Dr David Colin-Thome answered questions on health reform in a Downing Street webchat.
Read the transcript
David says:Hello. I have been a GP in Runcorn for 35 years as National Clinical Director for Primary care and as a GP I have been in an advisory role in developing the White Paper. I will try and answer as many of your questions as I can.
Val Smith:On the issue of increasing access to a GP: is there any intention to review the current policy whereby it is only possible to make appointments on the day? My GPs surgery is unhelpful and inflexible and as a commuting, full time working parent of two children aged 5 and 7, a sensible approach to routine but necessary healthcare matters is virtually impossible.
David replies:We want to offer patients a GP appointment at a time that is convenient to the patient. Of course there willbe less GPs on call out of hours but wil be some on call. During the day we strongly disagree with some doctors not allowing future booking. Where this happened we will be encouraging other practices to set up services that will meet your needs.
mick brady:will this mean i can see a doctor of my choice when i want ?
David replies:No. Your doctor won’t be on call 24 hours a day seven days a week but we will make certain that you will have a doctor or a nurse available at times when you need it for your advice or treatment. We’ll have to build up services in primary care to even achieve that and we are determined to do so.
Rowan Purdy:How important would you say the listening exercises have been in influencing the white paper? What are the implications for future government policy?
David replies:The listening exercise was hugely important in developing the White Paper because we were determined the public should be telling us what services they want in the future. There was a another listening exercise in response to the social services green paper which also influenced what went in the final white paper.
alan:How can Doctors cope with the added responsibilities of providing Health MOTS when they are overrun with work at the present time.
David replies:Doctors won’t be providing the bulk of the life check. The first part will be to fill in a questionnaire either online or hard copy. If there are lifestyle changes you need to make we will offer you an expert in health promotion. However you may wish to consult your GP about this as well. That is your prerogative as a patient of a practice.
Cllr Jill Wright: How are GP surgeries supposed to provide all these excellent additional services when we are working in premises which are not fit for purpose at present and the PCT informs us there is a small cash limited capital pot and no recurring money to improve premises? We would be only too happy to give our patients a better and improved service, if only we had the building in which so to do.
Cllr Jill Wright,
Practice Manager,
Bridgemary Medical Centre, Gosport, Hants.
David replies:We have already got over £1 billion going into developing GP premises and so over the years there will be sufficient money to upgrade general practice facilities. However if you are a rapidly expanding service because you are attracting new patients and can offer extended hours we will ensure your practice will get priority in monies to develop your premises.
bob cullen: If you are now proposing GP surgeries to be open longer, why were GP’s allowed to opt out of working evenings and weekends 2 years ago. They now work office hours Monday to Friday.
David replies:The reason we agreed for GPs to have set hours in their contract was because the demands on general practice were too huge for them to provide extended hours also. We agreed with the BMA this was an essential step in trying to recruit more GPs into the NHS. At the time recruitment into general practice was poor because of the pressure of work. As a result, it seems, of the contract, we have managed to increase the number of GPs by 2,000 so gradually as we are building up services so we can offer extended hours. This wouldn’t have happened if we hadn’t introduced the contract 2 years ago.
Peter O’Connell:The website states that the reforms will make it "people to choose a practice which offers more convenient opening hours". How will this work in a rural area where there is only one practice which will even accept you as a patient?
David replies:If there is only one practice we will ensure there are enough resources going to that practice or develop a walk in centre or some such facility to ensure extended hours. Rural areas won’t be excluded from the benefits we are promising people. Some GP out of hours services are offering evening surgeries to go with their on call responsibilities
Philip Hutcheon:Will we have enough GP’s to handle the longer opening hours and will they (additional GPs) be of the same good quality as or much appreciated individual GPs?
David replies:We will have enough GPs to provide extended services and they will have to go through the same rigorous training as current GPs. Not all care has to be provided by GPs. In the listening exercise many people said they would be happy for the first contact to be with the nurse. So extended services can in many cases be provided by well trained and qualified other clinical professionals such as nurses.
bledi jashari:Dear sir, will the reforms include anything for 24 hour pharmacy? Because pharmacies are closed in the night and the only way to get a medicine is to see a doctor at the A&E.
David replies:All pharmacies won’t be open 24 hours but we would expect your PCT to make available 24 hour access to medicines. This will mostly be through pharmacies but possibly we will use out of hours GPs or A&E to provide this service. Our aim is that there will be clear information so that people will have 24 hour access to medicines.
Jenny Furber: the ‘family’ doctor appears to be vanishing, do you think that having access to any doctor at any time will mean your GP will not have knowledge of other things happening in the family which may be relevant to treatment?
David replies:We would encourage patients still to choose a specific doctor for most of your needs. However that doctor may not be on call when you wish to have medical advice but with modern IT the continuity of care will be ensured through the computer records and so your quality of care can be guaranteed. This is a new service which means even if you go to a hospital in a distant part of the country they will be able to access your medical records.
Bert Finch:GPs seem very overpaid now. Is a £100k salary justified?
David replies:This is a difficult question for me to answer to some extent as I am a GP. GPs do 85% of the medical contacts in the health service and internationally British general practice is recognised as being of a very high quality . The monies only put us on a par with our hospital colleagues and since the NHS is dependant on the quality of general practice and despite my personal interest in my matter the salaries are probably justified.
Richard:Is there any part of the White Paper you disagree with? Or do you lack the autonomy to not agree with the government?
David replies:I agree with all aspects of the white paper because it is about offering patients, the public, a more responsive health service. In the past sometimes the public sector was a take it or leave it service rather than addressing what people wanted. The white paper addresses that as it was a product of the public having input into the listening exercise. As a part time GP I’m not a full time employee of the government but choose to support the white paper because think it will be good for patients, public, doctors and nurses alike.
Jenny Furber: thank you for that David. I was concerned that ‘communications’ may break down between the patient and the GP but if the new service provides access to medical records continuity should be apparent. However, can you assure me that my records will not be seen by a computer ‘hacker’?
David replies:We have made certain our IT system is as good as internationally possible to ensure the privacy of your records and arguably they are more private than the old fashioned written records but I understand your concerns.
Michael Pantridge:Might you consider - for mature & responsible patients - self-prescription-requests for previously prescribed drugs - for example for occasionally recurrent ear infections where there is no underlying threat but which currently needs a valuable 10 minute appointment for a 10 second
outcome?
David replies:We already allow people to buy increasing number of drugs over the counter as we think for many of these conditions patients are competent to self prescribe. We have a committee for the safety of medicines and other fail safes where the debate as to what can be bought over the counter and what cannot takes place. I expect in the future more and more drugs will be available over the counter.
liz bartley:Nurses are at last being recognised for the skills they possess, however we do need support from our medical colleagues to advance our practice. How can we persuade local GP’s to become our mentors, to advance the community matron role for example.
David replies:How we can persuade local GPs has to be undertaken locally by people such as yourself and your PCT. Nurses to me are absolutely key if we are to meet the needs of the public and patients . That’s why we have developed new roles for nurses and the ability of nurses to independently prescribe drugs. In many areas GPs have been very willing to be mentors.
JOhn Parsons:Hi David
Do you see a role for Social Enterprises in delivering the new health assessments?
John P
David replies:I see a huge role for social enterprises to deliver many aspects of the white paper and this certainly is one. For instance we are exploring how social enterprise could provide actual services for patients, educational programmes for the public . The DoH is setting up a social enterprise unit to encourage such activity.
Mrs Valerie Houghton:The problem in our area is not the gp`s, ours is brilliant but they’re let down by the consultants who they refer patients too. All to often records go missing , or one particular consultant will keep hold of patients records - that happens a lot to my husband, so much so that he was recently sent a discharge questionnaire before a diagnosis! So you turn up for a hospital appointment but its just a waste of time without your notes for the hospital doctor to see.Plus the waiting list to get on a waiting list!
Too me, this is just piling more pressure on the gp`s and nurses that they can well do without.They`re in the firing line and why are`nt you giving them more help?Thank you.
David replies:I understand your frustration as I recognise it well as a GP. The new IT system will link general practice and the hospitals so it will lessen the chance of notes going missing and vital information being lost. One of the reasons we have developed a community matron for people who suffer longer term conditions is that the nurse will actually be a practical link between the hospital and general practice and in our experience of working in this way the nurse visited the patient to ensure care was co-ordinated
Brian Farquhar:I work for the NHs the drive by the government to make NHS trusts Foundation Trusts is having a push sending them into large debts affecting patient care. what does the government plan to do to alleviate this problem
David replies:I don’t think foundation trusts themselves are the reason some hospitals are in debt. Some 25% of hospitals are in debt whether foundation trusts or not. As we make certain more care can be delivered in community settings and therefore more staff will work in the community as well as the hospital and will have some of their earnings paid for by primary care we would hope this would at least in part address hospital deficits. Remember the vast majority of hospitals aren’t in debt so there are ways of working to ensure we all stick within our budgets.
Michael Pantridge:You answered my question about self-prescribing, thank you, saying more items may become available over the counter- but really I mean drugs like anti-biotic which could surely be "self-prescribed" but also are unlikely to be an OTC medicine?
David replies:There is quite a controversy about antibiotics self prescribing which won’t be resolved easily. In many countries where you can purchase antibiotics over the counter their use has been over excessive which has contributed to drug resistant organisms so this debate will run for some time.
Simon Knight: If I understand the proposals correctly, those in need of a controlled exercise regime will be allocated a fitness expert . One problem is that if one cannot afford fresh fruit and vegetables for your children, the fact they have a fitness coach is of questionable assistance. Is there going to be a Govt subsidy/voucher scheme to encourage healthy eating along with access to medical opinions?
David replies:There certainly isn’t any proposal currently to subsidise fruit or veg on the NHS. It may be of interest to know that some parts of the country, including my practice, we have used lottery funds to persuade local supermarkets to give cut price fruit and vegetables and give free fruit in our practice to encourage more people, especially children, to increase their healthy food intake.
Dr J D Sawers: David, can you please explain where you recruited 2000 GPs from in the past 2 years? I believe the BMA will dispute these figures without hard evidence.
David replies:The figure is 2,300 extra GPs from 2003. Of course these aren’t whole time equivalents but we have never used whole time equivalents over the many years we have counted GP numbers so we haven’t changed the definition. The figures have been collected by DoH but I would be happy to receive any other information in detail.
Jonathan Whitney:Great that all this is happening but we need the total smoke ban to go through and more action on cutting obesity. This effective action will help the next generation.
David replies:I agree totally we need to do more about smoking and obesity and in fact in smoking we have already made huge strides over the years which has been the main reasons for the reduction in premature cancer and heart disease rates. Tackling obesity is going to be a harder problem. As a simple GP I am not going to get involved in political discussions over smoking bans.
Abigail Reed:In the White Paper it is stated that innovation will be encouraged by offering greater patient choice. How do you think this will be achieved in practice?
David replies:We will encourage innovative organisations whether general practice, social enterprises or the independent sector to increase the number of services available to people including that of general practice. We will of course concentrate on under doctored areas. More choice for the public will provide more and more innovation as there is currently insufficient choice.
veronica sinclair:Wlll gp’s surgeries, dentists etc better address the needs of the disabled who use wheelchairs i.e lower reception counters, couches which are height adjustable to enable a wheelchair user to more easily transfer. Wheelchair users needs are not considered adequately at present.
David replies:In most of the older general practice and dental surgeries I agree there has been insufficient access for people with disabilities. We are keen to address this over the next few years with increased money going into better premises. All the modern premises that are being developed and built will have access for patients with disabilities, including for those who are visually and hearing impaired. We all agree with you it is a big priority. What may seem slow to you is because we have 9,000 GP practices alone so there is a huge task in upgrading facilities.
Lyndsay Hairon: If I’m not happy with my doctor is it going to be easier to change GPs?
Thanks.
David replies:Yes it will be easier to change. As I have said we are keen to increase alternative provision of practice in areas where there are insufficient numbers of services. Specifically we will make registration with another practice easier as we are developing our plans to deliver on the white paper. Better access and choice is what the public want and therefore it is our big priority.
vanda cowan:I am a nurse practitioner working in a busy walk in centre.
Why are we given additional responsibilities and work in a similar remit to GPs but we are only paid as nurses. Why are we not paid according to our additional skills? I understand we have our banding system but some people do more than others.
I am on band 6 of our pay scale but that is only 11.60 hr. approx.
If it was performance related pay we would be earning a lot more.
Vanda
David replies:I’m not an expert enough in nurses pay but as a general principle if staff do equal work, hours and take the same clinical responsibility they need to be rewarded. Controversially it may seem, and I know I’m a doctor, but doctors in general have wider clinical responsibility for patients than other health service professionals.
Kailash Chand:White Paper seem to be game, set and match for corporate sector. Commercial operators, with their ability to borrow to invest, will be in a better position than GPs to set these up. It could mark the beginning of a shift from the corner shop (the GP surgery) to the supermarket at the cost of the personal relationship lost for good. Is this the end of traditional General Practice?
David replies:Kailash how are you? I think the answer lies in our own hands as GPs. We know we provide in general an excellent service to our patients and we seem to be much loved so any commissioner would want to encourage what has been the heritage of British general practice. But private providers may want to own and manage practices but the PCT will ensure the quality of care which includes continuity will not be damaged. I do not see this in any way as the death knell of British general practice and if I was a young doctor again I would again choose general practice and with confidence.
Nigel Higson: Would it not be better to improve patient care by integrating pharmacies into Gp Surgery premises in order to improve communication and patient service rather than opening up internet and 24 hr supermarket prescribing. Our 10000 patients would have chosen that as an expression of patient choice but the regulations did not allow
David replies:Nigel I’m not certain what regulations prevent this as in many of the LIFT premises I have visited pharmacies and GPs are in the same premises which makes a lot of sense if we wish to have a one stop shop for patients and for us professionals to have close contact with each other to ensure quality.
Matthew Hurrell:I’m very keen on the idea that I can register with a practice near work rather than home. But what if I’m home off sick who will give me a home visit if I need it? I know you GPs all got rid of your out-of-hours commitment so the night’s not a problem but who would visit me during the day if I’m off sick?
David replies:That is a really important point you make and the choice is yours which is all we are offering. Out of hours won’t be a problem as you say, but an in hours visit will present difficulties unless your local practice where you live is prepared to visit you. We will try and ensure that if you are out of your area local general practice will provide a service but when you have chosen to register near where you work you will have to set the pros against the cons.
Polly Lutter :You’ve already mentioned pharmacists; how do you see the role of nurses changing in general practice?
David replies:In answer to a previous question I have said that the role of nursing is central to delivering on the white paper so we still have first contact nurses working in GP practices, walk in centres and hospitals; community matrons delivering on patients with longer term conditions, nurse specialists and consultants experts in their field. In general practice already nurses through PMS are managing and running practices as the managing partner so the world is at your feet.
Reg Fraser: Dear Sir, I would like to know why certain Health Trust are being allowed to refuse operations to people in pain because they are unable to lose weight, next it will be smokers, and drinkers. Ernie bevan must be turning in his grave , to see how his Health service is being overtaken by financial administrators, Reg Fraser secretary Plymouth Senior citizens Forum.
David replies:It isn’t policy or good practice to refuse care to patients in pain. This will almost certainly have been a clinical decision because the weight problem or smoking habits could make the operation too unsafe to carry out. This will not be a financial consideration.
Nigel Higson: The regulations that prevent a pharmacy opening in an existing GP practice are those designed to prevent commercial competition. LIFT premises can only have pharmacies if an existing pharmacy licence is moved into premises from another site… they are not necessarily new licences. This therefore prevents a lot of GP practices either employing dispensing pharmacists or making space for them. The creation of large multi tasking polyclinics will removes the high street pharmacy licence at present
David replies:Thanks for this Nigel will look into this.
Helen Wilkinson:David your reply to the above question re out of hours does not cover the NHS Care Record guarantee were patients are allowed to restrict access to NHS CRS
Helen Wilkinson-makey
David replies:The NHS Care Record Guarantee does allow patients to restrict access but we strongly advise them not to restrict access as this could harm their future care if we have insufficient information. However the choice must always be the patients and with it the possible consequences.
Mrs Esther Shogunle:what is the national and local agendas that influence the reducing length of hospital stays?
David replies:Do you mean by this the length of stay when you are an in-patient as distinct from shorter waiting lists? The best way of reducing the need for people to stay over long in hospitals is such as through community matrons who can arrange access to good quality care in community settings - as good a care as you would get in the hospital and near to where you live. The shorter waiting times have been because of the huge expansion of doctors and nurses into the NHS over the last few years.
Elaine Normoyle:Why does NICE have to take so long in their deliberations about Herceptin when for some women it’s a matter of life and death?
David replies:NICE have a responsibility to ensure that decisions are reached through as comprehensive a set of information as possible but they have agreed they can in certain conditions speed this process up because of the speedy access to better information. There is now a fast track NICE process when such information is rapidly available and this will apply to Herceptin. The problem for NICE was that they were also waiting for the licensing of the drug before they could reach their own decision. Such licensing decisions will also be fast tracked when information is quickly available.
Jenny Furber: doesn’t your question from a gentleman in Plymouth highlight the fact that ‘preventative medicine’ is power for the cause in getting the money available for the new initiative put to good use. If people undertook to look after their bodies as best they could, are given help from the professionals to do so, the rate of operations and treatments for things such as the effects of alcoholism and smoking as examples would be less? Perhaps we could do with a ‘Care for Your Body’ centre before it fails the MOT!
David replies:The life check is a care for your body approach rather than a simple tick box MOT which medically has been shown to be ineffective, so we agree with you helping people to improve their lifestyle will improve their health and well being hugely and will lessen their need for medical interventions. I’ve already said the reduction in premature death rates in cancer and heart disease have been mainly achieved because people have stopped smoking and not in the main because of medical achievements, although that played a part.
David says:Thank you for your questions. I have thoroughly enjoyed the session even though it has been a bit of hard work! I look forward to another session in the future.
Jenny Furber: thank you too David. It has been really informative and thank you for the hard work you have put in. I have enjoyed reading the questions sent in as well as mine being answered. thanks again.
Moderator replies:Thank you Jenny
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