Margaret McCartney's Blog, page 12

Clare Gerada, Anna Soubry and 'part time' doctors

Clare was great.

Anna Soubry was not.

Andrew Neil: Anna Soubry's boss, Simon Burns, he claims you don't represent the views of GPs up and down the country in opposing these health reforms. What do you say to that?

Clare Gerada: I think I do, I represent 44,000 GPs, of which over 90%, when we've surveyed them very recently, wanted me to ask for withdrawal of the bill, and that's against the background of 1 and a half years of consultation, 3 surveys, 5 councils, 5 executive councils, a national conference, endless consultations, I can categorically tell you that my members of the Royal College of GPs do not want this bill. Some of the parts of the bill are good, I mean putting GPs in control of money, putting patients first, addressing health inequalities, but in it's totality, the bill is a mess, the bill is flawed, and the bill will not achieve what you and Andrew Lansley and the Prime Minister are setting out to achieve.

Andrew Neil: She represents 90% of GPs..

Anna Soubry MP : I think she's wrong. I don't agree. Hang on, let me….let me tell you what I think. I go into my consistency, I talk to GPs, real GPs, on the ground, in my area, the consortia was formed before we got elected into government, they are putting into operation already what we are seeking to achieve, that is my experience in my constituency, with my GPs, and let me tell you this. I was approached by a doctor who lives in my consistency, but practices in Nottingham. And he took hold of me and said 'for god's sakes, get this bill through, so I can deliver the treatment to my patient, that I want to do'.

AN: But that's anecdotal evidence. Her evidence is surveys and conferences …

AS: But I'm talking about life at the real end.

AN: ..why should your anecodal evidence be.more important than hers?

AS: I didn't say it was, I didn't say it was more important, I think…

CG: I work as a GP, we're part of one of the first waves -

AS: But you work part time.

I thought I might feel less angry about this since it was broadcast on the 23/2/12, but I don't.

Sourby seems to think we need reform, but also says that GPs are already providing what she wants the NHS to achieve. She notes the survey from the RCGP, but believes only the evidence she has personally come across. (Has she received no letters of dissent?) She believes that a GP who works in Nottingham can't provide a service to patients that he wants to and therefore needs reform of the law to do so (what service? Private enterprise is the major incentive to this bill – is that what he wanted? )

But what makes me really angry was Soubry's dismissal of Clare Gerada's knowledge of life at the front end as a GP because she was 'part time'. I don't think I've heard this put down used quite so dismissively in some time, and interestingly, I've never heard it used against a man – and also, many doctors work 'part time' in clinical care because of academic, management or other commitments - do we deride them equally as part-timers? What I do when I'm not at work is just as important – why do we degrade caring for family as a reason to somehow be stripped of ability?

Clare Gerada is clearly working full time plus – as a GP but also as chair of the largest College at a tumultous time in the NHS. To attempt to play the 'part time card' is unintelligent and unfair not just to Clare but to the thousands of part time doctors in the UK who work hard and who have just as much right and ability to know what is happening in the front line – and who know that this health bill is bad for patients, and will worsen inequalities - and who know that the government are not listening to them.

I'm still angry.

 

Clare Gerada, Anna Sourbry and 'part time' doctors

Clare was great.

Anna Soubry was not.

Andrew Neil: Anna Soubry's boss, Simon Burns, he claims you don't represent the views of GPs up and down the country in opposing these health reforms. What do you say to that?

Clare Gerada: I think I do, I represent 44,000 GPs, of which over 90%, when we've surveyed them very recently, wanted me to ask for withdrawal of the bill, and that's against the background of 1 and a half years of consultation, 3 surveys, 5 councils, 5 executive councils, a national conference, endless consultations, I can categorically tell you that my members of the Royal College of GPs do not want this bill. Some of the parts of the bill are good, I mean putting GPs in control of money, putting patients first, addressing health inequalities, but in it's totality, the bill is a mess, the bill is flawed, and the bill will not achieve what you and Andrew Lansley and the Prime Minister are setting out to achieve.

Andrew Neil: She represents 90% of GPs..

Anna Soubry MP : I think she's wrong. I don't agree. Hang on, let me….let me tell you what I think. I go into my consistency, I talk to GPs, real GPs, on the ground, in my area, the consortia was formed before we got elected into government, they are putting into operation already what we are seeking to achieve, that is my experience in my constituency, with my GPs, and let me tell you this. I was approached by a doctor who lives in my consistency, but practices in Nottingham. And he took hold of me and said 'for god's sakes, get this bill through, so I can deliver the treatment to my patient, that I want to do'.

AN: But that's anecdotal evidence. Her evidence is surveys and conferences …

AS: But I'm talking about life at the real end.

AN: ..why should your anecodal evidence be.more important than hers?

AS: I didn't say it was, I didn't say it was more important, I think…

CG: I work as a GP, we're part of one of the first waves -

AS: But you work part time.

I thought I might feel less angry about this since it was broadcast on the 23/2/12, but I don't.

Sourby seems to think we need reform, but also says that GPs are already providing what she wants the NHS to achieve. She notes the survey from the RCGP, but believes only the evidence she has personally come across. (Has she received no letters of dissent?) She believes that a GP who works in Nottingham can't provide a service to patients that he wants to and therefore needs reform of the law to do so (what service? Private enterprise is the major incentive to this bill – is that what he wanted? )

But what makes me really angry was Soubry's dismissal of Clare Gerada's knowledge of life at the front end as a GP because she was 'part time'. I don't think I've heard this put down used quite so dismissively in some time, and interestingly, I've never heard it used against a man – and also, many doctors work 'part time' in clinical care because of academic, management or other commitments - do we deride them equally as part-timers? What I do when I'm not at work is just as important – why do we degrade caring for family as a reason to somehow be stripped of ability?

Clare Gerada is clearly working full time plus – as a GP but also as chair of the largest College at a tumultous time in the NHS. To attempt to play the 'part time card' is unintelligent and unfair not just to Clare but to the thousands of part time doctors in the UK who work hard and who have just as much right and ability to know what is happening in the front line – and who know that this health bill is bad for patients, and will worsen inequalities - and who know that the government are not listening to them.

I'm still angry.

 

The Patient Paradox has arrived.

I am cringing rather, but I've written a book, and I hope that it will a useful contribution to the debate about the limits of medicine and what doctors are for. The book covers the making of well people into patients for little gain and often harm (screening), what is normal and not, the perverse political incentives that dictate what doctors do, and the real benefits of medicine. These I think are evidence based, compassionate, professional benefits – listening, taking time with patients, and generating the 'placebo effect' without the use of deceptive placebos.

You can search inside at Amazon, and the publishers have 20% off and free delivery here. All the references are available here with as many live links as possible, although of course many papers beyond the abstract are behind a paywall, with apologies.

Comments and criticisms welcome.

 

CMOs and vitamin D

Am rather concerned by the stipulation that all over 65s should have a vitamin D supplement
when the evidence is rather less clear: see Cochrane, who are also clear about risk of harms.
Ironic, given how few commercial skin products are SPF- free.

Our reference: CEM/CMO/2012/04
Gateway reference: 17193
To:
General Practitioners
Practice Nurses
Health Visitors
Community Pharmacists
2 February 2012
Dear Colleague
~~~
The Scottish
Government
,DH)Department
of Health
VITAMIN D - ADVICE ON SUPPLEMENTS FOR AT RISK GROUPS
We are aware that some of the UK population may be at risk of vitamin D deficiency. This is a
concern, particularly for at-risk groups such as pregnant women and infants and young
children, which is why we, the Chief Medical Officers for the United Kingdom, are writing to
health professionals to increase awareness of this important issue.
Last year the Chief Medical Officer for Scotland, Sir Harry Burns, wrote to health professionals
in Scotland on this topic.
http://www .scotland.gov. uk/Topics/Health/health/Health/EatingHealth/vitamind/CMOletter
This letter is a restatement of this advice and contains important information about prescribing
and recommending vitamin D supplements to those groups of the population at risk of vitamin
D deficiency.
The National Diet and Nutrition Survey, demonstrates that up to a quarter of people in the UK
have low levels of vitamin D in their blood, which means they are at risk of the clinical
consequences of vitamin D deficiency!. Although we do not have clear data on the
implementation of the current advice on the use of dietary supplements containing vitamin D by
1 Data from years 1 & 2 of the National Diet and Nutrition Survey (NDNS) rolling programme. Low status is defined
by the Department of Health as a plasma concentration of 25-hydroxyvitamin D (25(OH)D, the main circulating form
of the vitamin) of below 25nmol/l (equal to 10 ng/ml).
the at-risk groups listed below, information from the 2005 Infant Feeding Surve/ suggests that
the majority of women do not take vitamin D supplements during pregnancy.
Vitamin D deficiency impairs the absorption of dietary calcium and phosphorus, which can give
rise to bone problems such as rickets in children, and bone pain and tenderness as a result of
osteomalacia in adults.
The following groups of people are at risk of vitamin D deficiency:
• All pregnant and breastfeeding women, especially teenagers and young women.
• Infants and young children under 5 years of age.
• Older people aged 65 years and over.
• People who have low or no exposure to the sun, for example those who cover their skin
for cultural reasons, who are housebound or confined indoors for long periods.
• People who have darker skin, for example people of African, African-Caribbean and
South Asian origin, because their bodies are not able to make as much vitamin D.
Recommendations
All UK Health Departments recommend:
• All pregnant and breastfeeding women should take a daily supplement containing
10 micrograms of vitamin D, to ensure the mother'srequirements for vitamin D are met
and to build adequate fetal stores for early infancy.
• All infants and young children aged 6 months to 5 years should take a daily supplement
containing vitamin D in the form of vitamin drops, to help them meet the requirement
set for this age group of 7-8.5 micrograms of vitamin D per day. However, those infants
who are fed infant formula will not need vitamin drops until they are receiving less than
500ml of infant formula a day, as these products are fortified with vitamin D. Breastfed
infants may need to receive drops containing vitamin D from one month of age if their
mother has not taken vitamin D supplements throughout pregnancy.
• People aged 65 years and over and people who are not exposed to much sun should
also take a daily supplement containing 10 micrograms of vitamin D.
Are free vitamin D supplements available?
Women and children from families who are eligible for the Government's Healthy Start scheme3
can get free vitamin supplements which include vitamin D, in the form of tablets for women and
drops for children.
It is the statutory responsibility of PCTs, the local trust or Health Board4 to make Healthy Start
vitamins available locally to women and children on the scheme. Health
2 Bolling K, Grant C, Hamlyn B, Thornton A (2007). Infant Feeding Survey 2005. The Information Centre
3 Healthy Start is a UK-wide statutory scheme providing a means-tested nutritional safety net to pregnant women
and families with children under four years old in very low income and disadvantaged families. It provides vouchers
for basic healthy foods and coupons for Healthy Start vitamin supplements to women and children in around
460,000 UK families.
professionals should fa milia rise themselves with local distribution arrangements for Healthy
Start vitamins.
Uptake of the Healthy Start vitamins among families qualifying for the scheme is currently low.
However, the UK Health Departments are committed to continuing to support NHS staff
involved in maintaining local distribution arrangements, and those in a position to champion
Healthy Start, to share and encourage good practice.
It is important that women and families who may be eligible for Healthy Start know how they
can apply for the scheme, and are made aware of how they can obtain vitamins locally.
Women qualify for Healthy Start from the 10th week of pregnancy or if they have a child under
four years old, and if she or her family receive:
• Income Support, or
• Income-based Jobseeker's Allowance, or
• Income-related Employment and Support Allowance, or
• Child Tax Credit (but not Working Tax Credit unless the family is receiving Working Tax
Credit run-on only) and has an annual family income of £16,190 or less.
Women who are under 18 and pregnant also qualify, even if they do not get any of the above
benefits or tax credits. Further information can be found on the Healthy Start website at
www.healthystart.nhs.uk
NHS organisations can choose to sell the vitamins or supply them free of charge to those who
are not eligible for Healthy Start, and we encourage thiss. Alternatively, vitamin D supplements
are available for purchase or can be prescribed for those who are not eligible for the scheme.
The National Institute for Health and Clinical Excellence (NICE) publiC health guidance on
maternal and child nutrition6 (publiShed in 2008 and updated in 2011), supports the UK Health
Departments' recommendations on vitamin D supplements. NICE recommend that during the
booking appointment at the beginning of pregnancy, midwives should offer every woman
information and advice on the benefits of taking a vitamin D supplement during pregnancy and
while breastfeeding. NICE also recommend health professionals take particular care to check
that women at greatest risk of deficiency are following the advice during pregnancy and while
breastfeeding. This includes women from ethnic minority groups (particularly of African, South
Asian or African-Caribbean origin) and women who do not get much sun (for example, women
who cover their skin when outside or who spend large amounts of time indoors).
4 The Healthy Start Scheme and Welfare Food (amendment No.2) Regulations 2006 (2818). Section 7 and The
Healthy Start Scheme and Day Care Food Scheme Regulations (Northern Ireland) 2006 (S.R. 2006 No. 478)
Regulation 11 'Provision of Healthy Start vitamins'
5 For more information about Healthy Start vitamins including distribution case studies visit
www.healthvstart.nhs. uklfor -health-professionals/vitam ins
6 NICE public health guidance (2008). PH 11 Improving the nutrition of pregnant and breastfeeding mothers and
children in low-income households.
It is important for public health that low levels of vitamin D are avoided. As health
professionals, you can make a significant difference to people's health by making those at risk
aware of how important it is to make sure they get enough vitamin D, and how they can get
access to these important daily supplements.
We, the Chief Medical Officers, thank you for your continued help and support with raising
awareness of this issue, which in turn should raise the levels of vitamin D in those at risk, and
vulnerable groups.
PROFESSOR DAME SALLY C DAVIES
CHIEF MEDICAL OFFICER ENGLAND
CHIEF SCIENTIFIC ADVISER
DR TONY JEWELL
CHIEF MEDICAL OFFICER WALES
DR MICHAEL McBRIDE
CHIEF MEDICAL OFFICER NORTHERN IRELAND ~C~b~q~
Sir HARRY BURNS
CHIEF MEDICAL OFFICER SCOTLAND

Inside Health

What's happening in the consulting room – it's not just about you, but the silent politician on my shoulder. Column on political incentives to GPs.

ECT : Why it shouldn't be banned.

 

This is in reply to David Colquhoun after a twitter discussion.  @david_colquhounhas signed a petition calling for ECT to be banned. I think this is a very bad idea.

First off: ECT has been overused and badly used in the past. I don't think it should be used where a patient doesn't consent to it, and neither does the RCPsych – see here – "f you have made it very clear that you do not wish to have ECT then you should not receive it". There are many reasons why people who have been helped by ECT may not wish to disclose that they've had it – which is absolutely fine – and this means that, if we go by anecdote, the good outcomes may not be as audible or visible as others.

ECT is not used lightly. There are clear guidelines saying that it should be considered in high-risk or very severe illness. Banning ECT would mean that these groups of patients wouldn't have it as an option. If ECT works, this would effectively mean prolonging suffering or risk for longer than necessary.

So does it work? One of the very difficult issues with depression research has been the problematic categorisation of low mood. We know that most people have low mood at some point, but we also know that most of this is not depression. David Healy has noted that originally, in the 1950s, pharma were reluctant to do research into antidepressants because depression was uncommon and they were unlikely to recoup their costs. What we term 'depression' is likely to be a large mixed bag, with different causes, severities, impacts and best treatments. This problem makes it difficult to tease out what works best for who – we have seem the same problem with SSRIs, for example. I've written before about why these medications are effectively overused. I'm also not going to defend poor research, or the lack of useful research into treatments for many mood disorders. The placebo effect is also likely to be strong in many cases, and another frequent problem is the tendency for pharma companies not to include a placebo arm but simply compare one antidepressant to a newer (usually more expensive) one.

So what is the evidence? Cochrane have not found enough evidence to say whether it's better than antidepressants in older people, and have recommended better research. However, the trials don't appear to have clearly separated conditions like psychotic depression, or depression where life is at risk eg due to not eating or serious suicide attempts. Cochrane have also published a protocol to assess ECT in adults with depression, and I look forward to reading their conclusions.

ECT has had around 12 trials looking at sham versus 'real' ECT. These have been critically assessed here (need Athens login). Interestingly, the review found that there was a similar situation to the SSRI trials, in that the more severe the depression, the greater the distinction between additional response and placebo effect. However, it's important to note that 'placebo' may not be quite accurate: these patients were inpatients, likely to have been receiving support from nursing, psychological and medical staff; they may have been receiving other medication. All we know is that a substantial portion of patients got better over time – whether we can call that 'placebo', really, is moot, especially given this Cochrane review. This systematic review in the Lancet grouped 'depression' together and found a positive effect in the short term for ECT  (it's well recognised that ECT should be supported by starting other treatment at the same time as it's instigated.)

I think ECT has a role, though limited. Part of the problem is the poor classification of depression. I think  a ban is unfair to people who have found it effective before and would elect to have it in the future. Better research does need to be done. But banning it is unhelpful and disregards the evidence.

Principal CORE Study Reports, 2001-2010.

 

 

1. The influence of age on the response of patients with major depression to

electroconvulsive therapy. Am  J Geriatr Psychiatry  2001; 9:382-390.   [O'Connor MK Knapp R, Husain M, Rummans TA, Petrides G, Smith G, Mueller M, Snyder K,Bernstein H, Rush AJ, Fink M., Kellner C. ]

 

2. ECT remission rates in psychotic versus non-psychotic depressed patients: A

report from CORE.  JECT 2001; 17:244-253.  [Petrides G, Fink M, Husain MM,

Knapp R, Rush AJ, Mueller M, Rummans TA, O'Connor KM, Rasmussen KG,

Bernstein HJ, Biggs M, Bailine SH, KellnerCH.].

 

3. Speed of Response and Remission in Major Depressive Disorder with Acute

ECT: A Consortium for Research in ECT (CORE) Report. J Clin Psychiatry
2004; 65:485-491.  [Husain MM, Rush AJ, Fink M, Knapp R, Petrides G, Rummans T, Biggs MM, O'Connor K, Rasmussen K, Litle M, Zhao W, Bernstein HJ, Smith G, Mueller M, McClintock SM, Bailine SH, Kellner CH.]

 

4. Relief of expressed suicidal intent by ECT: A Consortium for Research in ECT Study.

Am J Psychiatry 2005;162: 977-982.  [Kellner CH, Fink M, Knapp R, Petrides G,

Husain MM, Rummans T, Mueller M, Bernstein H, Rasmussen K, O'Connor K,

Smith G, Rush AJ, Biggs M, McClintock S, Bailine SH, Malur C.]

 

5. Continuation ECT versus pharmacotherapy for relapse prevention in major depression:

a multi-site study from CORE. Archives General Psychiatry . 2006;  63:1337-44.

[Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM,

Rasmussen K, Mueller M, Bernstein HJ, O'Connor K, Smith  G, Biggs M, Bailine

SH, Malur C, Yim E, Sampson S, Rush AJ, Fink M.]

 

6. Patterns of Psychotropic Medication Use Among Severely Depressed Patients

Referred for Electroconvulsive Therapy: Data from the Consortium for Research

on ECT. J ECT 2006; 116-123.  [Rasmussen KG, Mueller M, Kellner CH, Knapp

RG, Petrides G, Rummans TA, Husain MM, O'Connor K, Black JL, Sampson S,

Fink M.]

 

7. DSM Melancholic Features are Unreliable Predictors of ECT Response.

J ECT, 2007; 23:139-146. [ Fink M, Rush AJ, Knapp R, Rasmussen K, Mueller M, Rummans T, O'Connor K, Husain M, Biggs M, Bailine S, Kellner CH, and CORE group.]

 

 

8. Antidepressant Treatment Failure Does Not Predict Lower Remission Rates

with ECT for Major Depressive Disorder. J Clin Psychiatry  2007; 68:1701-1706.  [Rasmussen KG, Mueller M, Knapp RG, Husain MM, Rummans TA, Sampson SM, O'Connor MK, Petrides G, Kellner CH, Fink M.]

 

9. Data management and design issues in an unmasked randomized trial of

electroconvulsive therapy for relapse prevention of severe depression. J ECT

2007; 23:244-250.[Rasmussen KG, Knapp RG, Biggs MM, Smith GE,

Rummans  TA, Petrides G, Husain MM, O'Connor MK, Fink M, Kellner CH]

 

10. Change in seizure threshold during ECT: A CORE study. J ECT  2008; 24:114-

116. [Fink M, Petrides G, Kellner CH, Mueller M, Knapp R, Husain MM,

Rasmussen K, Rummans TA, O'Connor K]

 

11. Outcome of ECT by race in the CORE multi-site study. J ECT 2008; 24:117-

121. [Williams M, Rummans T, Sampson S, Knapp R, Mueller M, Husain

M, Fink M, Rasmussen K, O'Connor K, Smith G, Petrides G, KellnerCH.]

 

12a. The efficacy of acute ECT in atypical depression. J Clin Psychiatry 2008;

69:406-411.  [Husain MM, McClintock SM, Rush AJ, Knapp RG, Fink

M, Rummans TA, Rasmussen K, Claassen C, Petrides G, Biggs MM,

Mueller M, Sampson S, Bailine SH, KellnerCH.]

 

12b. ECT not proven for atypical depression. Response to Letter CM Swartz. J Clin

              Psychiatry 2008; 69:1662-3. [McClintock SM, Husain MM, Rush AJ,

Claassen C, Biggs MM, Knapp RG, Mueller M, Fink M, Bailine S,

Rummans TA, Sampson S, Petrides G, Kellner CH, Lisanby SH.]

 

13. Is baseline medication non-response associated with potential for relapse

after  successful remission of a depressive episode with ECT? Data from

the Consortium for Research in ECT. J Clin Psychiatry  2009; 70:232-237.

[Rasmussen KG, Mueller M, Rummans TA, Husain MM, Petrides G, Knapp

RG, Fink M, Sampson SM, O'Connor MK, Bailine SH, KellnerCH.]

 

14. Seizure threshold in a large sample: Implications for stimulus dosing strategies
  in bitemporal ECT. A report from CORE. J ECT  2009; 25:232-237. [Petrides
  G, Fink M,BragaRJ, Mueller M, Knapp R, Rummans T, Husain M,
  Rasmuussen K, Bailine S, Malur C, O'Connor K, Kellner CH]

 

 

15. ECT is equally effective in bipolar depression. Acta psychiatr scand  2010:121:431-36  

              [Bailine S, Fink M, Knapp R, Petrides G, Husain M, Rasmussen K, Sampson S,

Mueller M, McClintock S, Tobias KG, KellnerCH.]

 

16. Comparing Bifrontal, Bitemporal, and Right Unilateral Electrode Placement in

ECT: A Multisite Study from CORE. Br. J. Psychiatry 2010; 196: 226-

234.  [Kellner CH, Knapp R, Husain M, Rasmussen K, Sampson S, Cullum

M, McClintock S, Tobias K, Martino C, Mueller M, Bailine S, Fink M,

Petrides G. ]

 

17. A randomized controlled trial comparing the memory effects of

continuation ECT versus continuation pharmacotherapy: Results

from the CORE study. J Clin Psychiatry 2010; 71:185-193.  [Smith GE,

Rasmussen KG, Cullum M, Felmlee MD, Petrides             G, Rummans TA, Husain M,

Mueller M, Bernstein H, Knapp R, O'Connor MK, Fink M, Sampson S, Bailine  SH, Kellner CH.]

 

Glasgow skeptics in the pub

V pleased to be talking at Glasgow Skeptics in the pub on Monday 5th March.

Currently scanning in the most irritating adverts for screening tests you just don't need. Joy!

Atos and medical records

Two new things

first, an article on the Welfare Reform Bill and Atos in the BMJ – should we really entrust Atos to reassess all people currently recieving Disability Living Allowance? I don't think so, and here's why.

And a column for Inside Health about medical records and why they come with many perils. The Big Opt Out, incidentally, is here. (Update – their website is currently down, but you can make contact via https://www.facebook.com/pages/The-Big-Opt-Out/108203685886747?sk=wall

My favourite bike shop

Common Wheel, in Maryhill.

Article in the Guardian here.

Why I'm not a businessman

In reply to Dirk Vinegar on the Guardian, who says "It is often forgotten that GPs are not salaried NHS clones, but independent business people, most of whom happen to be contracted to the NHS for the main source of their income."

This is important to get right, because the Health Bill will make it easier for companies wanting to provide primary care services to bid and compete. We have recently seen providers back out of the primary care market.

I'm a GP partner. The reasons why I don't see myself as a businessman are these:

1) There is no  marketing or advertising. Practices inform what we do, but we don't make effort to lure patients from other practices. Businessmen would be actively recruiting (preferably healthier, wealthier) people to their lists.

2) There is no attempt to make our workload lighter. Patients who need a lot of appointments, who need a lot of house calls, or who take up a lot of administrative time are not discriminated against. Were I in business, I'd be looking at ways of removing this 'workload' (of course, we don't.)

3) If I was a business, I'd work on attracting people who didn't have much wrong with them, and encourage them into having tests that they didn't need. So, for example, regular multiple blood test and physical examinations for 'MOT' check ups and other assorted non evidence based nonsense; this would attract customers, we could charge extra as it was non-NHS, and we could advertise our additional services.

I don't offer this, because it's not backed up by evidence, and can do real harm. But – ha – it's a great 'business opportunity'. It's also not good medicine.

4) I see patients, front line. If we wanted to make profit first, it would be better to put someone who wasn't a GP in the front line. Or pay someone less to do my job, or bits of my job. And let me concentrate on management.

But I've been trained to do this job, so it's me seeing patients, not accounts balance sheets.

In honestly, I think I'd prefer to be on a national salaried contract, with no more daft boxticking as  the GP contract dictates. I am not sure what we'd have to replace it – given that professionalism seems hardly trusted by politicians. Yet patients generally do trust doctors – and peer review is a very useful and underused tool.  I can't help but think there is a better way to pay GPs – not as businessmen but professionals.