Wednesday, January 21, 2015

Seven. I did a quick headcount as I sat down. There were seven GPs in the room. The there were GP trainees, the practice nurses, the practice manager, the community diabetes specialist nurse and finally me. It was the regulation biannual visit to one of our local surgeries..Swan surgery in Petersfield to be part of our diabetes model of care. And tell you what? A few hours whizzed by.

It was actually fun..and those hours had everything, chat about patients in whom everything else had been tried, discussion about evidence of new drugs, chatter about the condition of pre-diabetes, review of an audit, talk about the difference between type 1 and type 2 diabetes, suitability for an insulin pump, the services available...and you know what? I go back to again the same was actually fun. There was light hearted banter amongst all, there was a GP amongst them who worked for the local CCG who took a few jokes on the chin, we joked about how who was the busiest..and we did so over lunch..we talked about patients, we talked about improving care, we talked about the next steps...and in case you missed it...Yep, it was fun.

Why do I share this with you? Simply to also give you a perspective that not all GPs are entrenched and want "more GPs", not all simply say "it's too much"...there is a huge carder of them who actually are very VERY open minded about working..differently..appreciate the help specialists can give..stay away from the sarcasm laced comments about "you can't do my job" and actually are bending over backwards to work with different quarters of the system to make care better, looking at different ways of delivering care.
To those who form an opinion about primary care based on social media or the general media ( or even the generation next who aren't sure about taking this profession up) , let me offer you a counterbalance. There are two extreme opinions in the is that they are lazy fat cats who earn in the most six figure salaries and form the top 4% of the earning population and don't do weekends or out of hours. The other is that they work day in, day out, and are drained to the hilt, on the verge of quitting and work in a battle zone . The reality is that both those extremes do exist but the majority sit away, as with any debate, from the extremes.
Where do I base that opinion from?Locally I have had now nearly 5 years experience of working with 83 GP surgeries along with travelling up and down the country discussing with primary care and meeting GPs everywhere you can name.  I don't know whether its just by coincidence that I meet nice people or we are just blessed with good primary care colleagues but I have yet to meet the snappy ones who offer judgements or opinions in 140 characters and will not brook any further debate or care to stick to the archaic terms of "primary care" and "secondary care". Hospitals are part of the community..lets get that fact straight. Not separate.

Just to emphasise that Swan Surgery wasn't an outlier, this week I also visited Denmead surgery...again, 4 GPs in attendance, practice nurses, practice managers, discussion over lunch, reference to studies, discussion of Yudkins controversial talk on pre diabetes ( check it on's fascinating), chat about clearing up the confusion for type 1 diabetes patients as to where they should have their essential health checks done if under hospital care...what can I say? It was fun, it was enjoyable, it was a privilege to be out there amongst such fantastic GPs. Did we jest about those letters from secondary care? Of course we did..but not in anger, not with was more with a need to ensure we do get the process right. The best decision we ever made as a diabetes team was to decide, apart from the super specialised bit, not to do clinics in isolation in the community. It has been an amazing experience working with can never discount the human touch, the education provided by face to face ..and that's a 2 way education..respect doesn't come from reading documents and stamping your foot harder, it comes from talking to a fellow professional and understanding that all at on the same side, just with different skills.

So, you know what? Try it, try going to GP surgeries and vice versa..make your OWN opinion about GPs after meeting with them. I promise you one will be fun. It has been for us over the last 4-5 years and to the question what has the super six model of care done? Outcomes are come slowly...but it has done one fundamental has shown us the value of GPs and specialists working colleagues...while having some fun along the way.


Tuesday, January 6, 2015

To clarify

You must have noticed it, haven't you? The words that were uttered in black humour, with a wink and a dash, words which were said in closed quarters at the end of a busy day, words which came forth over the nth's all quite openly spoken now. It's the patient..or rather the fault of them. Their fault they waste doctors time, nurses time, ED time..inappropriate, awful, wastage of precious time of healthcare professionals. Trivial issues brought dare they ask for help.

And it opens a Pandora's box, doesn't it? We have all seen the patients we deem are unsuitable, the drunks we have encountered in ED queues, the ones who forgot their prescriptions and needed better planning- but in a system which treats millions- the question has to be what proportion of that are what we term as "time wasters". We ask, no, demand that the public should look after their health better and bother us less, yet how many times have we followed the mantra of regular exercise and the healthy diet we are so quick to profess? As a Diabetologist, I look at HCPs everywhere and can only say this...practicing what you preach ain't easy, so why be so quick with the judgements? Some of the recent Twitter exchanges have been uncomfortable..challenge is good but with respect too, right?

It's a difficult argument and there are many fold reasons why the system is creaking but from my own perspective, blaming patients ain't gonna quite help. Making people feel guilty about coming to see a healthcare professional ain't the way ahead in my book. I have recently been to ED and yes, I have seen folks who perhaps could have gone "elsewhere" but how is it their fault that we have so many avenues to access when ill? How is it their fault if 111 follows an algorithm and goes down the risk averse route to send them to to ED? How is it their fault that the out of hours GP is too swamped and has a waiting time of 6 hours to see them? Blame anyone, blame ourselves for not being adult enough to work together, blame leaders for never quite getting out of their silos, blame politicians for not being honest with the overall situation, blame anyone but don't make people feel guilty about seeing us.

I write this with a bit of sadness after recently seeing an elderly lady who tried to stay away from GPs and hospitals while trying to manage her COPD. She said she didn't want to bother her overworked doctors, she said she had read a blog which said patients needed to self manage better. You know what? The message maybe the right one, but that is not the patient we are trying to educate, this is the wrong message gone to the wrong person. What do we call her now? Stupid for not understanding the message of the article? Or kind for trying her best to help out her poor doctor?

I urge all to be careful with the rhetoric. It's easy to shift the blame, easy to blame all...let's leave the patient out of this one, shall we? Today, categorically, via my blog, let me be crystal clear. As a Consultant in Diabetes and Endocrinology who works across organisations, any patient who is under my care, I do NOT want you to feel guilty about contacting me. I do NOT want you to feel you are disturbing my peace by asking me a question which may keep you safe. I do NOT want you to go without your insulin if you have lost your pen and then worry about disturbing the overworked doctor. If you want help, email or text is easier to do rather than you being admitted in ketoacidosis. If it is within my power, I will help. I cannot speak for anyone else, I certainly can't speak for GPs who are far busier than me but I can certainly speak for myself. If you are stuck, call me, email me, leave a message with our administration staff, I will help to the best of my ability.

Let me end with a disclaimer too. This isn't a blog lecturing others, this isn't a swipe at those once-motivated individuals who feel so beaten by the system that they have now turned part of their ire against patients. This is to simply establish one thing publicly for patients under MY care. I don't want anyone admitted because they felt I needed a bit of respite. If it's an inappropriate request, I will point it out with humour and a smile. In 2015, I am trying my best to be more mellow and smile a bit more.
As the saying goes..everyone is going through something you don't know much about..and no one speaks on my behalf when they want you to "go away". Amen

Thursday, January 1, 2015

The mirror of Galadriel

1st January's that day of the year when you think of what's ahead, what could be, what may become. In the world of Tolkein, there existed such a device..a basin of water used in the Elven realm by Galadriel that could possibly show things that were, things that are and things that yet we dare to have a peak? Do we dare to have a look at a possible future and either batten down the hatches or do we step up to the plate and try and change what we see- beyond 140 characters, a vent in a blog or pledging on a wall? We shall see, won't we?

Let me have a peak though..let me see what I think may happen - if not over the next 12 months, but over many more..

1) Hospitals- unscheduled care will continue to swell, flow will become even more difficult, realisation will set in that all across the land the 4 hour target is unachievable. We shall all seek for the one who bears the ring- many pretenders will arise- alas, it won't change. It will no longer be about flow, it will be about acuity. ED staff, acute medical staff, ambulance crews will continue to buckle. they will step up to the plate one more time, one more day, hospital status alerts will stay at black mostly...the age of Sauron is upon us. Within hospitals, apart from those taking the heat, plenty will pay lip service, we will have a few stepping up to help, the rest will continue to do their specialist work. Social care or lack of it will be the critical reason why hospitals stagnate - the managers will look that bit more battered, a bit more frazzled- pushing the staff for a bit more while in their heart of hearts knowing there isn't much else to give.

2) General Practice - the pressure will ramp up- times are not going to change. They will ask for reinforcements but this time, the reinforcements may arrive to Helms Deep- perhaps a bit too late. The entrepreneurs will make hay- take over neighbouring surgeries, start employing Consultants, be innovative- the rest will get angry, distraught..go to work one more day- asking for one more effort. The natural instinct will be to lash out..hospitals, specialists, politicians, patients...the mood is dark, the forces are restless but there isn't much to stop the heat. A few rebellions will erupt- countered by the few entrepreneurs while the majority will go to work- one more day, one more effort to bring. One leader to unite them all, one Aragorn? Not quite visible in the mirror, yet.

3) Specialists - have been mostly quiet in the ensuing chaos but this maybe the start of them - either by choice or force, being asked to explore other avenues of work. Those who do private practice will CCGs cut off or restrict certain procedures, they will do more of those in the private sector. A few will rise to lead hospitals taking control of a system where primary care is rudderless and without will be the age of the Trusts..otherwise known as PACS. They may will become vital commodities- as entrepreneur GPs and Trusts battle for their services- whether doctors or nurses.

4) CCGs - Purse strings will will be all about relations with them. Payment by results will continue to drop and evaporate thus forcing Trusts to look at different ways of doing things- some silly, some fantastic. CCGs will become more powerful as they come into their own- look at working together with organisations like Public Health etc to form ideas..some silly, some will be up for grabs..entrepreneurs will flourish, Trusts will either join hands or take each other over. The time of the Entrepreneurs is here.

Finally, there will be an election...and irrespective of colour, hue or whatever, the above will stay the same. Next 5 months will be silly season, making promises which will be unachievable. We have rejoiced at Stevens ask for £8 billion...we have forgotten the £22 billion of efficiency savings we have been asked to make. No one has the answers, no one actually knows the way out of this...and no one has even breathed a word about increasing taxes...there is a tacit understanding that this efficiency savings will need to come..from us.Ladies and gentlemen, there is no white  wizard coming post May- there is no game-changer in the offing.

So...keeping to the Tolkein references, remember this..what Frodo saw in the mirror of Galadriel didn't come to pass in the end..we all know what he did to stop that happening. The key however was needed folks from different, elves, hobbits, dwarves to come together to make it happen. The question is whether we, as a whole, can come together, beyond the " I am special" argument and make it work. Singularly, all those visions in the mirror will come to pass. Together? We may just prevent it.

Time's ticking, ladies and gentlemen, Make any resolution you want..but better include the one to join hands with another beyond your own "clan". As Gandalf says.."The board is set.The pieces are moving.We come to it at last, the great battle of our times".

Have a lovely 2015, won't you?

Friday, December 26, 2014

Mastering the fire

It's been a magical many many to look back and smile..  but inevitably the major highs have been the ones linked with friends and family..the times spent together, the holidays with friends, the special weekends with all in London, surprise birthday parties in Southsea, celebrating my daughters's all been linked with family..there's been a theme there, hasn't it? 

From a team perspective, its been another year of progress, battling the perceptions of diabetes being a Cinderella service, trying to focus on patient care, trying to avoid harm and as recognition arrived - whether it be via the Kings Fund report or Diabetes UK, realisation started to dawn that we may just have done something which has the potential to be special. It's been a personal vindication being asked by other CCGs to share what we have done- sniffy comments from many seem to have turned to a bit more of a grudging admiration. You look, listen and smile. Getting old,you see, to remind all of the past negativity towards changes made by the team..

Lots of highs...doing the Mary Mackinnon lecture- what an honour - what a privilege- hope I did some justice to that great woman; rolling out 7 day service for diabetes care; HSJ honour for acute services;moving out of general medicine to prioritise diabetes care; a mention as a social media pioneer..all good recognition for a hard working crew- and as ever, the need to "make things happen" has caused frictions.
There has always been a key question for me...Improve patient care and sacrifice a few things for need of haste or take your time, try and get all on board and spend a bit more time when so many suffer while you wait for egos to settle, politics to take a you worry more about the relations with your colleagues or does the hurt you see when you see an insulin error enough to make you stand up and growl one more time? In a culture where it appears that relation maintenance are of a higher priority than patient care, clashes are inevitable. Avoidance of that takes time and our patients have that time while we as patient advocates have yet another meeting? Tough questions for all of us, aren't they?

It's difficult to do so..and thereby lies the crux. You want to do things swiftly in an era of silos, vested will rub off people the wrong way. The decision is whether patients can afford the time you tale or not- and for 5 years and a bit, that has not even been a question or debate in my head. A simple rule in life...not here to win a popularity to improve diabetes care...but how long do you keep pushing the edges?

There have been lows too- perhaps not so much individually apart from personal ailments (touch wood) but also a growing realisation that social media has its more mischievous sides- apart from the realisation that it can do plenty of good- it has also given avenues for some to build up reputations without actually doing much. A change of stance, a new buzzword, a new hash-tag, different titles- and the personality of self has grown- with little changing for patients.It irked..but strangely, in a cathartic has stopped irking me. Personalities such as that will always exist- they always media is just another forum for the ones who have to justify their existence.It involved a Kings Fund meeting - Mark Newbold and Vijayanath- and something they certainly is time to prioritise

As has happened many a times in my life, by luck or default, on a personal have arrived at a position where there perhaps isn't many more battles to fight locally..the chips are in place- the time is now for delivery- and we have some awesome staff to do so. It has indeed been a long goodbye trying to step down from the department role- but I think we are finally, hopefully, there . It is time for family, a time for a calmer soul..a time for perhaps a more charming side, rather than an angry side. The plan was always to blitzkrieg the local system for the first 5 years with energy, passion and drive...6 years in..its time for the next phase.

What will that bring? I know exactly what it is- it was always part of the bigger plan..what does need adding to it is the need for family time, a bit more laughing and jousting at home. This Christmas day was one of the best I ever had...main factor? We were together- all day- as a family.

Wish you all a fabulous 2015...I know it will be...Let the next phase begin. The fire still rages..mastering it will be fun. Will the softening of the edginess dilute the impact or is the firebrand reputation strong enough to allow things to progress? Let's touch base again in 1 year, shall we? 

Friday, December 19, 2014

GPs...all up to you Part 3

Last blog was fun wasn't it...some high praise indeed from GP colleagues...a lot seemed to like it...but this will be the last in suggestions..because it's time to stop, time for those who do this job themselves a bit different..and for one last time? No, it's not more GPs.
Let's take time to look at an alternative universe...there is no more GPs around to fill posts, no locums, most have retired...what actually happens to the health system? Yes, we can scream and say it's all gone Pete Tong...but what would that force the system to do? What would happen if there were no more GPs? The system will have to look for alternatives..did I hear you say no one else can do what a GP does...yes, I agree...but needs must and in this alternative universe, they ergo GPs don't what now?

Well, one option is the NHS collapses simply due to the financial implication as it has been proven beyond argument that GPs are cost effective resources. So what now? We go insurance based? As a Consultant, that's not a bad option. Yes, it's rubbish for the population but we are in an alternate universe where we don't care about them, so hey presto, the Consultants or specialists are raking it in now. Let's be honest, if you have diabetes, and capacity to pay insurance, would you go see a GP or a diabetes specialist? Forget about cost effective medicine, evidence would want to see a specialist. Don't believe it? Look around the world...look at the systems are desperate including insurance companies to set up primary care...just to get some semblance of control. I know so as have been involved with organisations looking at setting up primary care in India etc....led by GP leaders from..hold your breath..the UK. Trying to show the way, ah the irony..don't you just love Pythonesque humour?

What else? How about this? Not enough GPs..struggling...hey how about I tot up all the hours used by the practice nurses to do diabetes care, give up the QoF points for diabetes and the local Trust runs diabetes for you? You don't have to see a single patient with diabetes ever. Did you say multi morbidity? Heck, most diabetes docs are general physicians too..we can do it all...just relinquish the money,..that ok? Palatable? Well, if you don't like last weeks suggestion, that's the alternative up again the Five Year Forward View. Think fast amigos..make your choice soon.Either take up the leadership or be led. Your shout. The cavalry of extra GPs may arrive a tad too late to rescue the show.

But we don't live in that alternative world, I actually would like the NHS to survive as a free at point of care system? Is that a personal wish? No...I am blessed enough to afford insurance and give me and my family the best treatment, the best specialists needed. Work wise, again, if GPs collapse, ah well, I go down the PACS model, employ more specialists, and boom, bobs your uncle, innit?  So what if all can't afford it, I am better what the heck? Right?
Well, no..wrong actually. Why? Because I have worked in systems which isn't free for all and it simply isn't fair. Health is a basic right for all, as is education and as lovely as it would be for me individually, I would love to think a little bit broader for me. The present system rewards me well enough, thank you very much.

So I am going to end this series by exhorting all GPs to spend even an hour a week by trying to convince even one undecided trainee to take up your chosen profession. Show them why you are proud. I get it ...the media have dissed you, I get it ...politicians don't like you..I get it all. I also know there's a huge collective of fantastic folks who are immensely proud of the work they do. Do whatever it takes to encourage people to join. See what is being published in Pulse..see what medial students are saying. Check the Deanery are losing the recruitment battle hand over fist. Say it loud, say it proud..its a good ,proud profession...heck if you want a specialist to do it for you, ask and I will help.

And you know why? Not because I feel sorry for GPs, not because I am trying to suck up to anyone...but because I am more keen on making sure the NHS survives. Because ladies and gentlemen, if you can't recruit and it collapses, I will be fine. Many, many other...simply put...won't.

I will stop throwing my tuppence in anymore..and I wish you all the best. It's a tough battle and certainly not an easy one to win. But if you ever need an ally, you know where to ask. It would be easier to say "not my circus"...the problem is it actually if you all collapse, you bring the whole house down with you.

Wishing you all a Merry Christmas x 

Wednesday, December 17, 2014

GPs...the Hail Mary pass ? Part 2

It's been fascinating having the last blog published...the reaction was as expected- a smattering of "no facts" ; "not wise for an endocrine doctor to comment"; "rhetoric" - and indeed it came from expected quarters. What however was pleasantly surprising was the positive vibes too from GP colleagues and even better were the the suggestions. I kept ribbing about people stealing my ideas for the part 2..but weren't they just fantastic ones? Wasn't it nice to see some sensible suggestions- all from GPS- suggestions which were beyond the rhetoric of "more GPs"; a display of obvious pride at the job GPs do...THAT'S what I was looking for and you know what- the NHS has indeed a future with passionate folks like that in the fray.

Let's cut to the chase- we can tango around the perennial debate whether GPs are independent private businessmen/women or not. To be honest, its immaterial- without blowing smoke up anyone else, 5 years and more of working in the community has taught me one thing- without GPs, the NHS doesn't exist. pretty simple as that. If this was a game of american football, most external folks would be perplexed at the effort the system has put to make sure the quarterback was tired and incapable of making the pass the rest of the team needs. Know what a Hail Mary pass is? Look it up...the quarterbacks are now reduced to that- and guess what, the team is losing and with it, so is the rest of the morale.

So let's get some radical thinking going. Stop thinking that only more GPs will solve it- it won't. Not to mention they are actually not out there...but more of that later. Broaden your horizon and thinking ladies and gentlemen. The RCGP and RCP have now come out with a joint statement how organisational boundaries shouldn't be a barrier to patient care- so why not start actually employing Specialists under yourselves? I hear you say where's the money- well, take some time to understand the fallacy of Payment By Results. It is a system which works well for surgical procedures but has crippled us all, Commissioners included, where Medicine or specifically long term conditions are concerned.

Like him or not, Stevens 5 year Forward View is here to stay- and irrespective of elections, is pretty much the direction of travel. Look at pages 16-20 of the PDF document- is your answer there? Can GP surgeries - if you don't like the word federation- then at least buddy up together and come up with a plan to run a long term condition? Can you show that you can employ nurses, specialists to own the whole process? I am sure I will be called naive- let me counter that by saying that most GPs don't have much idea either about Consultant contracts, Payment by results..look, ask and you shall find. By the way, read a bit beyond on that report, there is another model there too...check that out..and think whether that maybe suitable too...views on that welcome indeed!

I will give you an example- as part of our diabetes work, as a team, we go to each surgery twice a  year at the surgeries discretion. The mantra is very simple. "I" am "YOUR" employee for 3-4 hours or however long you want me  in your surgery. YOU use my skills to improve care of patients under YOUR care- as simple as that. That could be done by education sessions, chatting, seeing patients with you, audits- the call is YOURS. YOU are the quarterback- you tell me which channel to run in. I have a skill set YOU need to use for your own patients- can't be that difficult, can it?

At the moment, most GPs can't even look up beyond their daily work to think broad- I get it. But trust me, there are many like me who want to help, want to keep the NHS afloat as there is a simple realisation- given the efficiency to which GPs run, without them in the pack, you can kiss "free at the point of delivery" goodbye. Love the NHS and its ethos a lot? Then broaden your let's face it...there is no cavalry coming right now. Maybe it will- but it's going to take at least 3-4 you have the time for that? We are losing GPs NOW...when and if the cavalry arrives, what will they be left with?

I could go on and on and am sure will still be criticised for "not getting it". Maybe I don't, maybe I am too naive- but I work with GPs everyday- and I see folks every day who genuinely want to help. The future maybe different..and more on that in the next part...but for now, you need a plan pretty sharpish. Heck, you guys have been throwing plenty of Hail Mary passes...try this one out...a lot of professionals- inclusive of specialists, pharmacists, nurses are ready to make that run. The billion dollar question you trust us?

Saturday, December 13, 2014

General Practice..beyond the anger? Part 1

GPs are least on social media they are.Look at twitter or any social media for that matter, apart from anything else, any suggestions to even do something, have a debate about anything different descends pretty much within 3-4 minutes to total a pack, you get absolutely overwhelmed by someone "out of touch", someone "who misses the point", someone being "protective about their patch"...140 characters condenses strong emotions into what appears to be rude, recalcitrant and disengaged. But hey, its always worth a discussion because lets be honest, its not working, is it? The dangled carrot of more GPs seems more like hunting for the El Dorado gold- while the reality on the ground is that most trainees are not picking this specialty, many do NOT want to be partners...a reality check is always important and no, you can't force anyone to be a GP.

It must be said however that there is a difference with people I meet day in, day out though. I interact with GPs every day- all across 80 surgeries or more- and rarely if ever I see angry folks. In the main, they are pleasant, keen to help- yes, tired, brow beaten, aware of increased pressures but importantly very appreciative that they aren't the only ones. The british sense of humour is ever present- and I do enjoy a lot my time spent with them...maybe twitter is skewed. The issue however is that this isn't a complete rarity. The system now has ground all into such a corner that now you have what one could describe as trench mentality. Yes, I am a Consultant in Diabetes but I have been fortunate enough to hold different roles in community beyond diabetes, within hospitals in unscheduled care to understand that there are many-, many others who are as busy as anyone else. District Nurses, Community nurses, ED doctors, MAU their feet, busy, horrendously busy, tired faces- and if I am being brutally honest? As I have said before, yes GPs are busy but so are plenty others- its not a monopoly on the level of busy-ness neither is there a prize or competition out there to win. The system is squeezed, money is short, politics is huge- we are ALL under pressure.
There are 2 views at looking at this- and let me make this clear- these are views from GP colleagues themselves- NOT from ivory towered specialists or managers or anyone who has no experience of General Practice. View A is that people are well paid on a public tax funded structure, amongst the top 5-10% of the whole population, armed with a pension scheme which is gilt edged and now that the pressure is on, there are too many complaints. Be grateful for what you have, do the hard yard, earn your pennies and retire happily. Do the job you trained to do- and accept public srutiny is more- and get on with it. View B is its all too much- work has descended on GPs without agreement, without resources, public expectation has been fuelled and its time to take a stand and say "Enough". Time to stop doing X, Y and Z.

My view? Either views are too entrenched. I will be perfectly honest- if you want more people to join GP land while at the same time, you consistently say its too much- you forget the basic psychology of the generation we live in. This is no longer the Baby-Boomers or Generation X who would grit their teeth and do it in times of pressure- the next generation is a mixture of Generation Y and Generation "Me". We can critiicise that as much as we want but for that generation, work life balance is extremely important. I know lot of people turn their nose up at it- but I never ever fault anyone for that. THAT'S the world we live in- THAT'S what we have to work with- so if you want to attract more to a specialty- you must balance out your views- YES absolutely make it clear its hard, tough- but also show how amazing GP life can be- how rewarding it can be- how much work life balanace there can be...its can't be all bad, can it? Your present angst at the system shouldn't result in the future being bust, should it? And let's be honest, if GP surgeries collapse, thats pretty much the end of our beloved "free for all" NHS.

So...apart from the nebulous Narnia-esque idea of "more GPs" there actually any solution to the crisis looming? The future path for the NHS has been outlined in the Stevens report...does any of the clues lie there? More importantly, is there an appetite for this amongst GPs? Can they genuinely be in charge and think beyond their individual surgeries? In my next blog, I will throw open some questions ...

Finally,those who feel strongly against any of the thoughts above or in next blog, my appeal..have a proper debate, not a condensed angry one in 140 characters...but let me be perfectly honest, more GPs isn't going to solve the NHS conundrum- and will only act as yet another finger in the dyke.