The Newsletter of the National Association of Non-Principals

Trust Me, I’m a Part Time Doctor

I’m having a crisis of confidence about my competence. First, I overheard a patient in the waiting room say “One day a week? I don’t want to see a doctor who does one day a week!” She did – because I was the only one available – but it was a fair point. How could I convince her I was up to it if I only dabbled in the dark art of General Practice? Then off to Manchester for the annual BMA Medical Student Committee Conference. When I was a student, I had the political awareness of a dead skunk. My reactionary statements were strictly limited to drinking 10 pints, dropping my trousers and pissing in someone’s flower-bed. But today’s students are a different breed. “What gives you the right to question the competence of other doctors when you can’t prove your own?” Move over Jeremy Paxman.

I was about to mumble something embarrassing about an MRCGP success (six years ago) and – wait for it – a Diploma of Geriatric Medicine. But my interrogator was quite right. I have a small collection of PGEA points and I discuss difficult cases with my wife. She is –thankfully – a GP but I doubt this would qualify as systematic audit. So when the GMC/ RCGP/PGC/CHIMP/NICE/CHEW VALLEY WOMEN’S INSTITUTE come knocking, I’m going to be in all sorts of trouble.

The NHS, as we know, was founded on a wave of optimism. It was the sort of thing we fought the war for. It was built on blind trust with very little quality control, and even today most of us are pretty clueless about how we’re doing. Indeed, the problems of competence go right back to medical school. A medical degree is no guarantee of fitness to practice and I sailed through my finals and onto the wards without knowing how to put up a drip, write a fluid chart, break bad news or elicit informed consent. The students at last week’s conference complained that even now, the teaching of resuscitation skills is very patchy. As one put it; “I’m hoping to turn up and just wing it.” I know how he feels – I carried the crash bleep for two months before I had my training. In 1996, a study published in Health Trends found that 62% of a sample of house officers had

obtained consent from patients on more than five occasions for operations they didn’t understand and 80% failed to answer correctly simple questions about legal aspects of consent. Also in 1996, the Audit Commission found that a quarter of weekend and night operations were carried out by unsupervised juniors and that 20% of house-officers and 10% of SHOs performed at least one procedure a week that they felt was beyond their competence. And in 1997, the BMJ reported that 80% of junior surgeons had done operations for the first time unsupervised, including salivary gland excision, aneurysm repair, splenectomy and gastrectomy.

Of course, you get the health service you pay for, and with so few doctors and – until recently – a largely compliant public, medical training has developed by stretching doctors beyond their competence or at least expecting them to do procedures for which they have no proven competence. As one surgeon confided in me; “If we all had to prove our competence before performing an operation, the NHS would collapse overnight.”

However, competence is very much on the agenda and although GP errors or omissions tend to be less immediately catastrophic than botched surgery, you can be sure most medical negligence lawyers will have copies of NICE’s guidelines in their office. Indeed, a cardiologist recently wrote in the Lancet that if a patient with heart failure was not on appropriate medication (e.g. an ACE inhibitor or a beta-blocker), it was tantamount to “involuntary euthanasia”. So what about all those uncontrolled hypertensives and the 13,500 lives that could be saved a year if every patient who should be on aspirin actually took it. Is it all the GP’s fault? Are we committing involuntary euthanasia on a grand scale?

Who knows, but clearly GPs need help in monitoring what we do, and those who work part time or flitter from one surgery to another more than ever. Indeed, given that audit and clinical

governance are here for keeps, we may as well try to turn it into something positive. All the students I speak to have open minds and can’t understand why doctors don’t routinely get systematic feedback as to how they’re doing. They see it as something positive and useful, and so should we.

But we’ve got a lot of catching up to do. No-one has ever observed me doing my job as a GP. True, I’ve had my communication skills scrutinised with simulated patients, but never real ones. In surgery, I spend nearly all my time in professional isolation with patients who probably wouldn’t dare challenge me even if they thought I’d got something wrong. There is a moral duty for me to stay up to date, refresh my skills, drink a sensible amount of alcohol and keep my fingers out of the drug cabinet, but no-one is obliged to check up on this. So as things stand, I could be a bloody disaster for 40 years and get away with it.

But not any more. Now, I have the NASGP log-book to record how I’m doing, reflect on my practice, analyse knowledge gaps and areas of weakness and close the audit loop There may even be a column to record my daily alcohol intake. A very wise GP once summed up the job by saying “Life is a pool of shit, and our job is to direct people to the shallow end.” In the new NHS, we need to provide proof that we’re sending them to the right end. If we don ’t, we may be asked to leave the pool.

Phil Hammond is a GP Assistant, Lecturer in Communication Skills and author of the best-seller “Trust Me (I’m a Doctor).” He is a member of the Bristol Non-Principals Group, only it’s not called that because of the unfortunate association with the British National Party. He is also Honorary President of the NASGP. You can E.mail him at Phil_Hammond@msn.com. But only if you buy his book first (£9.99 – phone 0500 418419)

Striving for Quality Personal Learning Portfolio

NASGP conference

Well, it was so good last year that we just had to have another one this year. Taking place in Stockport (close to Alton Towers) on the weekend of the 6th and 7th of November, this year’s conference is entitled “Quality and Equality” and will concentrate on our agenda of improving our access to and provision of education for non-principals. As usual, we’ll be providing a free crèche as well as an exciting mixture of workshops, debates and hospitality.

The conference this year is being organised by In Any Event and we’ve had some generous offers of sponsorship from Stockport Health Authority, the Royal Air Force and Glaxo. If you’d like to come, please use the application form that has been posted to you, download a copy from our website or contact In Any Event on 0117 977 9477.

The Newsletter of the National Association of Non-Principals

From the shires...

...Bro Taf

Our Southeast Wales group is growing stronger. We have about 80 members and are now meeting about every 6 weeks - recent meetings include an IT /internet evening, ‘telephone advice’, non verbal communication skills, portfolio careers, ‘benchmarking’ and ‘business matters’. We’re also now looking in to formalising our committee. We also now have a representative on Cardiff LMC and are looking to send a representative to Newport LMC. This is a big step from two years ago when we weren't even considered as a group worth representing!

As for employment, there is an anomaly in the area where there are more jobs outside Cardiff than in, although there is the possibility of PCAPS starting in the area and this would provide some salaried jobs. Sadly we have not yet had any funding this year but we are still told it may be forthcoming. Anyone interested in joining or moving to the area ring Cardiff 402402 and speak to Glenys Stimpson or e mail me on amanda.kirby@btinternet.com

...South Midlands

Now up and running for a year, we’ve been asked to present a talk for our local VTS. Our local practices are still insisting on paying the locums amongst us £70 for a 2-hour surgery but we’re working on it! At our recent meeting we discussed alternative careers, and are looking at running a “stocks and shares” group. We’ve also started to look at the issue of sporting events and pay rates over the millennium period. We’ve discussed the issue of holding a personal learning portfolio for our CME and agree that, rather than wait to be told what to do, we’ll instead be pro-active and organise it ourselves.

...Basingstoke

We’ve now had our first meeting. Eleven people came to the pub and we have agreed to have a combination of educational and social monthly meetings and hold them in our local postgraduate medical centre. We will be producing a locum list with our availability which we hope to sell to local practices.

...East Sussex, Brighton and Hove

Tom Scanlon, a non-principal and consultant in Public Health medicine, has set up a new non-principal initiative in East Sussex. All non-principals known in the area have been sent information on fees, retainer scheme details, various local clinical guidelines, medical bulletins, and a copy of the BNF. Tom Scanlon said “The role of non-principals is set to become much more important in the NHS and it is vital that we are kept in touch with what is going on”. Non-principals in the scheme will also be entitled to receive an annual fee of £100 if they can demonstrate a minimum of 10 GP sessions and 15 hours of continuing professional development sessions each year. There are plans to develop the scheme further by setting up local non-principal groups, training and links with particular practices.

Tom can be contacted on 01273 403594 or email toms@esbhhealth.cix.co.uk

...Torbay and South Devon

We’re now well established with 26 members and have been running for over a year now, and our Health Authority have acquired a PC for us. Noticeable achievements locally have been mainly through involvement with Torbay PCG.

Although we have no voting rights or formal representation, we have a member on the clinical governance committee and are involved with other committees regarding workforce and CPD. By getting more involved in policy making we hope to gain more recognition and representation.

...Norfolk

Norfolk LMC have set a voluntary levy for all NPs in the area, with the help and unanimous support of the NP Group.

Rates are based on “average sessions per week worked” and are subject to review next year assuming locums will be superannuated by then. The bands are: 1 or 2 sessions £10, 3 or 4 sessions £25 and 5 or more sessions £40.

...Northern Ireland

We have a separate GPC here which is affiliated to, but not under the jurisdiction of, GPC(UK). At the end of January GPC(NI) agreed to allow NPs voting representation on GPC at a rate of one voting member for every 50 NPs. This should allow us 3-4 members out of a total voting membership of about 26.

This accurately reflects the proportions of NPs to GPs in N. Ireland (145/1000). A sub-committee was thought to be impractical given the small numbers on GPC. To finance this a voluntary levy of 0.3% of GMS earnings (only) will be requested from all NPs. This will be paid directly to GPC and subsequently redirected to our 4 LMCs as deemed appropriate. The financial matters will be administered by BMA (NI) and the N.I. NP Association will assist in this by supplying an up to date list of NPs each quarter. This nicely circumvents the problem of LMCs having no mechanism for allowing NPs to contribute to the levy. NPs are encouraged to approach LMCs for inclusion on their mailing list etc. and to attend meetings. The GPC has also “recommended” that LMCs allow a fair proportion of NP members to have full voting rights. One of the 4 LMCs (the Western) has written to me to say that it has accepted this and now has an NP as a full voting member. The mechanics of how elections to the GPC (NI) from the NP constituency are to be held and financed are still to be worked out. I suspect there will be some feet dragging here. But it’s a start!

...Cambridge

Veronica Stephenson, a non-principal in Cambridge, has now been appointed for one session a week as a non-principal adviser to the Cambridgeshire Health Authority as well as holding the pilot post of deanery educational facilitator for non-principals. These are local initiatives which it is hoped may be duplicated or adapted in other areas.

Veronica said “It is at present not clear how the Health Authority Advisory post will develop but we hope it will improve local links enormously and allow a database to be formally established. The second has a remit which will change as we go along”. Plans include support of the known NP groups, helping establish others, providing general educational support and encouraging many of the NPs to develop their own educational portfolios. Veronica is keen to hear from other non-principals in a similar position by email on locum@crhunt.demon.co.uk

...Lincolnshire

At our most recent meeting we heard about those seasonally topical problems of urticaria and dermatitis - and very interesting it was too. However, it was the ‘private’ part of the meeting that was most provocative. News of the government’s reneging on Alan Milburn’s promise to amend the Health Bill to include legislation that would allow LMCs and the GPC to constitutionally represent non-principals, met with little surprise. Although we have been invited to nominate a representative for Lincolnshire LMC, we have been made aware that there is little support for all NPs to be fully involved - despite our willingness to pay a levy. General consensus seemed to be that the failed amendment would probably be used as an excuse for not including NPs, by those LMCs who had no intention of doing so anyway.

Pay issues were again high on the agenda, especially the fact that there now seem to be three groups of NPs - self-employed, employed and retainers - with the latter group getting the lowest rates. This segued nicely into the puzzling fact that retainers can get maternity and sick pay, but not holiday pay - well, are retainers employees or not?

Some of our members work sessions either as clinical assistants in hospitals and in community family planning and it transpired that their rates of pay were even more of a joke. However, one member reported an interesting spin-off from this - an entreaty from the local BMA office. Apparently, they were unaware that these doctors considered the rates received derisory and asked our member to put his concerns in writing. The BMA officer then widened this appeal and made a general plea that any member who felt they had such problems should write to BMA House and copy their local office in. Only in this way could a dossier of discontent be compiled and used by the negotiators. So, the message is clear, if you are a NP BMA member and do not feel you are being represented by your ‘Union’ - complain! After all that politics the meeting was relieved to hear that next month’s meeting is to be a purely social one.

GPC fighting battle for non-principal representation

A major problem faced by non-principals over the last few decades, (whether we knew it or not) has been the issue of statutory representation by LMCs - or lack of it. Indeed, one of the NASGP’s main aims has been to achieve national representation for all non-principals. The recent Health Bill going through parliament, however, was struck a blow in May when the government thought fit to try to exclude non-principals from being represented by LMCs - in effect dividing the profession. Fortunately, intense lobbying by the GPC negotiating team has persuaded the Health Minister to table amendments to allow full representation of all GPs by LMCs. Once the Health Bill becomes law, LMCs can be formally recognised as representing our views to Health Authorities. So, no time like the present to ‘phone your local LMC and tell them where you are!

The Newsletter of the National Association of Non-Principals

NHS PCG Alliance -
what's in a name?

The English Doctor

A non-principal is required to attend the South Thames East Postgraduate GP Education Board. Abdol Tavabie, Dean of Postgraduate Education, has written to the NASGP asking for a local representative. He said “since my recent appointment it has been a priority for me to extend the remit of education in my region to include non-principals”. If you are interested in a position on this committee, please contact 0171 940 9109 or email gpse@tpmde.ac.uk.

Steve Vincent, Associate Advisor in General Practice, Southampton, has created a post for a non-principal GP Tutor for 1 session per week. If you are interested in applying for this post, please contact Steve on 01703 794795, or email steve@sotonpgc.demon.co.uk

Working Group on Revalidation in General Practice

The Royal College of General Practitioners has invited a member of the NASGP council to join its new working group. The group will consider the principles and methodology to be used for revalidation for all GPs with the aim of recommending a system for revalidation in General Practice. As well as an NASGP member, the group also includes five members from the RCGP council, two from the GPC and a representative from the Overseas Doctors’ Association.

GMC Revalidation Consultative Group

More recently, the General Medical Council’s Revalidation Steering Group has also asked the NASGP to join its General Practitioners Consultative Group. The Revalidation Steering Group has a responsibility to the GMC to develop a fully worked up model for revalidation within two years, and will thus use this Consultative Group to promote discussion and an exchange of ideas between the key players in general practice and ensure that their proposals are suitable to demonstrate fitness to practise in each specialty.

Isolated GPs

We like to think of ourselves here at the NASGP as looking at the wider agenda when it comes to working as a GP. One particular issue that many GPs face is isolation from other colleagues. In this respect, we are delighted to be working with the Small Practices Association (SPA) in helping isolated GPs – both principals and non-principals – to share problems and work together towards improved patient care. We are currently looking at the particular area of accredited educational events whereby local SPA and non-principal groups can share meetings and journal clubs etc.

The Newsletter of the National Association of Non-Principals

Letters

Wot no PGEA?

Dear Editor,

Are non-principals eligible for the PGEA allowance i.e. £2,400? If not, why not?

N.K. Deb

In a word, no. The PGEA system is a misnomer – it’s more of a tax than an allowance, to which the GP is entitled to a full rebate. It is simply a fixed amount of a GP principal's income that they have already earned, but are only entitled to claim if they can prove that they have attended a certain amount of PGEA accredited sessions – usually 30 hours worth of sessions annually for the full amount. Contrary to popular belief, the PGEA system of payments is not a good idea, and if anyone approaches you offering you a similar package we suggest you give them a polite but firm refusal.

Practice stalling on retainer superannuation

Dear Editor,

I am currently having problems rejoining the NHS superannuation scheme as a retainer – there is agreement in principle, but the drawback is who exactly pays the employers contribution. The Health Authority does not feel inclined to reimburse this as they do for other members of staff, although it would only amount to about £350 per annum. Do you have any information on this, as the delaying factor is that it has yet to be agreed?

Joan Freis

We have had several members with precisely this problem. The practice is obliged to pay your employers contribution as they do with all other staff – end of story. However, the practice can try and persuade the Health Authority to reimburse them for your contribution although it sounds they may have already failed. Either way, it is your right to contribute to the scheme.

Any advance on superannuation?

Dear Editor,

Have there been any further advances with NHS superannuation for non-principals? Do you feel there is a realistic chance that this could come about? Please let me know as I am in a quandary about whether to start a private pension plan (PPP) or wait for a while.

Tim Wright

This is the question on everyone’s lips. The infuriating reply has to be no, but this isn’t through lack of trying. Both Peter Harvey from the NASGP and Simon Fradd from the BMA have been making enormous efforts on our behalf but have become extremely annoyed at the Departments of Health’s handling of the situation. There is no logic to the Department’s lack of progress, andthey are still saying that they have yet to analyse a survey, which was carried out last year. We now expect progress will be made as the BMA are planning a campaign to give the Government a hard time on this issue in the coming months . On the question of PPPs, we strongly suggest you seek advice on this, either from a fee-charging Independent Financial Advisor or by reading a book such as the Motley Fool UK Investment Guide reviewed on page 6 (or see their web page at www.fool.co.uk). Be particularly careful when looking at “front-loaded” PPPs (all the charges occurring at the beginning of the policy) though, as if/when superannuation for self-employed non-principals does happen, you won’t have spent all this investment on charges.

A police matter

Dear Editor,

I have recently been asked by the police to give a statement about a patient who I saw whilst working as a locum. Happy to oblige and in my own time, I travelled to the practice to look at the notes and compile the statement. Am I due the payment that the practice has kept?

Name supplied

Probably. If you agreed with the practice beforehand that you would receive a fee than the answer would be a definite yes, although I fully understand that you will naturally have assumed you would receive some sort of fee and/or expenses. Indeed, the NASGP’s own Code of Good Practice says “non-principals should be appropriately and promptly remunerated for all aspects of the work they do”. Even if you didn’t agree, the police should pay this fee directly to the doctor who wrote the statement, partly because it was your time used and also because you carry the legal responsibility for the accuracy of the statement. Either way, if the practice can’t see your side of the argument then either contact your local BMA Industrial Relations Officer or your local Citizens Advice Bureau who should be able to offer advice.

Free medical newspapers

Dear Editor,

I was hoping that by joining the NASGP I would get some help with obtaining my own copies of GP, Pulse, Doctor etc. I believe that you supplied a form to help with this. Is this true?

Peter Gooderham

Sadly not Peter, but hey, what a great idea! You’ll already have received your letter to send to your local Health Authority to prompt them to send your BNF and, from what we’ve heard, this has been quite successful. Its slightly more difficult when it comes to freeby GP mags as no GP has an actual right to receive one, but that’s not a good excuse for why we don’t. GP will actually send copies to non-principals if asked. Perhaps the NASGP could send a standardised letter to all our members similar to our BNF letter. We’ll look into it, and let you know.

Non-principal educational facilitators

The Newsletter of the National Association of Non-Principals

Great Expectations Bursary

• The NASGP was founded in January 1997 to address and meet the needs of GP non-principals.
• With an ever-increasing network of non-principal groups, we aim to provide support and representation at both a local and national level.
• To help us achieve these aims and objectives, we ask all GPs to support this voluntary organisation by joining the NASGP.

• To achieve independent national representation for all non-principals.
• To achieve equivalent status for non-principals to that of GP principals.
• To promote and support the identification of non-principals.

• Represent all GP Non-Principals who are eligible to work in NHS General Practice and who perform any NHS Non-Principal GP work. GP registrars and GP principals will be welcome as associate members.
• Commission and co-ordinate research into the welfare of non-principals.
• Promote the recognition of and remuneration for continuing medical education.
• Recognition of our work experience in terms of seniority and parity.
• Publish guidelines for a professional Code of Good Practice, both for non-principals and employers.
• Publish and distribute a Handbook to contain all relevant information for non-principals.
• Provide help for local non-principals by promoting and supporting local non-principal groups to provide a setting for relief of social and professional isolation.
• Disseminate information relevant to all non-principals via the Non-Principal Newsletter.
• Reassess and negotiate guidelines for pay.
• Obtain equal pension rights for non-principals to that of GP principals.
• Host an annual conference.

Honorary President: Phil Hammond
Chairman/Editor: Richard Fieldhouse
Deputy Chairman: Tina Ambury
Secretary (England): Peter Harvey
Secretary (Wales): Tony Downes
Secretary (NI): Susan Walker^*
Secretary (Scotland): vacant
Treasurers: Anita Goraya and Tara Watson
Educational Advisor: Rebecca Viney

^*co-opted

The Newsletter of the National Association of Non-Principals

Reviews

The Very Stuff of General Practice

Philippa Moreton
Radcliffe Medical Press 1999
201pages hardback £35

The rather austere cover of this book belies its inner warmth, simplicity and value. Don’t be mistaken by its appearance for thinking it somewhat dated, because inside it provides fundamental summaries of where general practice is and how it got there. It should be given to all those interested in training for general practice and should prescribed to those wondering why they did. Training practice approval should be questioned if it’s absent.

The book is dedicated to John Hasler for his enormous contributions to the development of the discipline. The book reflects on the process and substance of these developments over the years.

The first chapter on The Consultation is a wonderful summary of how patient-centred consulting models were developed and moreover, describes the evidence for its further promotion. The second chapter by Pendleton is quite simply inspiring. The Chapter on Practice Management imparts new understanding and appreciation of the difficult role of GPs’ managers. Pringle’s chapter on informatics succinctly demonstrates how indispensable good data is, its benefits and potential. Reading the chapters on making change happen, quality improvement and training are (I imagine) like having therapy. It’s not too far fetched to say one comes away from this book thinking, if not saying, ‘Yes! Yes! Yes!’ It's easy and quick to read. It will be one of those books you’ll never forget who you’ve lent it to because you’ll always be relieved to get it back.

Shaun O’Connell

Oxford Handbook of Clinical Medicine

Oxford Medical Publications
806 pages

It is almost inconceivable that readers will be unfamiliar with the Oxford Handbook of Clinical Medicine which, having first been published in 1985, is now in its fourth edition. For the benefit of any doctors who have been on Mars for the last decade-and-a-half, the handbook has been a best-selling success which provides, in a package of compact dimensions, the essentials of clinical medicine. Although it is designed to cater for medical students, with a section on history-taking and clinical signs, and although much of the information contained is relevant only to hospital practice, it remains the perfect aide-memoir for medicine in general practice. Small enough to fit in any medical bag, and yet detailed enough to cover the major sub-specialities in appropriate detail, it could suffice as a reference for the majority of medical problems encountered in practice. Its appeal is paradoxical because, for a book that could be little more than a glorified collection of lists, it balances hard information with sofer commentary in a very readable format. In the new edition the readability has been further enhanced, with marginally larger pages, colour-coded chapters and section headings, and a rating system for important topics ranging from U (dangerous) to UUU (deadly). With its detestable plastic cover the handbook has always been waterproof, but it should now also be future-proof, with an updating service for topics available on the Internet (http://www.oup.co.uk). Criticisms? The colour-plate section is disappointing, because with only twelve pictures in total it cannot contribute anything useful to the book. It is perhaps also a book for younger doctors only, because the microscopic font size will be invisible to older colleagues. However until such time as a general practice edition is produced - with larger type, a soft cover, and no blank facing pages - the Handbook remains the perfect pocket reference.

Martin Breach

Hormone Replacement Therapy - A guide for primary care

S. Hope, M. Rees & J.Brockie.
Oxford Medical Publications
161 pages

Despite a lot of useful information about current developments within HRT research and covers the topics very thoroughly, but as the subject is rapidly changing is inevitably slightly out-of-date by the time of publication. For example, there is a major addendum at the chapter on HRT & ischaemic heart disease, which invalidates a lot of that chapter (and some other comments in the book).

Some of the most useful parts are the little gems of information sprinkled through this book. For instance the general paragraphs on thrombophilia were well written and updated me on the new discoveries since I graduated in the mid-80s. Also other ideas such as delaying HRT till women are older, the fact that some women are non-compliers of the progesterone part of HRT and checking males presenting with hypogonadism for osteoporosis are all very helpful.

Perhaps of most use is a table of a suggested protocol for monitoring HRT that is very helpful and well worth any NP getting hold of to check that they are following "best practise" when prescribing or discussing HRT.

All in all, this book is worth buying for a practice library, or even borrowing from a colleague, but not for an individual as a permanent reference book. Some of the chapters are bit heavy in style and detail in places and the index is not complete enough, though anyone reading this will emerge better equipped to deal with HRT.

Tara Watson

The Motley Fool UK Investment Guide

Berger, Gardner and Gardner
Boxtree 1998 £12.99

For novice investors who’ve reached the ranks of those who are cash rich and time poor The Motley Fool UK Investment Guide is, a bible. Without a doubt this book will change lives.

It is jointly written by (coincidentally) a GP with the US founders of the Motley Fool organisation. It's the easiest book I've read since the ECG Made Easy and much funnier. Although this latter book is essential for house jobs, the former is essential for life.

At parties many readers will recount their own mortgage-buying horror stories. Remember hearing ‘I really must do something about my pension’ or ‘I think buying shares should be left to experts - you can lose all your money, you know?’ Remember who got angry that despite being a very intelligent person, she didn't understand a word of money-speak and recall Mike, the envied bore who stocks are blossoming. Who invited him? Recognise these parties? Then read this book! Feel sick no more. It explains money. It tells the story of the little guy (you and me - the Fools) triumphing over the big guys (the financial world, the Wise). Most importantly you remain in control. You'll give as little as legally possible to the tax man and almost none to financial 'advisers' (Independent or otherwise).

It's a quick read - enough to have you financially secure for the rest of your days, but if you want more visit its interactive website (www.fool.co.uk) from where I’ve ordered and received discounted copies of the book overnight. You’ll soon feel quite smug and sufficiently informed to talk to anyone about compound interest, index tracking, price to earnings ratios and beating the FTSE. Perhaps (most attractively) you’ll be independent of any so called Independent Financial Adviser.

To friends you will scream 'read this book!' To enemies (and the grudge should be significant) just keep quiet. I know what my friends are reading and so should you.

Shaun O'Connell

The Newsletter of the National Association of Non-Principals

Non-principals Down Under

So you have come to the end of your registrar year, fed up with MRCGP study, need a change of scene? Maybe you’re just plain jealous of all your friends who have been out to Australia bringing home stories of sun and surf? Well it’s an experience not to be missed and you certainly don’t need us to sing the praises of the country and people. If you’re thinking of heading off to Australia, or just simply interested how the other half do it, see how these three non-principals fared.

GP deputising

Most of the big cities have some form of after-hours cover provided by one or two deputising organisations, some more formal and business-like than others. They actively recruit overseas doctors, some with grandiose promises of big money and big opportunities. Some will put together attractive packages, providing everything from picking you up at the airport to accommodation, car and equipment. This has the obvious benefit of letting you slip easily into an unfamiliar place and health care system. In fact to work as a GP in these cities may even be impossible without their help in accrediting you with the Health Insurance Commission. But why aren’t the locals doing their own on-call and is there such a thing as a free lunch?

Firstly one is “sponsored”, rather than employed, by these companies. There are no employment contracts, terms of service, benefits, insurance etc. They can, and will, change their minds about the hours you work, the cut they take, whether to arrange locum jobs for you or just about anything else. You can walk away, but in order to work elsewhere they must agree to relinquish that sponsorship. You may as well be fruit picking in the Outback for all the professional courtesy and respect you are likely to attract.

Secondly, many places have a huge problem with therapeutic opiate addiction; call after call being for pethidine, normally given for “migraine” but for any condition from period pains to dysuria. Often these patients will have letters from their own GP authorising the drug; some will have their own supply and just want you to draw it up for them. Refusing to do so can lead to unpleasant conflict with the patient. Stating over the phone that you may not agree to give the drug, or simply refusing to visit, could lead to unpleasant conflict with your sponsor. One particular manager, with no medical qualifications, insisted I should be seeing all these people requesting sleeping tablets in the middle of the night. When I pointed out this was poor practice and that I didn’t carry such tablets anyway he strongly suggested that I inject the patient instead.

The third issue is the strange mixture of private and state funded care. A deputy is only paid for each face to face consultation, with an after-hours visit at A$45 (currently A$2.30 to the pound) and a surgery consultation at A$19. A car and driver will charge you by the hour and your sponsor will take a cut of up to 50%. Sponsors tend to overestimate earnings by a factor of two.

There are benefits to this type of work, but for most it seems to be a disappointing experience. So unless you enjoy feeling like a drug pusher, working long hours for relatively little money or being used and abused by those taking a cut from your wages it might be worth considering other options such as locum or hospital work. If you do decide to try out deputising then speak with someone who has used that agency, get as much in writing as possible and good luck.

Clive Cole
clivecole@hotmail.com

City locum work

I loved my time in Australia and the lifestyle there but did not find the work particularly enjoyable – it was a means to an end to provide the opportunity and cash to finance travel plans. As well as deputising, I also did work in a number of practices in Brisbane for short periods ranging from half a day to 2 weeks.

On the whole, the premises are much poorer than the UK and some no better than a shed. I did work in a very “high tech” paperless practice in one of the big shopping malls which I expect would meet with Tony Blair’s approval given his view of the future of primary care. However, most practices don’t even have computers. There seemed to be large numbers of single handed or 2 partner practices. Consultations were generally longer than in the UK at 10 to 15 minutes but surgeries lasted 3 to 4 hours and had fewer visits.

Primary health care teams didn’t seem to exist as far as I could tell with practice nurses virtually unheard of. As a GP I was expected to do dressings, immunisations, injections etc. In my short time there I surprisingly never had any contact with a CPN or health visitor so I don’t know if they exist.

The remuneration for Australian principals is variable, with everything “item of service” including the consultation itself. One consequence of this is that patients are often brought back for BP checks on a regular basis every couple of weeks! There are no personal lists or capitation fees, so patients can change their GP on a whim, see different GP practices with different problems or even with the same problem. Notes do not follow the patient automatically, if at all, so it is possible for patients to see as many GPs as they want until they get an answer they like – so called “Doctor shopping”. I found that some GP’s practice what I would describe as “popularist medicine” in order to ensure the patient will stay with them.

Medicine in Australia is secondary care led, so at times one feels more like a rubber stamp than a gatekeeper. A patient will ask for a specialist referral whether appropriate or not, and if you don’t supply they simply see another GP who will. A GP will write a prescription that will have a fixed number of repeats on it. Repeat prescriptions are monitored by pharmacists, so when the patient runs out of repeats they must see GP for review and it’s a system that works quite well.

Nick kaye
nick@kaye1000.freeserve.co.uk

Rural locum work

Rural General Practice in Australia is very much a money-making business - GPs tend to have much bigger list sizes, and work a lot longer hours than their city-based colleagues. As with anywhere in the world, the GPs will try to pay locums as little as possible - I did two stints with rural practices, and was earning AU$2000 per week. This was taxed before I got it (40%), though I did get a bit of superannuation and the perks of free accommodation and a vehicle (of sorts). There’s not much to spend your money on in the rural communities, so the cash can soon add up. The exchange rate is poor at present, so my advice is to try and earn enough to have a lot of great trips around the various bits of Australasia while you’re there - there’s loads to see and do.

Rural GPs in Australia are a breed of their own – they all need extra skills such as anaesthetics, surgery, ATLS and obstetrics. I worked with a principal who, as well as all the normal work, did an endoscopy list once a month, the odd post mortem, and flew himself off to even more rural communities every now and then. Rural GPs can also look after "private patients" as inpatients in the small local hospitals, as the patients with money seem to trust the skills of their GP rather than the SHO grade medical officers. This seems to be quite a little earner for them but, as far as the locum is concerned, don’t be expecting to get paid extra for the pre-surgery ward rounds, or having to look after patients with conditions more suited to secondary care.

The practices themselves seemed to run pretty much as the UK. Locums may be expected to travel to outlying villages to do a surgery, and the on-call can be quite onerous. It is important to make sure that you work within the limits of your clinical experience (and medical defence cover) - I was once phoned in the middle of the night to administer an anaesthetic to a patient with a ruptured ectopic pregnancy. I was assured that the surgeon would cover me if there was any problem. I really don’t think it’s worth taking the risk of attempting something way beyond one’s capabilities, and I’m still glad that I refused, even though I was made to feel guilty about the cost of having to fly in an anaesthetist instead.

There generally isn’t a lot to do in the outback towns during your free time. The pubs are full of the traditional redneck Aussie blokes and the Australian TV is rubbish, so bring a pile of good books. I did enjoy getting the chance to meet the more traditional Australians than I would have met if I’d stuck to the city work.

In summary - a great experience, though I would advise short stints only. Don’t get bogged down or stressed out about the financial side of things - treat it as a working holiday, and make sure that you have a chance to see a lot of this wonderful country.

Catherine Marshall
mark.arndell@virgin.net

The Newsletter of the National Association of Non-Principals

Non-principal Groups - Summer 1999

The latest list of non-principal groups are available on the Local Groups web page.