Editors' Blog

October 2008 - Posts

• When toothache becomes a headache for health professionals

  On the face of it, keeping one's own teeth long into old age sounds like a good thing. However, according to Help the Aged, improvements in dental care (which mean that fewer people have false teeth) are actually causing problems for older people, since those housebound or in care homes are struggling to access dental services. A lack of flexible clinics, such as mobile dental units, mean that people often go without treatment, which leads to tooth decay and pain that can affect eating habits and nutrition, resulting in health problems. Apparently, more than a third of over 75s fail to have regular check ups. However, it is not just pensioners who struggle to find an NHS dentist. Last January, a poll for Citizen's Advice found that one in six people had been unable to see an NHS dentist for almost two years and there were warnings that the shortage of dentists was having an impact on doctors' workload: GPs have been seeing increasing numbers of patients with dental problems, which they cannot treat, extending waiting times for patients who need medical care. In May, it was reported that the number of hospital admissions for abscesses had nearly doubled in ten years, to just under 1,500 a year. The situation was described as ‘a major public health problem' by Bristol University researchers, who laid the blame squarely at the door of the new dental contract, agreed in 2006. The contract was designed to improve access to NHS dentists, but subsequent evaluation indicates that it has made little impact. A report from the House of Commons Health Committee, published in July 2008, suggests that the number of patients without an NHS dentist remains roughly the same, as does the patchy cover. Meanwhile, it is said that NHS dentists are earning six figure salaries, without any increase in workload, an image which does nothing to endear them to the general public (nor to GPs and practice nurses, who have been bullied into offering extended hours). The Patients' Association has been quoted as saying that ‘dentists are working the system for themselves, not for the patients'. Dentists deny their lives are cushy, a denial backed up by the fact that the new contract was rejected by one in ten dentists, according to the British Dental Association (BDA), with 60 per cent of those who did sign up ‘in dispute' over the deal offered to them. The contract has not curbed the exodus of NHS dentists into private-only practices and a massive  85 per cent of dentists have told the BDA that they feel the new system has not improved access to NHS dentistry. It therefore seems that dentists, patients and medical professionals share the same desire for the 2006 dental contract to be scrutinised and changed. However, despite the Commons Health Committee report, the Department insists that the benefits of the reforms are already emerging, highlighting its £200m investment in dentistry this year, over and above increases in the last three years, taking the total investment to more than £2bn. When will ministers learn that blindly pumping cash into initiatives, in the face of evidence that they are not working, is simply a waste of taxpayers' money - and at a time when every penny counts, as never before? Posted Oct 31 2008, 03:15 AM by Sarah Wild with 1 comment(s) Filed under: workload, dentists, access

• Risky business being a high-flyer

  Treating a patient is just like flying an aeroplane, apparently.  Both pilots and doctors operate in an environment where on-the-spot decisions must be made and errors have significant consequences. Without the safety net of the hospital setting, GPs are performing a risk assessment on many of the patients they see - whether to refer now or to follow up next week.  Comparisons of the risks faced in the healthcare and aviation industries have been drawn by the defence organisation the MDDUS, who are running a human factors and safety masterclass for doctors with help from British Airways pilots.  Risk assessment in the aviation industry is streets ahead of that in healthcare and analysis reveals that ‘human factors' (otherwise known as human fallibility) are often the cause of adverse incidents. In healthcare, clinical skills coupled with the knowledge of how to manage such human factors will go a long way to improving patient safety.  It would seem, however, that the patients themselves aren't as risk averse.  Two reports out this week show how individuals seem happy to take unnecessary risks with their health either by opting for an unnecessary procedure - healthy and fertile couples going abroad to receive IVF treatment in order to be able to choose the sex of their baby - or by opting out in the case of the 1 million women ignoring their invitation for a smear test this year.   Choosing the sex of your unborn child is illegal in the UK and there is a public sense of disapproval of such a procedure. Using IVF and embryo screening it is possible to almost guarantee the sex of a baby.  The proportion of women receiving a smear test has dropped in the last ten years. It seems it is young women in particular who are not accessing screening when they have been invited. This is particularly worrying as if women fail to attend their first appointment then they may never get into the routine of factoring cervical screening into their later life. This seems a considerable risk for individuals to take when cervical screening saves over 4,000 lives every year, and at a time when improved technology means fewer repeat screens are required. If only we could embryo screen for human fallibility... Posted Oct 30 2008, 10:59 AM by Emma Quigley with no comments

• Is the credit crunch making GPs and nurses less indispensable?

  Medicine. It's the only area I was certain could never be affected by the credit crunch. (I have to apologise, I swore to myself I would avoid using the C word at any price but it's just awfully hard to avoid it. Let's just say financial turmoil from now on). No matter how much people can afford to spend, or whether they can pay their monthly mortgage repayments on time, there will never be a shortage of sick people and therefore the primary care community will never be out of work. Because as we all know too well, health does not have anything to do with wealth. Well that's what I tried to convince myself at least. But is healthcare really credit crunch-proof? Sorry, I meant "immune to financial crisis" of course? Well perhaps it is not totally. Just as people are buying less food in times of economic tumult (see, didn't use CC this time, I am getting there), the solution for making 'savings' for their health could just lie in self-diagnosis. How is this? I am not sure, perhaps it's a psychological effect; just like saving the pennies by not buying your usual skinny mocha every morning to then splurge on a brand new iPod just to reward yourself for being so financially sensible.  Or perhaps another reason for this is that for less than £25 you can buy a 1,000 page family medical encyclopaedia published by the BMA and have access to up-to-date and accurate information on over 700 diseases, so why bother going through the hassle of booking an appointment with your GP when you can just find out for yourself what is wrong with your health? Just like we shop around for the best deal for our car insurance, credit cards, mortgage, or internet provider, why not do the same for our health provider? That's the notion the Welsh government has certainly grasped as it has just announced it will spend over £5m a year on a new self screening programme to detect bowel cancer. All men and women aged 60–69, or 176,000 people in total, will now start to receive home bowel-screening kits which the health ministry hope can reduce the death rate from the disease by 15%. And the programme is expected to be rolled out to everyone aged 50–74 in Wales by 2014/15. The rationale behind this initiative is that 'men often find it difficult to take care of their health', according Dr Hilary Fielder, director of Bowel Screening Wales. She also said that 'some find the subject – and bowel cancer, in particular – embarrassing'. It's quite surprising considering the amount of information easily available online. GPs are used to patients coming in the surgery thinking they've got a PhD in medicine just because they have Googled their symptoms and read an endless list of articles on less than reliable health websites. But as the world's economic downturn keeps getting worse, there are still illnesses that fall outside the general rules and for these, economic recession or not, GPs and nurse practitioners will remain indispensable. Posted Oct 28 2008, 11:18 AM by Emilie Reymond with no comments

• A new five-a-day will help keep you sane

  It's enough of a struggle to consume five portions of fruit and veg a day (especially now I've learnt that potatoes are not admissible), so how could I possibly fit in another five things a day to keep me healthy? Well, actually, it's not as bad as I first imagined. This new routine is designed to safeguard our mental health and much of it is in the mind. It's come from a government think-tank called Foresight, in a report compiled with the help of more than 400 scientists. They suggest a daily diet of simple activities that many of us do already. We might need to just tweak our routine a little or simply appreciate the significance of what we are doing. In other words, value the small things in life and the beauty of individual moments. This, apparently will all help to keep us sane, and I'm certainly up for that. In fact, I would go so far as to suggest that every surgery and health amenity in the country should print the five pieces of advice as posters, to be put up in all public areas. When modern life is so busy, and it's so easy to forget the really important things, we all need reminders to stop, think, and appreciate what we have. I get regular reminders on this theme from the National Trust. Having been a member for 16 years, I'm delighted to see that at last they are taking a more aggressive stance against the destruction of green spaces. In urban areas especially, these are vital to our general mental well-being. It's time that the government joined up its thoughts on mental health and house-building, and modified its policies accordingly to ensure that we all have space to think.   Posted Oct 27 2008, 10:56 AM by Colin Cooper with no comments Filed under: mental health, lifestyle, environment

• When ministerial 'dithering' might not be a bad thing

  Earlier this week, the Tories accused the DoH of ‘dithering' on personal health budgets by opting to run a series of pilots before rolling them out England-wide. While ministers do drag their heels over all manner of issues, in this case it seems to me to be unfair criticism. After all, this is not about funding issues or indecision: the Department has been influenced by a report on individual social care budgets which found that, although individual budgets brought benefits, there were significant challenges involved in introducing them. This appears to be less a matter of dithering than of testing things properly before rushing blindly ahead and introducing them, a course of action taken too often by government departments. Unproved initiatives may fail, wasting taxpayers' money, health professionals' time and confusing patients. New policies, like clinical practice, must surely be evidence-based? A recent feature about personal budgets in Independent Nurse made it plain that this is not a clear-cut initiative. The concept is sound; however, there are issues to be ironed out, for example, how to provide sufficient information that enables all patients to make informed choices; how to minimise bureaucracy and ensure investment is not cut in other areas. Questions to be asked include what happens when people make poor choices and waste money; can personal budgets run out? Will patients embrace the scheme or reject ‘choice' in favour of easier options, such as relying on the judgement of the health professionals they know and trust? Social care and healthcare are different environments and specific health pilots must be the sensible way forward, supported by robust independent evaluation. It should be added that a roll-out must not occur until the evaluation has been completed and analysed: there is otherwise little point in evaluating things at all. This sounds an obvious point but implementation so often begins before initial research has been scrutinised. Let's hope that the cautious trialling of personal health budgets signifies a departure from the government's track record of hasty implementation of untested policies. Perhaps the DoH might consider ‘dithering' over polyclinics before forging ahead in the face of strong opposition from health professionals. If ministers gathered real evidence to back-up their cases for change, clinicians might be more prepared to accept these changes.   Posted Oct 24 2008, 03:18 AM by Sarah Wild with no comments Filed under: polyclinics, personal budgets, patient choice

• Scotland slams door on private sector

  GPs in England who are waiting fearfully to find out if the new polyclinic up the road will decimate their patient list may be thinking how different their practices’ prospects would be if instead ‘I’d decided to practise in Scotland.’ For the Scottish Government is taking steps to prevent commercial companies from running GP surgeries, although not even one Scottish practice is currently run by a private provider. Yesterday health minister Nicola Sturgeon announced: ‘…we are proposing to amend the law to ensure that general practice is provided by those with a direct interest in the patients they treat and in the good of the wider NHS. ‘I believe that commercial companies, where shareholders may not be part of or have a direct interest in the NHS, should not be used to provide such vital services.’ Personally I find it interesting to speculate about the extent to which political loyalties and economic considerations have played their part in this. (And, even, to wonder if ancient rivalries between the Scots and the English have any bearing.) Scotland does not, of course, have numerous conurbations or indeed a large population compared to England. So, at the risk of offending Scots who take pride (at least until the credit crunch) in their country’s commercial achievements, it is small wonder that private companies have not tried hard to gain a toehold in its general practices. This is despite the lack, currently, of legal impediments. With support for Labour at a nadir in Scotland and the SNP ruling the roost in the Scottish Government, the political movers and shakers have certainly not been trying to drum up support for contracting out NHS healthcare to the private sector. It is the Labour government in Westminster that champions this. But Scotland’s decision should, I think, prompt everyone in the UK connected with the NHS to reflect. Health ministers in particular together with those PCTs in England that are gung ho about putting every contract possible out to tender need to consider whether privatisation of healthcare in England is going too far. Do the brakes need to be put on - or limits set - before general practice as we know it disappears with few to mourn its passing apart from patients who prefer seeing the same GP to walk-in-anytime care? The current economic difficulties may slow up private providers’ encroachment into primary care and GP practices. But it won’t stop them, given the potential for healthy profits funded by taxpayers. Is it too late turn late or even desirable to turn back the clock? Or, in Scotland’s case, simply stop it where it is? Certainly entrepreneurial practices in England all set to partner with private companies to run integrated health organisations are looking forward to a shiny, revitalised NHS. And even in Scotland there will surely come a day when the private sector can no longer be excluded from general practice. Posted Oct 23 2008, 10:05 AM by Carole Slingsby with no comments Filed under: Tendering, Scottish practices, Private providers

• Of course self-referral will increase demand

  What do you think about patients being able to self-refer to NHS physiotherapy services? My first reaction was that it would herald a stampede (albeit a slow, creaking stampede, emitting the odd ‘ooh' and ‘argh') and the already stretched services would be overwhelmed. When I read the DoH report on the year-long pilots, covering six areas of differing populations, I started to feel more at ease with the idea. The principal is sensible, 91 per cent of the GPs involved were happy with the scheme, and the patients and physios also wanted it to continue. But despite the repeated assurances in the report that there was ‘no increase in demand', my doubts persisted. Then I found that ‘self-referral does not increase demand except where there has previously been under-provision.' Also the publicity given to the self-referral service seemed decidedly low-key to me. And only 34 per cent of the physios felt that the general public understood what physiotherapy could do for them. It's also clear that the pilot areas were very well prepared for the scheme, and they reported back that investment in time was essential to the success of the initiative. Of course, time is not on the side of the current government and, given the dangerously misguided rush to build polyclinics, one wonders how long other PCTs will be given to implement similar vote-winning, self-referral schemes? So it will be interesting to see what happens to demand once the message about self-referral really gets out to the population at large. It's certainly a story that plays well in the media. Yesterday I was asked to do interviews with 11 regional BBC radio stations on this issue, stretching all the way from Devon to Cumbria. Is that the sound of creaking I hear? Posted Oct 22 2008, 10:35 AM by Colin Cooper with no comments Filed under: referrals, patient demand, self-referral, physiotherapy

• Does self-referral mean an end to GPs' gatekeeping role?

  Alan Johnson is about to announce new plans under which patients will be able to refer themselves for treatment with a physiotherapist, and other health professionals without having to be referred by their GP. The health secretary is expected to tell the Chief Health Professions Officers conference in London today that self-referral will allow more flexibility for patients, faster treatment and less time off work. It's not just physiotherapists who are included in the change: all Allied Health Professionals will be able to accept patients who self-refer. This includes podiatrists, chiropodists, speech therapists, and dieticians. The debate has been going on for years, and the Chartered Society of Physiotherapy (CSP) has released several studies showing the efficacy of self-referral to physios. Although many areas already allow self-referral, the Department of Health is today formally backing the policy. The strategy is already in place in Scotland, where pilot services have run and been fully evaluated. The green light in England follows two years of a pilot self-referral scheme accross the country. The question is: how is this new strategy going to take some of the burden off GPs? Well, apparently around 25 per cent of all GP consultations are related to musculoskeletal problems with a lot of consultations just ending with a referral to local physio services. There are therefore significant savings to be made. According to the CSP, GPs cost around £109 per hour and up to £25 per consultation whereas NHS physiotherapists cost approximately £35 per hour, based on Senior 1 salaries. In 2000 this represented a saving of £74 per hour if patients did not have to be referred on by a GP. What about the negative consequences of this policy? Are we going to see increased demand for such therapists? Will they be able to cope with potentially longer waiting lists? Will this mean the end of the GP's gatekeeper role? Posted Oct 21 2008, 10:55 AM by Emilie Reymond with no comments Filed under: referrals, patient demand, self-referral, physiotherapy

• Another incentive to bash GPs

  Just when you thought the world was finally starting to accept that GPs' pay is declining - as opposed to rising by ‘eye watering' amounts - the issue is back on the front pages. As the annual pay negotiations begin, and the BMA calls for a 4 per cent increase, the national newspapers have unearthed financial incentives for GPs to cut referrals.They have also managed to add these up into tens of thousands of pounds ‘for the average practice', and cause a national outrage in the process. Of course, for most primary care professionals, good practice is to treat patients within the community whenever possible, assuming that it's appropriate to do so. And no right-minded patient wants to go to hospital unless it's absolutely necessary. Likewise, PCTs would like as many patients treated as cheaply as possible outside of secondary care, but of course the hospitals are not so keen on seeing their income disappear. In short, this is how the NHS works. Nobody wants money flowing out of their own budgets, unless it's genuinely for the good of patients. And when practice funding has been under sustained attack recently, why shouldn't GPs sign up for schemes that have been legitimately initiated by the agents of the government? Indeed, how are referral incentive schemes any different from prescribing incentive schemes? Well, the difference is that the referral incentives have made their way in to the Sunday papers. The Mail has been able to scream: ‘How sick! GPs paid bonuses to NOT send you to hospital'. And GPs appear on its leader page as ‘over-nervous and lazy'. Even worse, they've been lumped in with the ‘lazy programme makers' who allow Jamie Oliver to use the f-word on television, and ‘little to do' MPs who want an extra-long Christmas break. So next time a PCT wants to grease the wheels of primary care, perhaps the officers should take the advice that I once heard from an executive at a global oil company. Whenever they ponder the ethics of a particular decision, the execs are told to ask themselves how they would feel if their actions were reported in the Sunday Times. It might just help to avoid the occasional national outrage.   Posted Oct 20 2008, 10:53 AM by Colin Cooper with no comments Filed under: referrals, GP bashing, GP pay

• When are inaccessible GPs accessible?

  Readers of the Daily Telegraph must be very confused. On Tuesday prime minister Gordon Brown congratulated himself mostly for encouraging more than half of practices in England to extend their hours. Then on Thursday the Daily Torygraph, sorry Telegraph, splashed with a story headlined: 'Millions of patients denied access to their GP'. Today HCR reveals the contents of a letter from Healthcare Commission chairman Sir Ian Kennedy complaining that: 'to be clear our assessment does not show that two thirds of patients cannot access a GP within 48 hours' as the Daily Telegraph had originally intro-ed the story. In fact, Sir Ian points out that '87 per cent of people report that they can see a GP within 48 hours and that this is improving'. Don't you just love figures? The magic of the internet means that the Daily Telegraph has now corrected the story online. Oddly, the Daily Telegraph hasn't yet seen fit to print Sir Ian's complaint, although old-fashioned print deadlines probably meant it wasn't available in time. I predict it will make Saturday's edition but, by then, my brain at least will have become post-work mush fit only to cope with Cheryl Cole's X-Factor journey and keeping John Sargeant on Strictly Come Dancing. What, you wonder, do patients make of it all? The other big GP story of the week was the NHS Information Centre finally waking up to the news that GP has been banging on about for the last two years that practice income is, in fact, declining. It doesn't quite fit with the media stereotype so beloved and promoted by the Labour government, does it? Just wait until the stattos at the Information Centre cotton on that practices have had global sums frozen for the last three years! Although, if the credit crunch keeps up we might all be living in boxes using newspapers only for warmth by then. So, when are inaccessible GPs accessible? When you are reading the Daily Telegraph it would appear. neil.durham@haymarket.com Posted Oct 17 2008, 08:23 AM by Neil Durham with no comments

• Why timing is the key to drug dosing

  Delivering a punch line, taking medicines, investing in an Icelandic bank - all things which need to be done at the right time to be a success. Too early and you miss the point, too late and your efforts fall flat and a host of other problems arise. In fact, changing when a patient takes a drug could be as important as changing what they take, a recent study has found. Some timing problems may be obvious - a patient who does not take metformin with food or a patient who takes the doses of an antibiotic at intervals of six hours, four hours and 13 hours, rather than every eight hours as advised. Is that a deliberate decision to avoid advice? Or is "every eight hours", read as "three times a day" and therefore breakfast, lunch and dinner to most people? Timing like that may make it more likely for doses to be remembered, but it leaves a three-fold difference in dose intervals and, potentially, a wide variation in blood levels of a drug. The importance of when medicines are taken goes well beyond splitting doses evenly across the day or taking medicines with food or on an empty stomach, though, and even affects once-daily medicines. A recent paper by Chinese researchers found that, although few pack inserts for once-daily medicines set out optimal dosing time, many drugs' efficacy could be improved, and adverse events reduced, by changing the time at which doses were taken. For drugs without information on dose timing, these should be taken at the same time everyday, they say. But once a decision has been made to take a drug at the same time every day, selecting which a particular time could have considerable effects on the success of treatment, the researchers found. This is particularly true for conditions that are not being effectively managed with current therapies. For instance, resistant hypertension could be due to a patient's blood pressure not falling during sleep. Such a "non-dipper circadian blood pressure pattern" increases the risk of a number of vascular conditions, but can be treated in some patients by asking them to take blood pressures at bedtime, rather than in the morning. In addition, the efficacy of a wide variety of medicines from asthma and allergy treatments to cancer drugs has been shown to be largely dependent on when these drugs are taken. Doctors, pharmacists and nurses need to be aware of what kinds of drug have an optimal dosing time and that changing dose timing can reduce adverse events and improve a drug's effectiveness, the researchers say. Patients also need to be told about these effects and to understand their importance, they add. International Journal of Clinical Practice 2008;62:1560-1571 Posted Oct 16 2008, 11:34 AM by Tom Moberly with no comments

• The DoH has surpassed itself on extended hours targets

  What a great week for the Department of Health and in particular for our dear Ben Bradshaw. The number of GP surgeries offering extended hours has now doubled in just three months. Well at least that's what the health minister announced yesterday. Over 50 per cent of practices across England are now opening on evenings and weekends - compared to just 28 per cent at the end of June (or for more dramatic effect, may I add that the figure was just 12 per cent in April). It did work then - the 'bullying' (in BMA's words), the threats, the ultimatums, the pressure on GPs - the government has had its way and around 4,250 practices are now opening on average three extra hours a week... The big hats from the DoH must be jumping up and down on their chairs (well I might be a bit over the top here, let's say grinning) after all, it's not everyday that the government hits a target three months earlier than planned. Not too shabby considering that just a few months ago, the results of a survey by the BMA showed that 65 per cent of GPs opposed extended hours. Of course, it's not all rosy and there are still regional variations; for example only 34 per cent of surgeries in the north west and 33 per cent in the east of England have embraced the extended hours. But still, definitely worth a pat in the back. And Bradshaw stressed that these results would force the remaining 48 per cent of PCTS to ensure GP surgeries in their area follow suit. Or will they? Those PCTs still fighting against out-of-hour care should make themselves heard (or rather read in our forums and leave comments with their reasons). Or can we expect the DoH to announce that 100 per cent of English practices offer extended hours by Christmas? It was not all good news yesterday though as NHS Employers and the GPC announced proposed changes to the GMS contract for 2009/10 which unsurprisingly led to disagreements on the level of the pay increase. They will now give evidence to the Doctors' and Dentists' Review Body (DDRB). A busy week indeed. Posted Oct 15 2008, 01:30 AM by Emilie Reymond with no comments

• Listening to real life health stories

  Last night (lured only slightly by the promise of drinks and canapés), I attended the launch of healthtalkonline.org, the UK's largest online collection of real life health stories and shared personal experiences of health and illness. It was essentially the relaunch and redevelopment of the former dipex.org site, which had been running successsfully for years but was in dire need of a name change: ‘dipex' didn't really give people a clue to the resources on offer. By contrast, ‘healthtalkonline' (and sister site ‘youthhealthtalk.org) are fairly self-explanatory and offer improved accessibility, enhanced navigation and search facilities as well as new health topics such as Parkinson's disease and autism. The event was held on the 29th floor of the Millbank Tower with incredible views over London and boasted presentations from DIPEx charity patron and broadcaster Jon Snow; doctor, theatre director (and author and sculptor!) Sir Jonathan Miller; health minister Ann Keen; plus children's writer Phillip Pullman. All were genuine draws: there was indeed free wine and tasty snacks; Jon Snow hosted the charity auction; and Phillip Pullman spoke intelligently about the value of ‘authenticity'. However, what really inspired me were the short film clips of patients talking openly about their individual and very personal experiences of their particular conditions. Patients with Parkinson's explained the inexplicable features of their disease: how it could be possible to play table tennis like a pro yet impossible to climb a flight of stairs or extend an arm at will; how good friends stopped visiting.  People with autism talked about their difficulties forming relationships, the ‘lonely journey' they faced; the sterotypes they wanted to break down. The importance of these first-hand testimonials was underlined passionately by former doctor Sir Jonathan Miller. He recalled his days as a medical student in the 1950s when there was comparatively ‘little we could do for patients' so time was invested in keeping the wards clean; making beds properly; and taking down the ‘intimate detail and narration of patient histories'. Today, he explained, medicine has advanced, but doctors are ‘less attentive to the narration of what it is like to suffer' or what it is like to be a relative or carer of somebody who is suffering. ‘Something is missing,' he said. ‘We don't pay enough attention to the details of what it is like to have one of these many disorders.' A change of attitude is needed if patients really are to be placed at the centre of the NHS. But at least, in the meantime, people have been given a platform upon which to express their views and share their experiences of living with a range of conditions. I think we could all learn a great deal from healthtalkonline. Posted Oct 14 2008, 03:49 AM by Sarah Wild with no comments

• Free drinks for women doth not maketh a café society

  Well it seems that the government's brave social experiment on 24-hour drinking has come a cropper. The idea that extending opening hours would turn Britain's rowdy pub culture in to a smart café society has been asked outside and given a good old-fashioned pasting. This will not have come as a surprise to normal people living outside of the Houses of Parliament, but has clearly shocked those sheltered beings who draw up the legislation that controls our daily lives. So now we face a backlash from legislators who are planning to outlaw free drinks for women. The government has obviously decided that drunken groups of young ladies are to blame for its failure to establish the café culture. Surely this is sex discrimination? Or maybe it's just The Guardian's self-righteous take on the issue? True, the last thing I want outside my local pub/café is a hen party while I'm sipping my coffee, puffing on a Gauloise and contemplating the meaning of life, but neither do I want a stag bash cramping my intellectual pursuits. So if free drinks are going to be banned then let's ensure that both sexes suffer the same deprivation and actually have to pay to get drunk in future. Having said all that, the government has inadvertently created a sort of café culture by forcing smokers to sit outside in all weathers. In which case, if they really want Britain's streets to be lined with chic, well-behaved, sensible drinkers, maybe all they have to do is ban alcohol indoors. Posted Oct 13 2008, 11:39 AM by Colin Cooper with no comments

• No need to repeal the new GMS contract

  When it was suggested last week that the profession should lobby to repeal the current GMS contract, I thought it sounded a slightly crazy idea. A bit like the 1983 Labour Party manifesto which threatened to nationalise banks that didn't play ball. But, of course, a week is a long time in medical politics, and now I'm thinking that maybe it would be better to start from a clean sheet. Professor Allyson Pollock made the suggestion - though it sounded more like a plea - at the RCGP conference in Bournemouth where Dr John Chisholm was also speaking. Dr Chisholm has kept a low profile since stepping down as chairman of the GPC, following his negotiation of the new GMS contract. He told the conference that the contract had brought good and bad things to general practice - which is a shame because he had originally claimed that it would spark a ‘renaissance' in the profession. Having said that, perhaps no one could have foreseen the smash-and-grab tactics of successive ministers since the contract was first agreed. Any benefits for GPs were quickly clawed back, using both lawful and unlawful means. Those practices on PMS contracts have also been cast aside, having apparently served the government's purpose as a means of dividing the profession. The quality framework stands out as probably the most successful element of the contract but even that is still a work in progress, open to abuse by politicians, and now likely to be smothered by NICE. So repealing the GMS contract is probably not such a crazy idea after all. In fact, if you add up all the changes over the past year, then this contract has been well and truly torn up, stamped on, burnt down and spat upon. There is no need to repeal new GMS because it's already been done - by the government. Posted Oct 10 2008, 02:51 AM by Colin Cooper with no comments Filed under: GMS contract