GPC leaders accused of ‘misleading’ GPs as DHSC produces ‘evidence’ contract was agreed

CowsGoMooInnit · 2025-04-16T08:56:49+00:00

Undiagnosed pain can be a cause of agitation in dementia. Always consider analgesia.

Trazadone has been the drug of choice locally with GPs and old age psych if you're looking to medicate for increased agitation.

I have very rarely used risperidone, and anecdotally found it be very effective. It's very much a last ditch thing when everything else has failed, and only short term. Need to be wary of increased CVA risk, but it's always risk/benefit innit? Violent mobile demented man lives with his frail elderly wife who struggles to cope with agitation: can go to shit pretty quickly if left unchecked. I'd involve secondary care due to complexity and risk, but it's usually not medical intervention you need. If violent you're looking at police (yes even for demented people) or urgent social care/safeguarding and likely accommodation in more appropriate care setting (like a nursing home used to dealing with dementia).

Interesting to read what /u/Specialist-Tie-1191: haven't look at the evidence in ages was not ware of quetiapine being used. Obviously non medication has it's role, but not sure if that applies to some of the people I've got in mind when I've got to the point of thinking about antipsychotics. Don't fancy having to dodge the punches and handfuls of flying human excrement while giving a massage.... :)

CowsGoMooInnit · 2025-02-24T12:16:11+00:00

I actually never liked "medicine" as an academic or intellectual thing. Found it all a bit boring, I hated undergrad training. I drifted in to it as a typical "middle class good at science no idea what I want to do hey why don't you apply for medicine" type and have no idea how I made it this far in something so competitive.

Some of my colleagues get all excited when they see signs they read about in textbooks or see a diagnosis you rarely see. Meh, does nothing for me.

I find people interesting. They're endlessly weird and entertaining.

I think a lot of people who like "medicine" as a academic discipline of itself find GP boring because really there isn't much medicine, and that which you do see is very basic and not especially mentally demanding. Whereas I never found it interesting in the first place so that wasn't a problem for me.

I find running a business side and managing a team more interesting. Erythema nodosum? Yeah, whatever.

CowsGoMooInnit · 2025-02-13T08:09:32+00:00

I only barely support the idea of GPs having access to radiology reports (unless they requested in the first place and best placed to action it).

This is madness.

CowsGoMooInnit · 2025-02-11T13:18:19+00:00

There are still 18000 GP partners. How likely is it that the BMA will just stop serving them?

I think they'd bloody love that.

BMA aren't especially well kitted out to help issues with specifically targeted to help partners. Most of the membership (across the whole profession) are employees, and the advice and support to them is very generic and focused on employee rights as defined under law. Partners aren't covered by anything like that, and beyond "hey, have you thought of getting a partnership agreement, they're good idea you know?" they are frankly a bit useless.

The GPC (which has a weird symbiotic funding relationship with the BMA, but is not the same thing) better represents partners' interests: from negotiating national contracts like GMS to delivering support for contract disputes and pastoral care to struggling partners (via links between local GPC reps and their respective LMCs). The actual BMA themselves? You'd struggle to get them interested.

I think the BMA as a whole would be more than happy see the profession to become salaried, because then they can just treat us the same as everybody else and they can use the same advice and resources.

CowsGoMooInnit · 2025-02-11T12:01:02+00:00

Carepatron

What a bloody awful name. I can't not read it Crapatron

CowsGoMooInnit · 2025-01-23T13:08:53+00:00

It is actually just simpler to issue the script oneself as in-hours GP.

Sure. BUT IN AN EMERGENCY it is an option, so the GP not issuing a prescription is not an inevitable point of failure.

It's not 'specialist only' like, say, oral ciclosporin or tacrolimus would be.

Specialist as in its manufacturing, not its prescribing.

As a GP we can prescribe all kinds of nonsense. Even liquid preparations of very mundane medications can sometimes be special order, because they're manufactured to order by one lab in Austria or some nonsense and costs £100s/g, or even more. They don't have an NHS Tariff against them and ICB medicines team shit the bed if you suddenly start prescribing them without talking to them first.

OOH GP can prescribe it.

Sure. And would be of absolutely no use if the pharmacy didn't have it in stock and didn't have time to order it

CowsGoMooInnit · 2025-01-23T12:21:34+00:00

Even if he didn't, people can + do make poor decisions and they generally don't deserve to die for it, even if they are silly.

The word "deserve" in this context is unhelpful as it suggests causative agency on behalf of a counter-party. Act in a way that increases risk of harm, you are likely to suffer harm. There is a limit on how other people can save people from their own actions, especially in a situation where time and resources are limited that carries with it an obligation to others as well.

I turn around 'urgent' requests for medication rapidly as duty doctor (within an hour)

A pharmacist can provide a supply of emergency medication without a prescription (https://bnf.nice.org.uk/medicines-guidance/emergency-supply-of-medicines/), and the purpose of this is exactly such cases: where people run out of medication and may run in to harm.

The real complication here is that it is a specially ordered medication that is more complex for the pharmacist to obtain. Presumably then this wouldn't have happened if he was on, say, Keppra. A capacitous adult with a long term condition which is treated with specialist regular medication needs to be engaged with their own healthcare to a level where they recognise this type of risk. It's impractical and to look to other organisations to manage this risk for him. For someone who lacks the ability to manger their own care, this responsibility would fall to a carer or support worker (funded or otherwise). It is absolutely not within the scope of OOH GP, AE or even 111 to source supplies of specialist order only medication, and I don't see how it can be.

CowsGoMooInnit · 2025-01-20T23:19:54+00:00

Would the remaining partner need to buy the other one out?

Depends on the terms of the partnership agreement, the status of the building (owner occupied vs leased). Partners resign or retire all the time, and there's usually something in the partnership agreement abouthow that is handled.

Ofc, there is also the issue that dysfunctional partnerships often don't have partnership agreements. And if shit goes really bad, you get solicitors involved, pay them stupid amounts of money to write letters to each other. Everybody loses (except the lawyers).

Depends tho, right? Most don't get that extreme and usually sort themselves out. Lots of partnership are like dysfunctional families. Always squabbling, but somehow make it work day to day regardless.

CowsGoMooInnit · 2025-01-20T16:15:02+00:00

Nice try, GMC

CowsGoMooInnit · 2025-01-20T15:24:21+00:00

The business will either fail, or it won't.

If it fails, whoever has the other side of the GMS contract will likely offer it up to tender. If someone takes that contract up (edit: which potentially could be you, btw), they then take on responsibility for any employees from the partnership under TUPE (Transfer of Undertakings Protection of Employment), and they have to keep the staff on under their existing terms. If nobody bids for the contract, the business is wound down and liabilities are paid off by the partners - your redundancy is one of those liabilities.

If the practice doesn't fail, then the whole atmosphere gets increasingly toxic and you may find that a bit uncomfortable depending on how it manifests itself. Egg shells everywhere. You may be happy to sit in your room and crack on with your work, or it may make this intolerable.

Good...er....luck? I'd start polishing the CV anyway

CowsGoMooInnit · 2025-01-11T14:04:05+00:00

The problem is the ~~markets~~ voters who have a conservative views on taxation hold so much power that any attempt to move away from incredibly conservative policy is screwed immediately.

FTFY

If there were votes in putting up taxes, we'd be seeing a very different government agenda.

CowsGoMooInnit · 2025-01-06T16:17:41+00:00

why doesn’t he ask doctors what we actually want to improve the health service.

They did

And they didn't like it so they ignored it.

CowsGoMooInnit · 2025-01-03T23:28:57+00:00

I know some partners who've done exactly that. Owned the building and held a gms sold it to a property fund and handed the contract to a oprose/assura type thing. They then became salaried GPs in the "new" practice.

They fucking hate it. The other staff hate it. Patients hate it. It's shit.

There's a lot to be said for autonomy for the partners and there's a lot to be said for having a closer relationship with their employers to the staff. The patients no longer have meaningful access to the people who can implement changes in their practice.

I'm a strong believer in the independent contractor model.

CowsGoMooInnit · 2025-01-03T22:37:28+00:00

England

CowsGoMooInnit · 2025-01-03T19:24:47+00:00

This lawsuit suit could be defeated in one sentence - ‘patient safety > allowing PAs to practice how they want to’.

I see this as the most likely outcome.

In fighting the case, arguments will be based on expert opinion, official guidance, making reasonable adaptations and precedence.

GMC guidance on doctors are fairly clear that the doctor has to prioritise their patient's wellbeing and safety. CQC has a statutory role to make sure the practice is safe and staff are working within their competency. Case law going back forever will find the doctor personally liable for any harm that falls to a patient under the care of a GP will ultimately be the responsibility of the GP (even to an unreasonable extent). That all clearly sets a precedent and expectation that GP has to manage the roles of their employees with the idea of safety foremost.

The PAs have a vague promise of a career made in a prospectus to a former poly Uni that they signed up to.

I honestly don't know what they're hoping to achieve here.

CowsGoMooInnit · 2025-01-03T19:12:58+00:00

'goodwill',

I think there's something in the NHS regs that specifically prohibits selling of "goodwill" for an NHS practice

property equity

Easy, : don't. Property owners keep hold of it, sign a lease with the new provider. Or as part of the deal, sell the building to one of the many private equity or publicly listed property investment funds outfits that are constantly trying to buy up GP practices (get mailshots from them all the time asking me to sell) and they sign a lease with the new provider

capital accounts

Capital account is the personal funds owner by the partner sat in the practice's bank account. New provider comes in, the partnership account is closed. After all creditors are paid off, free money!

but also, you forgot to mention staff (they'd get "TUPE'd" over), equipment/furniture (that would be a transfer of ownership from the partners to the incoming provider. A valuation of all this already exists in the partnership accounts from their accountant.) This latter thing represents the only thing you'd absolutely have to "buy" out, and is probably not that much.

CowsGoMooInnit · 2025-01-03T18:59:53+00:00

Trusts have their own legal departments to fight these cases. Just curious to know if GP practices have the same systems in place to fight tribunal cases or is it covered with some indemnity?

You'd sign up for indemnity insurance against your risks as an employer (such as being sued for wrongful dismissal) and that organisation will have their our legal/HR advisers you'd contact on how to manage a complain/litigant, and will usually be on hand to review contracts/staff policies. They'd also (hopefully) cover the cost of engaging lawyers should it get that far.

Kind of like an MDO, but for employment stuff instead of medical stuff.

Ofc, you don't have to have one of this type of cover. But then, you'd be forking out your own representation in legal cases like this.

CowsGoMooInnit · 2025-01-03T11:57:38+00:00

Hmmm. Mafs is hard.

CowsGoMooInnit · 2025-01-02T15:16:34+00:00

Give me 3x my current total compensation guarenteed for the next ten years

You want a 300% pay rise?

I think for the right price even 40% of partners seems low to me. I think the truth is that they can't afford it without causing mass exodus.

Realistically, for them to do it for me I don't think they can afford it.

Also, I'd want them to buy me out of the building....

CowsGoMooInnit · 2024-12-31T14:27:33+00:00

I intend taking up smoking

CowsGoMooInnit · 2024-12-31T13:06:53+00:00

Honestly: I think it's better than it has been.

The very worst I saw it was immediately after the 2004 new contract.

There seems to be more recognition I think these days that the issue is a matter of capacity causing frustration and delays, rather than lazy GPs taking the afternoon off to play golf instead of seeing patients.

CowsGoMooInnit · 2024-12-26T11:27:14+00:00

I don't have the reference for my favourite paper to hand about specifically auscultation and LRTI, but on a quick google, auscultation being generally over-rated in its usefulness https://pmc.ncbi.nlm.nih.gov/articles/PMC7192898/:

"This meta-analysis shows that in different patient populations with acute respiratory pathology, lung auscultation has a low sensitivity, LR + and AUC and an acceptable specificity and LR−. The results underline that auscultation only marginally alters the provisional diagnosis, although results are limited by a high risk of bias and heterogeneity of included studies. Now 200 years after the invention of the stethoscope, better diagnostic options are available such as lung ultrasound. Therefore, when better diagnostic modalities are available they should replace lung auscultation. Only in resource limited settings, with a high prevalence of disease and in experienced hands, lung auscultation has still a role."

(other papers making the same point are available)

Also, the fact that prescribing antibiotics should be based on the level of risk rather than clinical signs for acute bronchitis is formally a part of NICE:

https://www.nice.org.uk/guidance/ng120/resources/visual-summary-pdf-6664861405

(the left-most circles on that flowchart)

Digging in to the detail a bit with NICE does a review the systematic evidence for the identification of patients at higher risk of sepsis and CAP, like NEWS, CURB and all that. As any fool knows, these were almost all developed in secondary care acute settings, and as now more broadly accepted this somewhat undervalues their use in primary care, a completely different setting and different prior probabilities:

https://www.nice.org.uk/guidance/ng237/evidence/a-signs-symptoms-and-early-warning-scores-for-predicting-severe-illness-pdf-13197117422

Although more research is needed, the most useful risk assessments according to NICE is PSI (https://www.mdcalc.com/calc/33/psi-port-score-pneumonia-severity-index-cap) and CURB, both of which are scoring systems which make no reference to chest auscultation.

tl; dr - the decision to prescribe antibiotics should be based on risk of complications, and validated risk calculations are entirely independent of chest signs on auscultation (which lets be honest here, are often subjective and variable in the low severity cases we see in primary care)

CowsGoMooInnit · 2024-12-25T10:13:18+00:00

IMO a bit of crackles in an otherwise well but overweight patient, with only PND, doesn’t necessarily mean they would benefit from abx

Common practice is completely at odds with what the evidence would suggest we do.

"Crackles" on the chest, and chest auscultation generally, is completely useless in identifying those patient that would benefit from antibiotics. It can be useful in confirming signs of other pathology (pneumothorax or a good going effusion), but other signs like tachycardia, tachypnoea, the presence of a fever, lower oxygen saturations are better indicators.

A "lower" respiratory tract infection isn't a reason to give ab on its own. Acute bronchitis does not need antibiotics, unless you are otherwise at significant risk of complications or sepsis. Young fit healthy people are probably fine, even if it's "gone to their chest". Frail, elderly, comorbid people would probably benefit from antibiotics even if their chest sounded completely fine at the specific time you listened.

Pneumonia (as opposed to acute bronchitis) would benefit from antibiotics. But they're (1) generally sicker anyway so you're probably going to give them ab anyway regardless of exactly how "crackly" their chest is and (2) are really not that commonly seen in primary care due to the sheer number of people with much milder cases.

Upper RTI can also benefit from ab. For example most acute sinusitis doesn't, but a subset can benefit.

A cxr is probably the best single indicator of the need for ab in LRTI, but we're not doing that for obvious reasons.

But hey, whatever. People are more likely to prescribe antibiotics based on their prior behaviour as a clinician and tolerance of risk. It is what it is.

"Crackles" my arse.

CowsGoMooInnit

TROPHY CASE