Lib Dems live up to their reputation

So we hear that Dr Evan Harris will propose a motion on the NHS at the Lib Dem spring conference tomorrow. What a pathetic action that is. Not that I think the amendments that Dr Harris is suggesting are wrong. It is the disingenuous way that he is showing how much he "cares" for the NHS. he is proposing this motion at a time when he knows damned well the amendments will not be made. He has been quiet on the Health Bill (and White Paper) for 7 months, the fact that he is speaking up now is more to do with putting some life into his political career than to protect our NHS.

The Health Bill is substantially the same as the NHS White Paper. As anyone who has read Lansley's response to the "consultation" will tell you, his reply to any criticism was "tough, I will have my way regardless". And this will be his response to Dr Harris. Either Lib Dem MPs are extremely dim (a possibility*) or they are in favour of this Bill. Why do I say this? Well, we have already had two votes in the Commons and a lengthy debate when Lib Dem after Lib Dem stood up and supported the Bill. If the Bill violates their "values" why did they vote for it in the Second Reading? Either they are very dim or they support the Bill. Simple as that.

It has been clear since the end of July last year what Lansley was proposing, so why is it now, seven months later, that the Lib Dems are standing up to oppose the Bill? The right time would have been in their September conference (and I would have gladly volunteered to have given a talk at their conference explaining why they should have rejected the White Paper). All of the things that Dr Harris is whining about were in the White Paper, and a motion at the September Lib Dem conference would have had far more effect than a motion at this conference.

So why didn't it happen? Well, let's assume that the Lib Dems aren't all dim (I know, it is hard to do*), if they had presented, and voted in favour of a motion similar to the one Dr Harris is promoting now, then there would have been a clear message to Lansley that the Lib Dems would not support his Bill. Lansley would have said "all or nothing" (and he would be right, because Dr Harris' amendments will destroy the foundations to Lansley's Bill). The result would most likely have put so much strain on the coalition that we would now be going into another general election. The central core of Lib Dem ministers, lovin' their new cars and flunkies (regardless of the loss of their Short Money) had to keep the coalition alive past such a delicate time. So people like Dr Harris who could have killed this Bill in September deliberately sat on their hands.

We have even heard from Dr Sarah Wollaston - a Conservative MP! - that she was told that the only amendments that would be accepted during the Committee stage would be those from the Government. For any other amendments - even those from Dr Wollaston - the government would whip its MPs on the Committee to vote down the amendment. So does Dr Harris really think that his motion will have any effect at all?

I expect the Harris motion to be passed and Lansley to say to Clegg "deal with your little local difficulty". The Bill will pass largely unscathed and Dr Harris will be seen as having tried to amend the Bill. The only winner will be Dr Harris.


[*] The first time I had a deep discussion with a politician who was in favour of a bill like the one being pushed by Lansley was about 2003. I was at a BBQ at my brother's and a guest there (his kids went to the same school as my brother's) turned out to have almost been the MP for Brent East. In the Lib Dem selection meeting to choose their candidate for the seat this guy came second to Sarah Teather, Teather won the seat and is now in government. The thing that was most striking about this guy was that he looked, sounded and had the same intellectual ability of Harry Enfield's Tim-nice-but-dim. I spent a couple of hours with him and he described to me a healthcare market just like Lansley's. Nothing I could say would change his mind. After that encounter I have never trusted Lib Dems: in public they say they support the NHS, but when you get them a bit tipsy at a BBQ they are more radical privatisers than the Tories.

A response to Paul Cotterill

I don't want to get into a tit-for-tat my-doomsday-prediction-is-worse-than-yours, but I thought I ought to respond to Paul Cotterill's article (@BickerRecord) on Though Cowards Flinch, The NHS is dead (part1): facing facts. Paul has got the facts right, but he's only talking about one part of Lansley's policies. I don't blame him for this, just about every one does, and when I give talks about Lansley's policie the first thing I do is set people straight: commissioning is not the chief problem, the problem is what Lansley is doing about providers. In other words, look away from GPs and look towards hospitals and community health services.

Paul takes a gloomy attitude that the NHS is already lost. I beg to differ, he may be right about some GPs (though not all) wanting to profit from commissioning, but he's only looking at part of the service. So while half may well be a "done deal" the other half of the policy has not started yet, and there are still many people in the NHS willing to fight to stop that part of the policy being implemented.

Lansley is already implementing some of his Health Bill proposals (without Parliamentary approval) by creating the GP commissioning Pathfinder consortia, and through these, make PCTs irrelevant. This is a one way process: re-creating PCTs would be extremely expensive, so it is better to constructively amend what is happening rather than to oppose it altogether. If the Health Bill was binned today even the most enlightened and public service orientated Health Secretary would not want to try and re-create PCTs.

I do not oppose GP being involved in commissioning, and most patients when asked if they would like their GP to decide about how their care is delivered they would also agree. Lansley knows this, and this is why he only talks about GP commissioning and "patient choice". His argument against his opponents are that they do not want "patient choice" and that they do not want GPs to be involved in designing patient care, both powerful political arguments. The problem is how Lansley is implementing this policy. Cumbria has had GP commissioning for a couple of years, but the significant point is that this relied upon the help from the PCT rather than the abolition of the local PCT: it worked because of collaboration with the PCT rather than in spite of it. (The opposition has failed to make enough capital out of Lansley saying before the election that GP commissioning would involve PCTs and then his sudden decision ten days after the election to abolish PCTs.)

My main objection to the abolition of PCTs is because they were a layer that isolated GPs from the cash. This, to me is the most important thing because I want my GP to make decisions about me purely based on clinical decisions. However, the White Paper (section 5.12) gives Lansley's attitude towards healthcare:

"GP consortia will align clinical decisions in general practice with the financial consequences of those decisions."

This statement thrusts a rusty blade of commercialism right into the beating heart of our NHS. GPs are being told by Lansley to view their patients as customers. There are two aspects to this. First these "financial consequences" may mean an income stream for the GP (directly or indirectly): a positive aspect for those GPs wanting to make a lot of cash (Lansley calls this "innovation"). But second, these "financial consequences" also mean rationing: the negative side, the side that GPs do not want to do, and patients wish did not exist. We all know that rationing occurs in the NHS, but we know that through clinical decisions (and the evidence-based policies of NICE) the rationing occurs on a basis of what is best for the patient and the community as a whole. Under Lansley's plans a patient can simply become too expensive for a GP practice.

Paul says that GP consortia won't use PCT commissioners and instead will resort to private companies. I agree that this has happened, but I doubt if it will be widespread. There is too much institutional memory within the current PCT commissioners and the knowledge they hold is valuable. Many of the "pathfinder" GP consortia are either existing Practice Based Commissioning groups or collections of PBCs. PBCs are geographically based and associated with PCT boundaries, thus PCT commissioners know the PBCs, and have had years commissioning for them, and so it would be a natural move from the PCT to the PBC GP consortium. A private company will not necessarily have the local experience. GPs are cautious, they understand that if commissioning goes wrong the consequences are dire (in particular, but not exclusively, the "financial consequences"), so they are more likely to take an attitude of "better the devil you know", and that is the PCT commissioners

However, the smaller GP consortia are an issue, because the income the receive may not be enough to employ the commissioners they need. These consortia are likely to either cluster with other consortia (in which case, why be separate?) or buy-in the commissioning. (See here for an analysis of the consortia sizes.) Lansley's number one mistake was not giving any guidance at all about GP consortia size and location. Although there will be a huge upheaval in the run up to PCTs being abolished, there will be years and years of upheaval as the smaller GP consortia merge (as they come to terms with the fact that "small is beautiful, but financially unsustainable"), and the large consortia break apart. In a decades time we will achieve a steady state: but at what cost to healthcare?

Paul says that the private commissioning companies will maximise their profits "firstly by focusing entirely on the core business of purchasing secondary care, to the exclusion of all other considerations around preventative and public health". Well, since public health accounts for just 3% of the budget it is not surprising that it will take a back seat. Here are figures from my local PCT (and I guess they are representative): Acute care 49%, mental health 8.7%, community services 7.2%, continuing healthcare 6.4%, primary care 23%. Incidentally, that 23% for primary care is roughly half for GPs and half for "additional GP services". This latter part is important because it is work that used to be carried out in hospitals but is now done by GPs. It is a sector that will increase dramatically over the next few years (remember what I said above about what GPs will see as the positive side to "financial consequences"?).

However, GPs will not be allowed to ignore public health. The Health Bill specifically says that GP consortia will be held to account for the health inequalities and outcomes in their area (they will have to produce strategy documents on these, and will have to provide annual reports indicating how successful they have been). Whether this will be a paper exercise or not is yet to be seen, but I can assure Paul that the Bill has addressed the issue. The Bill also gives local authorities more responsibility for public health, and again, it is unknown whether this will be successful.

Paul then says:

"Second, they will purchase as much private healthcare as they can, and the percentage of the care bought from the private sector will increase dramatically within a year or two.  As state hospitals lose their business, they will close or – more likely in the shorter term – be bought up lock, stock and barrel by the private hospital operators."

I think that the situation is far more complicated than this. First, there is not the capacity in private hospitals at the moment, and there is not the money for those private companies to invest. For example, today I heard that profits at BUPA "tumbled 72% to £118m in 2010", BUPA are not doing well, so how will they expand their hospitals to take on the nuge numbers of NHS patients Paul suggests? The US company Humana has even pulled out of the UK because they are "unconvinced that Andrew Lansley’s plans to hand over the commissioning ... to GPs in England will necessarily open up a lucrative market in commissioning support". So I am not convinced that the numbers of patients sent to private hospitals will rise dramatically. (In any case, the NHS has been outsourcing a lot to private health care over the last decade, can the rate increase more than it is now?) Second, there is not the expertise: the vast majority of consultants in the country are NHS-based, and the private sector gets their expertise from these clinicians. Herein lies the actual threat.

Cameron announced a few weeks ago that

"We will create a new presumption – backed up by new rights for public service users and a new system of independent adjudication – that public services should be open to a range of providers competing to offer a better service."

Note that there is no mention of "patient choice", patients cannot choose to have a public provider, instead David Cameron will allow private providers to choose what services are available for the patient, through this new "presumption" that they will be able to take over NHS services. In practice, what this means is a private provider (or a collection of existing NHS consultants grouped as a company) can insist that they provide a service at an NHS hospital. The white paper (section 4.28) says that Monitor (the super-powerful economic regulator and headed by an arch-privatiser) will:

"require monopoly providers to grant access to their facilities to third parties"

The "monopoly providers" are NHS hospitals and the "third parties" will be these new groups of consultants. Think about it: there will be minimal start up costs to these companies and all the consultants need to do is get together and say to a hospital "we are now an Any Willing Provider for this service". In the future your NHS hospital will be run like a department store with "franchises" of Any Willing Providers running the facilities and providing the services.

Paul then makes the accusation:

"Insurance-based healthcare, and the exclusions that this brings, will come not through a government announcement, but by the surgery backdoor."

I disagree, it will come through a government announcement. First, let me give some background. In 2005 in the Independent Nick Clegg (the collaborator and traitor he is) said:

"One very, very important point - I think breaking up the NHS is exactly what you do need to do to make it a more responsive service." Then he goes further, even refusing to rule out the insurance-based models used in mainland Europe and Canada.

"I don't think anything should be ruled out. I think it would be really, really daft to rule out any other model from Europe or elsewhere. I do think they deserve to be looked out because frankly the faults of the British health service compared to others still leave much to be desired."

It frankly amazes me that anyone wanted to vote for this Hannan-esque monster, but that, sadly, is history. It is clear, however, that part of the government (the Orange Bookers) want to kill the principle of "free at the point of use".

On the other hand, Lansley constantly says that the NHS will be "free at the point of use, based on need, not ability to pay". I happen to think that Nick Clegg said what Lansley believes, but through political expediency Lansley has to continue to quote the NHS mantra "free at the point of use". Health insurance will come through a different vector.

At no point has Lansley ever said that he will outlaw co-pay. It has not been talked about. Curious, eh? I mean, if the NHS is costing the taxpayer too much, why not ask for a reasonable contribution from the patient? We already have this in dentistry where you are offered private care as well as NHS care, and it happens in social care too (councils means test vulnerable people and then impose a standard charge which is a contribution to, rather than the full cost of the social care they receive). We have a form of co-pay with prescription charges, so why not apply a co-pay commitment for NHS treatment too?

As rationing starts to get bad (and it will) the middle classes will clamour for co-pay. The current rules say that if you pay for a drug that you need for your treatment then it means that you are receiving private care and so you have to pay for all of the NHS care. This is right. If there is a clinical need for the care then the NHS should provide it. NICE was created to identify what was clinically required, and hence what the NHS will pay for. Lansley's policy is to neuter NICE, it will be merely "advisory". It won't be too long before patients feel the effects of rationing and the postcode lottery.

In a few years time, to placate the middle classes affected by the postcode lottery, Lansley will sanction co-pay, he will say that those who can afford to pay extra will be allowed to. We will see co-pay introduced into primary care first, followed by acute care.  Of course, not everyone can afford co-pay, and this will result in insurance companies providing products where the middle classes can pay an affordable monthly premium so that in the event that they need to pay for NHS co-pay the insurance company will provide the payment. (This is not what Americans regard as co-pay: to them co-pay is more like the car insurance excess that we pay; insurance pays the majority but patients are expected to pay a contribution out of pocket. What I am talking about is a top-up contribution, for patients to get extra care.) Indeed, the BMA consultants conference even voted that NHS patients should be allowed to pay "top-ups" in 2008 (how times have changed). Once Lansley sanctions co-pay, health insurance will follow.

Paul's article, like most people, ignores the policy of Any Willing Provider, and the effect this will have on NHS hospitals. This is the most significant part of Lansley policy and GP commissioning is minor compared to it. Lansley sells the policy as patient choice, but it is clear that it really is commissioner's choice: patients will not get to choose. Further, it has become apparent that the privatisation will be imposed top down. Yesterday Pulse magazine reported that the SHA in the East of England was designing integrated care pathways that used private companies. The SHA is a level above PCTs and their work in future will be provided by the soon to be constituted National Commissioning Board. It is clear to me that the NCB will impose privatisation top down onto GP commissioners through AWP.

Prof Chris Ham from the Kings Fund writing in the BMJ says:

"Although many organisations have focused their attention on plans to give general practices a major role in commissioning health services and to require all NHS providers to become foundation trusts, these changes are of secondary importance compared with the radical extension of competition in healthcare."

It is clear to me that the main focus of any opposition to the Health Bill should be focussed on the policy of Any Willing Provider.

Paul's article is announced as the first of two parts, and

"If I get round to a part 2, I’ll cover some things the Left and Labour still can do, but this will be with a mind to strategy, not pointless posturing (so I don’t suppose anyone will take any notice)."

Well, I have already covered what Labour should do in an article on Liberal Conspiracy and on this blog:

And one final point. Ed Miliband must pledge that Labour believes that hospitals and community health services should be publicly owned. Drop the "mutuals" idea because this is too close to Lansley's "social enterprises" idea. NHS hospitals should be publicly owned, publicly run and publicly accountable. Is that a simple enough message for Ed to understand

The battle in the future will be about keeping our hospitals publicly owned. I hope that Paul gets round to his part 2, and I hope that he follows my lead.

"GPs up against private firms in NHS sell-off of entire care pathways"

Pulse magazine issue an exclusive today that the intention of the government's "Any Willing Provider" policy is designed to privatise care pathways. So far Lansley has been careful to say that AWP is about "patient choice", but the Pulse article shows that the intention is actually to exclude patients and to offer only "integrated pathway hubs" that have been competitively tendered to private contractors.

Dr Steven Laitner, a GP in St Albans and associate medical director at [NHS East of England] SHA, said the plans could deliver 'transformational change' to the NHS. Dr Laitner is shared decision making lead at QIPP Right Care, a Government-backed unit set up to spearhead the NHS’s £20bn savings drive. He told Pulse: "We’ve got support from the Department of Health and are looking to test this model across the country."

This shows that the government intends that the Any Willing Provider policy to be about wholesale privatisation of care pathways. Pulse report:

Ms Parbinder Kaur, project lead for the hubs, said: "The push has come from GPs. They are open to the market coming in with new ideas."  She said a string of meetings with GPs and private providers had shown both had "appetite" for the idea, with the next stage a bidding process for contracts, which are due to go live in April 2012 to fit with the Government's ambitious transition timetable: "It will involve a competitive tender. We expect this to involve a combination of third-sector, independent-sector and NHS providers."

This is completely opposite to the briefing that the government is providing to their MPs which says:

Our plans for 'any willing provider' are precisely the opposite. Competitive tendering means identifying a single provider to offer a service exclusively. 'Any willing provider' means being clear that a service needs to meet NHS standards and NHS costs, and then allowing patients to choose themselves wherever they want to be treated. 

In other words, the government is telling their MPs that there will be no competitive tendering, but Pulse are reporting that in practice the policy is to competitive tender entire "integrated pathway hubs". This is wholesale privatisation of the NHS.

Cameron as Royalty

A new government will always want to go through some kind of re-branding, they want to be seen to be different to the last lot. I'm not a graphics designer, and I do not know the reasons behind the imagery, nor the subliminal messages they convey, but I have noticed a change in the symbols that Cameron uses. I started by doing some simple image searches on the internet for images of Cameron and Brown in front of a lectern at Number 10, since I know that the lectern is often adorned. These two images are typical.

Can you see the difference? Firstly Brown's lectern is dark oak and Cameron's is light ash. I am not sure what that means design-wise, probably nothing. Secondly, and I think more importantly, Brown's lectern (if it had any adornment) had the URL of Number 10. Cameron's has a crest. In other images it is clear that the crest that Cameron uses is the royal coat of arms.

(In my opinion, the URL looks more modern, the crest is too detailed with the effect that you cannot quite see what it is: from a distance it is just a blob.)


The items on a coat of arms have a lot of significance and in particular, coats of arms usually have a helmet of some kind that indicate the status of the family. The crest Cameron uses clearly shows that it has a crown as the crest, furthermore, the supporters (the lion and unicorn) have crowns. This is clearly the Queen's coat of arms, and the Queen (or institutions that represent her, like courts) is the only person who is allowed to use it. So why is Cameron using it?

The Queen is the head of state as the constitutional monarch, but the executive (and Cameron is the head of the executive) is separate. Indeed, the country fought a civil war to assert that Parliament and the monarch were separate. Parliament uses the crowned portcullis as its emblem (as used on the old style 1p piece before the Royal Mint gave us the horrible jigsaw puzzle piece that newer coins show) - and the crown is used for the House of Lords. Should Cameron, as Prime Minister, use the Parliamentary coat of arms? Perhaps not, but constitutionally he is closer to Parliament than the monarch.

I cannot find a single case of the previous government using the royal coat of arms as the symbol for the UK government, yet I find the coat of arms everywhere on the current government's websites.  This logo is used throughout:

A little more searching  gives me a civil service web page which explains the re-branding:

"The identity embodies integrity, trust, impartiality, quality of service, and professionalism – values thatare an integral part of the civil and public service. Its use should be governed by similiar values and be honest, effective, impartial and accountable."

I am not sure that Cameron (a politician who owes his status to the fact that he is the leader of a political party) can be described as impartial. This reinforces my question of why he uses the royal crest. The branding documents (irritatingly, there are several, each with a handful of pages, why couldn't they have been put together as one document?) further say:

"the Royal Coat of Arms can only be used by organisations that have Crown immunity from prosecution"

Does this mean that Cameron is immune from prosecution? I certainly hope not!

I think the reason Cameron uses the royal crest is quite simple: it is an indication of his inflated opinion of his own importance. He has royal blood in him, so he he thinks he is royalty.

Lies, damned lies and Lansley's utterances

The most bizarre thing about the government's NHS policy is that there is no evidence to support it, yet Lansley and his weird bunch of henchpeople keep telling us "evidence" that is verifiably untrue.

First we have the nonsense of Cameron's "myths" about outcomes on heart attacks and cancer which  were expertly debunked by the world re-known health economist Prof John Appleby in the BMJ. Then Ben Goldacre entered the fray questioning Lansley's lack of evidence. And, as if he has lost the ability to read (or comprehension), the Lib Dem human shield Minister of State, Paul Burstow, decided to take on the redoubtable Goldacre, quoting even more dodgy figures, and promptly lost the bout when Goldacre pointed out that Burstow was not telling the whole truth.

The BMJ published a survey about doctors opinions of the Health Bill, which effectively says that most do not want it, and Lansley's henchpeople respond (according to the BMA Tavistock blog)

with a statement calling it “unscientific” and “self selecting”.  They say, with a great deal of certainty, that the survey “does not represent the views of doctors in this country.”

Tavistock respond that the survey was conducted by "one of the UK’s leading market research companies" and it further goes on to debunk the government's irritatingly constant untruth that GPs are "voting with their actions" and showing that they are enthusiastic about the re-organisation by becoming consortia. Tavistock point out that GPs have formed consortia because:

"Many GPs have little choice but to get involved as primary care trusts become ineffective as they prepare for their abolition."

Yet Lansley's henchpeople still won't give up. Today the Guardian published an article from an NHS consultant Dr Mark Porter (no, not the BBC celeb doctor, a more eminent doctor) where Dr Porter says that Lansley's re-organisation will return the NHS "to the 1930s". This solicited a response by the soporific Minister of State, Simon Burns (in the first of his popular "Simon Says" tweets) who yet again stated Lansley's dodgy figures:

"Our cancer survival rates are amongst the worst in Europe so doing nothing is not an option"

As Prof Appleby says in his BMJ article this is not the case, the UK's cancer figures are not "the worst in Europe", quite the opposite in some cases.

Please could someone ask Lansley and his henchpeople to stop trying to justify their re-organisation with dodgy figures? All they have to do is be honest and say that they are changing the NHS because they know best and we just have to put up with it. Indeed, they could even justify that the changes have to be done because "Simon says..."

Private Healthcare

According to the Office Of Fair Trading:

PMI [private medical insurance], which is often provided by employers, is the main funding source for the provision of PH [private healthcare] by private hospitals and clinics (61 per cent), followed by NHS-funded patients (23 per cent) and then self-pay patients (15 per cent).

So most of private healthcare insurance is paid by employers. This is backed up by anecdotal evidence - those friends and neighbours who have had care in a private hospital always say "the company pays for private insurance, so I thought I would use it". I don't know anyone who actually admits to paying private health insurance themselves, but maybe that is because they don't want to admit it to me.



In the post today I got a letter from Aviva. Well, I didn't really get a letter since it was not addressed to me, it was simply a sales sheet in an envelope and every house in the street was delivered one. This "letter" reminds me that private medical treatment is available at a BMI hospital 30 miles away. Well whoopido, there's a private hospital that does private medical treatment, who would have thought that would be the case? The letter was the usual drivel: how the treatment is world class, rapid and affordable. Indeed, it even suggests that "the healthier you are, the wealthier you could be" which is rather bizarre since you are paying them, so you are slowly getting less wealthy with each premium payment. It indicates that they do not know how insurance works: if I am healthy I will not claim, but I will still contribute premiums, so surely it should be "the healthier I am, the wealthier Aviva will be".

Anyway, the reason I mention this is that I have not had a letter like this before. Why are private health insurers going on a sales drive? Surely if Any Willing Provider is the success that Lansley hopes it to be then private hospitals will not have the capacity with all of the NHS work they are doing, to be able to fit in any private patients with private health insurance? Or maybe the private health insurers know something that Lansley is not telling us? Like, for example, that the changes he will make to the NHS will deteriorate their care. Aviva say that the BMI hospital provides "rapid treatment, excellent care and comfortable surroundings" perhaps Aviva are actually saying that under Lansley the NHS will provide "long waiting lists, poor care and dilapidated hospitals", like, um, the situation after 18 years of Conservative government?

Spin

Can you imagine that, as a patient, the tick of a pen in Whitehall can give you more personalised care, and do this instantly? No? The lack of understanding of this fact shows how out of touch Lansley's Department of Health team are. The latest round of GP Commissioning "pathfinder" consortia was announced with a press release that had the following title:


Two thirds of the country now benefit from more personalised care

This refers to  the fact that commissioning consortia now cover 2/3 of the population. However, they are exactly the same GP practices as before (so no change there). This is just propagandist spin from one of the legions of spin doctors in the Department of Health. I thought civil servants weren't supposed to take a political line.

Ch...Ch...Changes

Perhaps things are changing. I have six-monthly diabetic check-ups at my local GP. The check-up is usually carried out by the practice nurse. The drill for the last decade and a half has been for me have a blood test and then two weeks later make an appointment with the practice nurse who weighs me, tests my urine sample, examines my feet and tests my reflexes. I also have an opportunity to discuss my diabetic control. Since I have had diabetes longer than the practice nurse has been alive, I rarely need advice on my care. But the regular monitoring is vital. How will I know if I have lost the feeling in my toes? I mean, I won't be able to feel it! The practice nurse tests for this.

This has now changed. I have just been asked to have a blood test for the diabetic clinic, and the letter informed me that I will only have an appointment with the practice nurse if there is a problem highlighted by the blood test results. Of course, this means that my urine (kidney function) now will only be tested once a year, rather than twice a year. Similarly with the monitoring of the nerves in my feet.Will this make a difference to my diabetic care? I don't know, but it is definitely a change in the amount of care my GP provides.

One less appointment a year is a saving for the GP, but I am not sure what contribution that will make towards the £5bn that the NHS has to "save" in the coming financial year.