GP News

Latest News from the Royal College of General Practitioners
https://www.rcgp.org.uk/
Updated: 21/08/2019 12:17

We must not become complacent with abysmal waiting lists, says RCGPNI

"Radically transforming our health and social care system was never going to be easy, but it is essential. We all have a part to play – including political leaders, clinicians, service managers, civil servants and patients – and we must work together to address the inherent challenges facing Health & Social Care. "There is little to be proud of when we reflect on our abysmal patient waiting times. While attempts have been made to address these in recent years, there have only been pockets of success. We simply cannot become complacent and accept that it is the norm to wait for years, in some specialties, for elective care appointments with a consultant. "Sufficient workforce numbers continue to be a huge challenge and recruitment of clinical and non-clinical staff across Health & Social Care is difficult at current levels. General practice services are under immense strain and waiting times only exacerbate the problem, as patients seek support and care from their only accessible healthcare professional – their GP. Despite the launch of the HSC Workforce Strategy last year, there is still no comprehensive plan to increase the number of GPs to ensure future sustainability of services. "Positive steps forward have certainly been made in supporting patients and GP workload through the introduction of the new multidisciplinary team model, embedded in general practice. However, it essential that this model is fully funded and rolled out across the entire region as soon as possible to ensure equitable services for patients, and equitable support for GP practices. "Genuine action must be taken to future-proof our health service and to address the serious issues we are currently facing."

Voice-assisted technology has potential, but we must not create a ‘digital divide’ between patients, says College

She said: "This idea is certainly interesting and it has the potential to help some patients work out what kind of care they need before considering whether to seek face-to-face medical help, especially for minor ailments that rarely need a GP appointment, such as coughs and colds that can be safely treated at home. "NHS Choices (nhs.uk) is already one of the most reliable online sources for health advice, symptom and treatment information, and many people are familiar with voice-assisted technology and feel comfortable using it. Combining the two could be an effective way of accessing information about your health without leaving your home – thereby freeing up more GP appointments for those patients who need them most. However, it is vital that independent research is done to ensure that the advice given is safe, otherwise it could prevent people seeking proper medical help and create even more pressure on our overstretched GP service. "While some patients might want to use symptom-checkers in this way, not everyone will be happy to do so and many people will not be able to afford the expense of this equipment, thus widening health inequalities and making access to care even harder for some of the most vulnerable people in our society. "Technology can be brilliant, when used appropriately, and it is playing an increasingly important part in the way we deliver care to our patients throughout the NHS, but we must be careful not to create a 'digital divide' between those patients who can afford it and are able to use it, and those who can't. "Patients who are frail often have more complex healthcare needs so it is important that they do not rely on this as their sole source of health advice, but seek the help of a healthcare professional such as a local pharmacist who can give further guidance on whether they need the expert care of a GP for more serious or ongoing symptoms."

RCGP welcomes roll-out of HPV vaccine to year-8 boys from September

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: "There is very strong evidence that shows the HPV vaccine can protect people from a virus that can trigger a wide range of cancers that affect both men and women, so it is vital that as many eligible boys and girls as possible get inoculated. "We are pleased that the HPV vaccine will be given to year-8 boys, as well as girls, from September – this is something the RCGP has long-called for. The potential of this vaccine to save lives and prevent the complications of cancer is huge, and since it has been available on the NHS for girls, it has had excellent take-up, with impressive results - it's important this success is replicated with boys. "We'd encourage all parents of eligible children to get their child vaccinated when it is offered, and if they miss the round for any reason that they let their school nurse know, so that they can be invited to a 'catch-up' clinic. It is also important that professionals across education and health are vigilant in offering it where appropriate, and checking that children in the eligible age bracket have had their vaccination."

Primary Care Networks have undeniable benefits, but there is no 'one size fits all' approach to solving GP pressures, says College

She said: "Primary Care Networks are essentially groups of practices working together and aiming to work with other agencies to deliver improved care for patients - and collaboration can have great benefits, particularly at a time when general practice is facing such intense resource and workforce pressures. "Working in networks should allow general practices to pool clinical and administrative resources, as well as making it easier to introduce truly multi-disciplinary teams - ultimately it should help to free up GPs' time to spend with patients who need us most, and improve access to more integrated services for our communities. "However, there is no 'one size fits all' approach to resolving the pressures facing general practice, and while structural reorganisation like this can be positive for surgeries with sufficient resources, others will need a lot more support and time to develop. "It is also essential that for Primary Care Networks to succeed, they are owned and designed by GPs and our teams - not subject to top-down imposition from commissioners. We are part of our local communities and are best-placed to understand our patient populations and their needs. "As well as embracing new models of care, we need to see the other promises laid out in the NHS Long-Term Plan delivered in full, and more detail about how the aspirations in the interim People Plan will be achieved, as soon as possible."

Take steps to keep symptoms under control and help prevent 'back to school asthma', says RCGP

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: "Asthma is an extremely distressing condition affecting one in 11 children, but in the majority of cases can be well-managed by parents with the support of GPs and our teams who are highly trained to identify symptoms, prescribe appropriately and monitor treatment to help patients of all ages. "Part of keeping symptoms under control and preventing asthma attacks can be identifying and avoiding potential ‘triggers’ such as cigarette smoke, pets or alcohol. But other triggers like pollen, pollution, and very cold or very hot weather are much harder, if not impossible, to control. "As this report highlights, some children find the start of the new school term an anxious time which could set off an attack in some vulnerable individuals, and there are clearly other factors at work that are not yet fully understood. So, it is crucial that schools are aware of the pupils who have asthma, and that there are adequate steps in place to support them including knowing when it is appropriate to summon additional medical assistance. "When a child has asthma, it is important to follow the treatment plan agreed with medical professionals and never ignore symptoms if there are changes or the asthma is getting worse. Keep an eye on your child’s weight, help them stay active, and ensure they carry their inhaler with them at all times. "While attacks can never be completely predicted or prevented, making sure that the action plan is up-to-date is one of the best ways to reduce the risk. "If there’s anything non-urgent about your child’s asthma that’s worrying you, this can be discussed at your child’s next routine GP appointment where any changes can be made to medication or the treatment plan and inhaler technique can be reviewed."

Promoting healthy eating to children can have huge benefits for later life says College

She said: "Embedding the importance of living a healthy lifestyle in children at the earliest possible stage in their lives can have huge long-term benefits for their overall health and wellbeing – and eating a healthy, balanced diet is a key factor. "GPs will always encourage our patients to eat healthily, including lots of fruit and veg, but we know that for some patients healthy eating can seem expensive or perceived as being difficult to prepare – particularly when they are faced with the temptation of cheaper, more convenient and unhealthy snacks – and this can lead to widening health inequalities. "This doesn't have to be the case - there are lots of great ways to buy and cook fresh food more easily and cheaply – but it is nevertheless encouraging to hear politicians recognising the barriers that might exist to healthy eating, and putting forward ideas to tackling them."

Future GPs call for fair tariffs for primary care teaching

National guidance on funding of GP teaching has not been issued since 1995, leaving practices receiving around 40 percent less funding to train undergraduate students than their secondary care equivalents – equalling a total underfunding of around £44 million per year.  GP practices currently receive on average £620 a week to host training placements, yet the true cost is estimated to be £1,100 - a 40% deficit, and around 40% less than the average amount received by hospitals to host training placements, despite costs being the same. Medical students and trainee doctors from the Royal College of General Practitioners took hundreds of signed postcards to the Department of Health and Social Care on Wednesday, urging the Government to invest in primary care teaching and bring funding tariffs line with other areas of medical training.  A selection of the signatures, collected by students and trainee doctors in medical schools and GP practices across the country, were presented to the department yesterday in an effort to bring the issue to the forefront of debate.   Emma Tonner and Dr Devina Maru, RCGP national co-chairs of the Medical Student and Foundation Doctor Committee, said: "This issue is really important to medical students, but we need the Secretary of State to know that this is also important to patients, as well as qualified GPs and their teams.  "Evidence shows that GP tutors have a profound influence on student perceptions of general practice. The higher the quality of the placement, the more likely we are to choose to train to work as a GP.  "Making sure our tutors have the funding they need to teach us and still provide amazing patient care is so important. We hope that the government will listen and understand that this is about securing the future of the profession and showing young people that general practice is the route they should be taking." Chair of the RCGP, Helen Stokes-Lampard, has written to the Secretary of State for Health and Social care a number of times over the past two years calling for sufficient funding to be provided for education and training across primary care.   Professor Stokes-Lampard said: "General practice is the bedrock of the NHS and we need at least half of medical students to choose the profession to ensure it will be fit for the future, yet undergraduate GP teaching continue to be severely under resourced compared to placements in secondary care.   "GPs do a fantastic job caring for their patients and training the future workforce in the face of strained resources and rising workload. However, having to 'make do' with inadequate funding to host students is not sustainable.  "The NHS Long-Term Plan sets out an ambitious vision for the future, with more care being delivered in the community where patients need it most - to make this a reality, it is vital that adequate resources are provided to fund high-quality teaching in general practice." The RCGP and Medical Schools Council's 2018 report, Destination GP [PDF] highlights the critical role of GP tutors and high-quality clinical placements in developing the future GP workforce.  

RCGP Scotland calls for GP Cluster model to be extended to Out of Hours general practice

"Currently GP Clusters are only funded for daytime general practice. Given that patient care in the evenings and at weekends is covered separately by the Out of Hours GP service, RCGP Scotland is calling for the Cluster model to be widened to include GPs working in the Out of Hours setting, where it is equally important to be able to undertake Quality Improvement work and influence how wider systems could work more effectively." The call comes as RCGP Scotland welcomes the release of new national guidance for GP Clusters in Scotland. Dr Carey Lunan said: "RCGP Scotland is delighted to see new guidance issued for Clusters across Scotland, drawing on joint working with Scottish Government, the Scottish General Practitioners Committee of the BMA (SGPC), Scottish Primary Care Clinical Leads and input from Healthcare Improvement Scotland." Clusters are groups of GP practices coming to together to share ideas and learning, focus on local quality improvement work, and influence how wider healthcare systems can be improved. RCGP Scotland has employed three GPs as ‘Local Advocates’ to meet with Clusters around Scotland, which has helped to develop an understanding of what is working well, what challenges are being faced, and to allow Clusters to be linked in with RCGP resources and support. Findings from Local Advocates have influenced how this new guidance has been developed. Dr Carey Lunan also said: "Working in this new way through GP Clusters offers enormous potential to develop and then deliver high quality patient care in Scotland according to the needs of local populations. There is currently a huge variation across the country in the resources that are available to support them in their work, which can mean variation in outcomes for patients. Clusters must be resourced equitably across the country, which would create conditions for those leading Clusters to fulfil this potential."

RCGP calls for whole-system approach to improving NHS care for trans patients

The College has also stated that there is an urgent need for more independent research into the effects and impact of interventions for gender dysphoria, particularly for children and young people – and that there needs to be greater consistency around regulation of gender identity care and services, as well as greater clarity for doctors from the General Medical Council on the issue. Its new position statement on the role of the GP in caring for gender-questioning and transgender patients, was approved by the College’s governing Council on Saturday. Recommendations in the paper include that: IT systems are updated to enable GPs to treat trans patients in a safe and respectful manner – and that NHS systems record codes for gender identity and trans status as well as biological sex The GP curriculum covers gender dysphoria and broader trans health issues – and that more training programmes be developed to support GPs and their teams to appropriately engage with and advise trans patients The principles of oversight and regulation applied by the Care Quality Commission in England and equivalent bodies in Scotland, Wales and Northern Ireland should be applied to all providers of gender identity services, not just NHS services Waiting times for Gender Identity Clinics are addressed, and that expanding services in all four UK nations is prioritised, and that Independent research into the effects of various forms of interventions for gender dysphoria is funded – particularly into the impacts of treatments for children and young people.  Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: "It goes without saying that GPs and our teams should treat our trans patients on the basis of need and without bias, as we would any patient. This includes being mindful of the terminology and language we use when talking to our trans patients, based on each patient's individual preference. "It sounds simple, but there are barriers to this, not least with our current NHS IT systems that only allow us to record a patient's gender in a binary way. As well as unintended misunderstandings and the apparent lack of respect that can result from this, it also has serious health implications, for example, around referring trans patients for appropriate screening. "This is an important area of medicine, and one for which GPs need greater clarity from regulators on where they stand. There is also a distinct lack of high-quality research in the area, and a lack of reputable clinical guidance available – particularly in respect to gender-questioning children – and addressing this must be a priority." The position statement also clarifies the GP's role in delivering care to trans patients. It recognises that GPs are not trained or experienced in treating and managing patients with gender dysphoria and trans health issues, and as such treatment should be initiated in specialist care – but it also recognises that current NHS gender identity services, across all four nations of the UK, are under severe strain with increasing patient demand. In England, for example, GICs have seen a 240% overall increase in referrals over five years, with referrals to the Tavistock and Portman clinic alone increasing 8.43% between March 2018-19. It notes that although under the NHS Constitution for England, the maximum waiting time for an initial specialist appointment following referral is 18 weeks, in 2018 the average waiting time for an initial appointment at a GIC was 18 months. Systems are equally as strained in Scotland, Wales and Northern Ireland. It says that role of a GP in delivering care to transgender patients is to: Holistically assess the patient's health needs, collaborating with other healthcare professionals and services as relevant Promptly refer patients to a GIC or equivalent if they exhibit signs of gender dysphoria and request treatment or wish to consult with a gender identity specialist for further advice Liaise and work with GICs and gender specialists - in the same way as any other specialist – to provide ongoing care following discharge from a GIC via a shared-care agreement Recognise that the family members of a patient experiencing gender dysphoria also face significant challenges and refer these family members to further support services where appropriate and Provide appropriate treatment or signposting to patients presenting with gender dysphoria alongside other social or medical issues, which may include referring the patient to mental health services or engaging with social care, safeguarding or sexual health colleagues. Professor Stokes-Lampard continued: "GPs and our teams make the vast majority of NHS patient contacts, and in the vast majority of cases, trans patients will present to the GP with the same conditions that any other patient does. "But new presentations of gender dysphoria in general practice are infrequent, and therefore initiating treatment sits outside of a generalist's role. However, we know that specialist services are overstretched and struggling to cope with increasing demand. "The situation is hugely frustrating for all involved – for trans patients and their families, those working in GICs and GPs - but as a result, GPs are often being put in a position where they are being asked to prescribe treatment that they are not trained to prescribe or monitor safely without expert support. "NHS bodies in all four nations are committed to improving access to gender identity services, and the overall care trans patients receive – and encouraging work is ongoing - but there is a long road ahead, and the potential challenges are not insignificant, so we urge them to take note of the recommendations made in this paper." The position statement highlights the current pilot scheme in Greater Manchester, which is trialling a new trans health model whereby multi-specialty teams, including GPs, deliver care to trans patients and people who may have gender dysphoria, working closely with existing GICs to develop their diagnostic skills. It also welcomes the forthcoming postgraduate diploma in Gender Identity Healthcare Practice being developed by the Royal College of Physicians and NHS England. In addition to this position paper, the College is currently funding and developing a new e-learning course for GPs on gender variance, which should be launched later this year. It has also received funding from the Government Equalities Office to develop resources to support GPs and other healthcare professionals to deliver the best quality care for our LGBT+ patients. Access the position statement here.

RCGP Scotland launches 2019 awards to highlight excellence across general practice

With many of the awards being peer-nominated, and with a submission deadline of 29 July 2019, RCGP Scotland is encouraging GPs, trainees, trainers and patients to submit nominees as soon as possible. New awards have been developed for medical students, early career academic GPs, established GPs, practice teams, GP trainees, GP educational supervisors and local improvement projects within GP clusters in Scotland. Several of the awards have been developed in partnership with NHS Education for Scotland (NES) and Scottish Government. RCGP Scotland Chair, Dr Carey Lunan, said: "I am delighted to support the launch of RCGP Scotland's 2019 awards. General practice is at the frontline of the NHS, playing a crucial role in providing care to patients in the heart of communities across Scotland, but the primary care landscape in Scotland is changing rapidly at the moment. "These new awards highlight the great work being done across Scotland at the frontline of the NHS, and I am delighted that we have partnered with NHS Education for Scotland (NES) and Scottish Government to develop new awards that recognise specific work areas. "I'd encourage the general practice community in Scotland to take a look at the different awards and nominate anyone that they think deserves recognition for their contribution to Scotland’s health and the NHS." RCGP Scotland has announced seven awards for 2019. They are: The RCGP Scotland Outstanding GP Award is a peer nominated award. The award will recognise the incredible, often unrecognised, work being done every day by colleagues. The RCGP Scotland Alastair Donald Award is a peer nominated award. It recognises the outstanding achievement in the areas of service delivery, education, research and wider contribution to society.  The RCGP Scotland Outstanding GP Practice Award recognises the outstanding achievement of quality patient care by a practice team. This is a patient, or patient group, nominated award. The RCGP Scotland/NES Outstanding GP Trainee Award recognises the outstanding achievement of a GP Trainee in Scotland who has completed GP training in the last 18 months. This is nominated by a GP Educational Supervisor (Trainer) or a Training Programme Director. The RCGP Scotland/NES Outstanding GP Educational Supervisor (Trainer) Award recognises the outstanding achievement of teaching and training by a Scottish GP Educational Supervisor (trainer). This is a Trainee-nominated award. The RCGP Scotland Early Career Academic GP Award demonstrates the achievements of GPs who are starting out in their academic careers, by showcasing their research. This award is self-nominated award. The RCGP Scotland/Scottish Government Cluster Local Improvement Project Award aims to encourage Clusters in Scotland to showcase innovative ways of working and local quality improvement, which embody the objectives of Realistic Medicine. This award is self-nominated. Read more about the awards or by emailing awards.scotland@rcgp.org.uk.

RCGP to consult members on assisted dying

The decision was made by the College's governing Council, which met today. The College last consulted its members on the issue in 2013. The result, announced in February 2014, was that the College should not change its stance, and as such, its current position is that it is opposed to any change in the law on assisted dying. Further details of how we consult will be made public in due course. Professor Helen Stokes-Lampard, Chair of the RCGP, said: "Assisted dying is an incredibly emotive issue that polarises opinions. "It has been nearly six years since we asked our members as to whether we should support a change in the law on assisted dying – since then, it is possible that views within our membership have shifted. "As such, RCGP Council has decided that the time is right to conduct this consultation, and we will be issuing further details of how we will do this in due course."

Better integration of routine and out-of-hours GP services needed, says RCGP

College Chair, Professor Helen Stokes-Lampard, said: "GPs and our teams make far more patient contacts than any other service in the NHS, and we do so where patients want it – at home and in the community, ensuring that we keep as many patients as possible out of hospital. "All GP practices in England now offer some form of extended access over weekends and evenings through out of hours opening, or by partnering with neighbouring services to offer routine appointments and on-call provision. "Ironically, however, many of our members report relatively low patient uptake for such services – and at a time when patients in some areas of the country are having to wait longer and longer for routine GP appointments, it does bring these services into question. "Patients should always be able to see a GP when they need to, either through routine GP services, or GP out of hours services – what we need to see is more integration between the two, a more collaborative approach to funding solutions and more public awareness campaigns about the appropriate urgent care services available, so that patients know where to turn when they are sick. "Investing in general practice is investment in the entire NHS, and we urgently need more resources and support, including more GPs and members of the practice team, so that we can provide more services in the community, close to home."

GPs need more time with their patients, says RCGP in response to eating disorders report

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: "Training in mental health, including eating disorders, makes up a key part of the GP curriculum and family doctors are well-trained to identify, diagnose, treat and manage these conditions, including when it may be appropriate to refer a patient for specialist treatment. "But for general practice, the real issue underlying this report is the immense pressure that GPs and their teams are currently facing and the urgent need for more time with our patients. "This is an incredibly complex area and the standard 10-minute appointment is simply not long enough for us to unravel the many complex issues affecting a patient's overall health, especially if an eating disorder is not the main reason they visit us in the first place. "While GPs can use the BMI scale to calculate whether a person is within a healthy weight range, it is simply not true that this is the only tool we rely on to help us determine whether someone has an eating disorder. "Instead, GPs will assess the physical, psychological and social aspects potentially affecting the person sitting in front of them and draw conclusions from a holistic discussion with the patient before making a diagnosis. "Mental health is an enduring priority for the College, and we have developed a number of eLearning courses in conjunction with a range of mental health organisations, including one on eating disorders with Anorexia Bulimia Care. "GPs are professional lifelong learners who will always embrace training and support to help raise standards of patient care. But ultimately, we need to see more resources and funding injected into general practice, including the delivery of the NHS Long-Term Plan, to ensure GPs and their teams can continue to deliver the best care possible to patients, including those with mental health conditions."

Prevent no-deal Brexit and safeguard the NHS, RCGP urges Tory leader hopefuls

In the letter, which has been sent to all remaining candidates in the leadership race - Boris Johnson, Jeremy Hunt, Michael Gove, Sajid Javid, Dominic Raab and Rory Stewart - Professor Helen Stokes-Lampard, RCGP Chair has written: "This is a transformational time for our country and the health service. General practice is the bedrock of our NHS. It is the first point of contact with the health service and is highly valued by patients.  "But it is also under immense strain. If we are to meet the challenges of the 21st century and put the NHS on a sustainable footing, it is essential that the next Government sets out a positive vision for the future of general practice and helps us realise the ambitions set out in NHS England's Long-Term Plan." As well as calling for assurances that the NHS will remain free at the point of use now and for future generations, Professor Stokes-Lampard also calls on whoever is the next Prime Minister to: Increase funding for frontline general practice to at least 11% of the NHS budget, and deliver NHS England's Long-Term Plan in full Recruit at least 5,000 additional GPs by 2021 in addition to more members of the wider practice team to work on the frontline of general practice and Ensure that general practice is an attractive career to prevent experienced GPs leaving the profession. These are all key to delivering the College's vision for general practice, Fit for the Future, launched last month – the result of a consultation with more than 3,000 GPs, other healthcare professionals and patients. Lastly, the College is urging all candidates to prevent a no-deal Brexit at any cost given the significant impact on patient care it could have by threatening the supply of medicines, medical devices and radioisotopes, and the recruitment and retention of vital EU national staff. The College officially opposes the UK's exit from the European Union following a decision by its governing Council in November 2018. Commenting on why she wrote the letter, Professor Stokes-Lampard said: "We need to know that regardless of who wins this contest, our health service will remain safe and free at the point of need for our patients – one of the foundations that this great source of national pride was built on. "Brexit has dominated the political landscape for several years, to the detriment of health, education and many other essential pillars of our society. As a College we oppose Brexit on the grounds that we believe it will have a profoundly negative impact on the NHS and patient safety – but if we are to leave the EU, at the very least we need assurances that we will not do so without a no deal. "As the UK's largest Medical Royal College, representing more than 53,000 doctors, it is not our place to say who will make the best Prime Minister, but whoever it is must make the NHS a priority; they must protect it, and the best way for them to do this will be to invest in general practice. "Our vision is that GPs will have more time to care for their patients – the standard consultation will be at least 15 minutes – and that being a GP is the best job in the world, but this future is only achievable if we equip general practice with the resources, infrastructure and skills that it needs." Read the letter to the Conservative Party candidates [PDF]

Ghost patients 'nothing sinister' – and the insinuation GPs are complicit in fraud is 'shocking’, says RCGP

"The insinuation that GPs – some of the most trusted professionals in society - are complicit in defrauding the health service is shocking and will be incredibly hurtful for hard-working GPs and their teams who are struggling to deliver care to more than a million patients a day across the country, with insufficient time, resources or workforce to do so. "It is, of course, important to make sure that patient lists are kept as up-to-date as possible, so that resources are used where they are most needed – and our administrative staff already spend a lot of time processing patients' notes when we are informed that they have died, left the surgery or moved elsewhere. "But so-called ‘ghost patients’ are nothing sinister - they are the result of a records management issue, not a case of surgeries deliberately profiting by keeping patients on their lists when they shouldn't be there. "People's circumstances, and therefore, our records, change all the time. Some practices, particularly in inner-city areas, have quite a high rate of turnover, and patients don't always tell us if they are moving on. It’s just an inevitable consequence of having a list in the first place. "It's also important that whilst we work to ensure patients who shouldn’t be on the list are ‘removed’, it’s equally important to make sure those who should be there are protected and not taken off without good reason, or before notifying them beforehand. "We appreciate that it is NHS England's responsibility to review patient lists and put the appropriate measures in place to ensure that methods of doing this are safe. But to publicise that they are getting their in-house ‘fraud squad’ involved, as well as outsourcing the task to a company that many healthcare professionals across the country have little faith in to do a good and fair job, is demoralising for GPs and a questionable use of scant NHS resources."