eventually she decided that she wasn’t going to bother as she thought it was all rubbish. Not exactly the informed choice I was hoping for, but it’s her choice nonetheless.

Then the invite came through for our children, I was faced with the same choice: to jab or not to jab? I won’t bore you with medical papers that I read to see if was really necessary to vaccinate an otherwise healthy child for a mild illness (in most) that she may have already had or may not even catch.
Click here to find out more!

But what I wasn’t prepared for was the amount of hand wringing and floor pacing about the decision to potentially stick a needle in my child’s arm. Previously the wife had taken the children to their jabs so she had to endure the sight of a needle piercing their flesh, the looks of betrayal on their cherub-like faces and the inevitable ear piercing shriek that followed.

The daughter was sick the other day, and three weeks later she is still harping on about how she puked – God knows who taught her that word. Would I be prepared for her constant whining about how Daddy let the nurse hurt her and the years of counselling she would no doubt need afterwards? Not to mention the fact that it’s not nice to see your child in pain. Would I get emotional? I couldn’t blame it on the hayfever as it was winter. Perhaps blaming the dusty environment might help.

It made me realise that what we might regard as trivial – a quick jab, or a blood test - can be very upsetting for the child and parent and that might discourage them from attending or going along with the management plan. How do you explain to a 3-year-old what is about to happen? It's no wonder children bawl their eyes out when they attend the doctors.

I’ve asked colleagues and friends about the swine flu jab and it's been more or less a 50:50 split over whether their children have had it or not. The uptake is poor in the otherwise healthy, which has got me wondering whether it was worth offering in the first place?

The government wasted million on Tamiflu, which was largely useless. Have they done the same for the swine flu vaccine?

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.