Editorial Comment

££ – General Practice Always Under Fire – ££

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Over the last few years the British Press has continued to take a relentless swipe at the NHS and General Practice in particular. Whilst there is no smoke without fire a lot can be blamed on the former Labour government and the 2004 contract.

Now one Labour Peer, Robert Winston thinks that Patients should be charged £200 per annum to see their GP so they ‘learn to appreciate the Patients should be charged £200 to see their GP so they ‘learn to appreciate the NHS’

Curiously, if every patient paid £7 per month a doctors NHS income would remain very similar to what it is now. So to suggest £200 smells of serious profiteering as there is no guarantee that surplus founds would be paid back into the provision of better services. The NHS would still need to fund premises and new initiatives. I recall one doctor in a West Midlands surgery who refused to accept the male head of a household on his list as an NHS patient but did accept that person privately I think at the time for an annual fee of £10. This was 40 years ago. At the time there was nothing to preclude refusing to accept a patient in this way in NHS Regulations. Nowadays even to remove a patient from a list causes quite a stir. Despite Open Lists patients living in nursing homes are shoved form pillar to post.

The idea of charging was only alien to the New NHS for a few years after 1948 – now the dental and ophthalmic service are almost at cost and the pharmaceutical service might soon reach a £10 prescription charge certainly in my lifetime. Hospitals are being asked to levy parking charges more fairly. Those attending outpatient appointments or visiting long term inpatients should never be expected to pay parking charges. Why one wonders have NHS managers not considered the appalling effect car parking charges has on people visiting a hospital and not knowing wht time they would expect to leave the hospital. The NHS has been asked to put this right.

There are still hidden charges already with telephone lines in use that offer a payback to Practices but charge callers higher rates. What evidence is there that the payback to practices is reinvested in the Practice.

The NHS is riddled with charging systems. Nothing is ever free. Nothing paid for comes without consequences. If patient’s paid for consultations, home visits as well as their drugs they would rightly expect a quality service. There would need to be value for money. No waiting a week for an appointment. A proper complaints system would need to be in place. An independent complaints investigation system would need to be in place.

Robert Campbell is a retired Practice Manager offering comments, information and advice to Practice Managers and their staff.

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Editorial Comment

Are Telephone Consultations Ineffective?

Telephone conversations or ‘consultations’

A report published in The Lancet and reported on BBC News questions the effectiveness of telephone consultations in general practice today. In my experience telephone ‘conversations‘ as opposed to ‘telephone consultations’ can be a very useful way for a patient to get a quick answer to a minor problem with their health care. You may have a query about taking your tablets or a reoccurring ailment that simply needs a prescription. The call could be taken by a doctor, a practice nurse or a nurse practitioner and in the overall scheme of things can make the surgery day better organized.

The telephone conversation can save both the patient’s time and the doctor’s time. Many doctors now offer a call back service for minor problems but if you have a new problem not seen by the doctor before this is when the problems start and yes experience does show that a significant number of patients still need to physically see the doctor. This effectively means that there are two contacts are made instead of one costing both more in time and staff involvement. The problem as I see it is that patients do not and cannot be expected to know what is minor, what is major, what is urgent and what is non-urgent. Sometimes reception staff are given some guidelines on how to deal with calls but basically speaking to or seeing personally a health professional is the safest way forward.

Some practices have introduced a system of a doctor vetting all incoming calls requesting an appointment and claim success as a way of managing work. I have also experienced the reluctance of experienced doctors just to handle a patients health care on the telephone.  Obviously there are enquiries from patients that suit the telephone conversation.  But again there are situations where to just take a phone might result in a serious risk to the patient.

Out of Hours services and 111 depend greatly on the expertise of ‘staff’ to elicit enough information from a caller upon which to base an informed and considered decision. Perhaps video calls might be a solution. Access to a patients record might be another solution.

Overall the way in which a service is provided depends on time, the number of doctors, nurses and staff on duty, the number of telephone lines available and the funding to do it. I have always said that there are never no appointments but to provide an effective service needs manpower, resources and adequate funding.

Robert Campbell – Retired GP practice manager

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Robert runs a web site offering information, comment and advice for GP Practice Managers and their staff.





The Practice Manager and the Train Set

Off the tracks!

On 14/7/14 the Daily Telegraph reported a case of a practice manager who stole £160,000 from the practice where he was employed. He had used the proceeds to build a model railway, pay for holidays and a car. He had created false invoices to ‘cover his tracks’ and withdrew cash using the practices bank card. It has taken around nine years to find him out. My interest was heightened by the model railway connection. I too have a model rail collection but not funded by theft.

Just not the ticket

Sadly fraud and theft of this type are not unknown in general practice. I am aware of two similar cases. Both involved considerable sums of money. The methodology was similar, misappropriation of petty cash and getting cheques signed whilst hiding the name of the payee. Using a bank card is a new one to me as normally bank cards are not issued on business accounts. The danger for practices is allowing access to ATMs and cheques that are made out to cash.

Spotting the Signals

What surprises me more is that the practices involved cannot have had any effective controls on the finances of their practices at the time. I once asked a group of over 30 doctors at a meeting I was speaking at how many had seen a practice bank statement or signed a cheque in the last six months – the answer was only a handful. So do doctors need to take a greater interest in their income and not just assume that drawings can be taken out willy nilly.

Definitely off the rails

In one case the manager had not kept thorough practice accounts and nine months had to be reconstituted. Not easy when cheque stubs, invoices and receipts are sparse. In another case the so-called manager became a coach driver and after a serious accident driving on the continent lost one of his legs. Rough justice to say the least.

Appoint a station master

I cannot emphasise enough how important it is for at least one doctor in a practice to fully understand the money that is floating in and out of a practice. One doctor once commented when told the overdraft would not cover the Inland Revenue tax payments that it would be alright at the end of the quarter. It took five years to get back to a credit balance. Yes this was one of the practices where a major theft had taken place.

Have a great rail journey!

Then there are practices that do not keep proper accounts and expect the accountant to sort it all out from a box of bank statements, invoices and payment schedules at the end of the year. One practice had kept no computer accounts and another only had a manual payroll in 2013.

So what could be done to avoid criminality happening in your practice.

1. Appoint a lead partner with financial responsibilities. In one practice a doctor took total responsibility for financial control and his partners became unhappy. When he left the practice his partners found that the accounts were spotlessly clean. Hence the phrase trust me I’m a doctor.

2. Ensure that there are two signatories to cheques with one signatory being consistent. Banking on-line usually involves a system whereby the manager can set up a payment whilst a doctor authorises it. Ask to see invoices. Do not allow a manager to sign cheques alone unless there is a limit to the value that can be spent and there is a reporting system to a partner. Spot checks and occasionally challenges can keep folks on their toes.

3. Limit the amount of cash kept in the practice and insist on receipts for all expenditure. Be clear about what happens to incoming cash. This money can be easily pocketed. This is often the weak link. Keep incoming cash separate from outgoing cash. Keep proper accounts.

4. Check bank balances on a regular basis. Banking online is very helpful in this respect. Check all income statements. Things get missed.

5. Set up a budget so that fluctuations can be spotted. Monitor cash flow.

6. Trust no one even yourself!


Since writing this article I have spotted another case in the national press of a practice manager going off the rails. I would be interested to hear of your experiences with fraud and theft as well as problems dealing with difficult staff and trying situations.

Robert Campbell – contact


Editorial Comment

NHS Pharmacies – Tablets change colour and size


As a patient who takes now 5 ‘white’ tablets each day I am often confused about which tablets I put into my daily medicine box. In the past 12 months one of my tablets has changed from a dark orange to a light orange. Another of my capsules has changed size and colour. And a third capsule has been replaced by a different brand. The capsule which I have taken for years is no longer widely available I believe due to manufacturing problems.

Then there are my inhalers – they too have changed in size and in my opinion their effectiveness. Thankfully the colour of the inhaler has not changed. The meanness of prescribers though s to issue one at a time. If you suffer with asthma you would understand the importance of having a sparfe inhaler.

The final twist to the change of colour and size is the prescription of quantities. Two months supply seems to be par for the course thesedays.

I do wonder if I was much older and did not have all (or most) of my faculties whether I could manage to cope with all the colour changes and the size and shape changes of my medication.



Quality of GP Surgeries in England


Health Centres – best thing since sliced bread

The quality of gp surgery premises was recently brought into question despite a tremendous growth in the rebuilding and replacement of surgeries over the last 40 years. In the 1950’sand 1960’s building health centres was the order of the day. The problem with these premises for gps was the level of service charges. Their design left much to be desired with a proliferation of internal doors, central quadrangles and flat roofs. From 1966 onwards schemes were introduced to allow gps to modernise their premises and later replace or rebuild using either the improvement grant or cost rent schemes. GPs received generous ‘reimbursements’ to fund new and improved premises.

High Running Costs in larger buildings

Personally I was involved in over 30 projects in one West Yorkshire city which left only two surgeries that were not improved.. So it is surprising that there is still a problem with the quality of sureries. There has been a trend in the last 20 years to building much larger surgeries costing a fortune and often not owned but leased. Theses surgeries are often shared between two or more practices. Again the problem for gp’s is running costs. It costs money to run and maintain large so-called environmentally economic buildings and in years to come unless there is proper funding for maintaining these premises the quality of upkeep of the premises will deteriorate. In leased buildings often the owner insists on a regular maintenance regime. In a surgery owned by a practice there might be more control on running costs.

Bigger and more rooms

Modern premises do however have their problems. The sheer size of waiting rooms that often look like inside of church fail to impress me. These areas have to be lit and heated. Stairwells are lit when the building is closed. There is also a generosity of spacious rooms which is applaudible but also of an excess of rooms which often lie idle for many years. Why not have a coffee shop or health library. Why not have a gym that can be used by fitness groups, yoga lessons or aerobics.

The service charge issue

It’s a pity that other parts of the NHS seem to think that it is free to use a GP surgery. I have experienced a serious resistance over the years to health organizations paying service charges. I also was involved in building new rooms for the community nursing team only to find quite disgracefully that the team was withdrawn after six months to another building. This suggested to me that the NHS organization using GP premises should be required to sign an agreement to occupy premises without a six month notice clause.

More thought to design; building big for the future

In the past the design of surgeries has followed design guides published by the Department of Health. The type of rooms provided has been prescribed and the size of those rooms has also been legislated for. Modern surgeries need to provide facilities for new technology. The cabling for a computer network and telephone system are now an integral part of a new surgery.

Tidy up your surgery

Perhaps there should be a tidy up your surgery campaign – little touches can make such a difference. How often are the toilets checked for cleanliness and toilet rolls. Is there a toilet brush to hand? Are there up to date books and magazines in the waiting room and are they kept tidy. Are there flowers in the reception area not artficial ones covered in dust. Is the surgery well signposted. Are the fire exit routes visible? Are the names and hours of availability of all the doctors shown on notice boards or on a sign outside the surgery. Are brass plates provided for each doctor. Remember that the duty pharmacist is required by law to display a registration certificate.

The future is large

The future for gp premises will be controlled by funding. More and more surgeries are being privately funded and leased back. Larger buildings are the order of the day. So two practices share a building one on the ground floor and the other on the first floor. So which surgery do new patients approach. Answer the ground floor. Reach agreement about accepting patients fairly. The future of branch surgeries is very much in doubt as rural surgeries are finding funding issues may result in closure.

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