The Importance of Locums

A GP online poll in 2016 suggested that three in five GP surgeries had to rely a great deal on locums to ensure they could provide services to patients.

23% of surgeries needed locums to provide nearly a fifth of GP appointments during the last year. (The poll had 370 partners and salaried GPs)

This was an increase compared to a similar poll conducted by GPonline last year. Last year just 14% said over a fifth of appointments were conducted by locums.

Around 6% of GPs confirmed more than 40% of appointments in their practice were being covered by locums.

The GPC said the data showed the ‘serious’ impact of workforce shortages and showed the essential role of locums.

GPC sessional committee chair Dr Zoe Norris warned earlier this month that many vulnerable practices would collapse overnight if doctors were forced out of locum roles.

Around 59% of GPs said the amount of appointments filled by locums in their surgeries increased over the last year.

It is becoming apparent that the NHS needs locums with their floating coverage in order to sustain services and relieve Partners for holidays or other commitments as surgeries are too stretched to be able to provide that cover from in-house. Shouldn’t NHS England and the local CCGs do more to support this fundamental part of the workforce instead of trying to force them out?


Compensation Nation

Medical indemnity and the fees that some GPs have to pay, is once again hitting the general practice arena, but this time the news is of a more positive note. Hope is on the horizon, and the first signs are now visible that ‘General Practice Forward View’ will soon begin to make a difference for those being hit hardest by the dramatic fee hikes. ‘Forward View’ promises large scale reform of some of the more inefficient, outdated and unfair working conditions facing today’s modern profession. It has recently been announced that with immediate effect NHS England will release £60million of funding, over a 2 year period, to Practices across the country in an effort to combat spiralling costs associated to indemnity fees.

In recent years fees have risen dramatically, as a result of an ever increasing number of claims being made against the profession. When claims have been successful, in some instances, the awards paid have been relatively staggering in their amounts. Ironically this comes at a time when quality and safety has never rated so highly amongst patients in relation to their service. With an upward trend in claims being made and the ‘compensation’ culture affecting the whole of the NHS, the situation looks set only to worsen.

Conservative estimations place fee rises during the last twelve months at 26%, which has affected 90% of all GPs. Clearly this isn’t sustainable for the workforce and it is also affecting where GPs choose to work. The greatest risks and therefore the greatest costs are associated to locum, urgent care and out of hours work. It’s often much cheaper for GPs to work part-time, which at a time when GP workloads are at saturation point is a major cause for concern. We need our GP workforce to work more sessions, not less. We should be incentivising the profession to give more and reap the rewards of their hard work and dedication. We shouldn’t be forcing GPs to work in other areas of the UK where it is more affordable to work because litigation claims, and the amounts paid out for successful claims are significantly lower than in England.

In the latest news it has been revealed that the additional money will be shared out according to the list size of individual Practices, and this will not be influenced by the current indemnity fees of the GPs working there. In the process that will no doubt follow this news, one can only hope that this additional funding filters through to the Locum workforce, to ensure equity to all of the profession. Locums can be the life line for many Practices across England, but often face some of the dramatic charges reported within the media.

It is too early to assess how much of a difference this cash injection will make in the pockets of GPs. £60million may not even scratch the surface, with some in the profession speculating that by just throwing money at the problem this may only prove to worsen the current situation in the future. NHS England and the Government need to take steps towards standardising and legitimising the amounts paid out by the MDU and MPS, if the ‘blame and claim’ culture is truly to be overcome. The rising and unrealistic expectations of the general public need to be addressed, especially when resource and funding fall short in attempts to meet demand.


Save the dragon receptionists from slaughter.

The public perception of access to GP services is already at an all-time low and as such this is having a devastating impact on our health service. In a recent analysis by the Royal College of GPs, this perception and now ‘fact’, is set only to worsen over the next five years. That is unless the actions promised within the GP Forward View begin to become a reality.

In 2015/2016 there were 9 million occasions when patients tried to access GP services and could not, but did not seek healthcare from an alternative provider. Whilst it can be safe to assume that not all of those patients would have required further intervention and follow-up, an ageing population means that a large proportion of them would have needed to have been seen. It is widely acknowledged that there is more risk of harm to patients within the system than ever before.

When patients do seek to access alternative health care providers, then this is often through 111 and more inappropriately via A&E. This just compounds the financial crisis and pressure on the system further, as bottlenecks develop in places that they shouldn’t and patients face referrals and investigations that they do not always need. This is unnecessary demand and waste on expensive services!

Why is it so difficult for the government to recognise, that by investing the finance and resource at the front door of the health service, this will ease the pressure at the back door? It doesn’t work if you do it the other way round ! Yes, patients need to be seen and cared for in the community, but they also need services they can access easily and they also need to feel supported enough so as to avoid going to hospital, unless it actually is an accident or an emergency.

The fact that Primary Care receives only 8% of the total budget assigned to the NHS in the face of so much reform is ludicrous. A new Prime Minister and a major cabinet reshuffle gave hope to many GPs that the inequality between primary and secondary care resource and funding would be addressed. These hopes were dashed when news was released that despite the cabinet reshuffle, Jeremy Hunt remains the Health Secretary. One can only hope that the new Prime Minister therefore honours the pledge and promises that David Cameron made, and funding increases significantly, giving primary care a chance of long term survival.

If not, then the RCGP’s analysis goes on to conclude that of the reported 69 million occasions whereby patients had to wait more than 7 days for an appointment in 2015/2016, is likely to rise to 98 million occasions by 2020/2021. GPs and patients around the country are being ‘called to arms’ to ensure that this situation is not allowed to escalate to the figures being forecast. The impact of doing nothing risks health care across the whole of England. And let’s face it, our poor GP receptionists take a hard enough hit as it is when patients can’t access our services, and they become branded the dragon on the other end of the phone.


Integrated Care – Why the big fuss?

A fundamental rethink of how healthcare should be organised and provided is now necessary if we are to ensure the long-term sustainability of Health and Social services, and meet the increased demand now being faced on our healthcare system, on all fronts. Demand has increased exponentially in recent years, due in some part to the success and advances made in modern medicine. People now live much longer than in previous years, there is a better understanding of disease aetiology and, as such ageing patients live with varying degrees of quality of life, with one or multiple long term health conditions. With increased specialisation and new options for diagnosis, treatment and care, these successes make healthcare much more complex and therefore more costly than ever before. Despite these successes more coordination of care is needed, not only between Primary and Secondary healthcare services, but between Health and Social services.
Pressure on the healthcare system arises in the form of sub-optimal care, avoidable ill health, inappropriate use of care and services, duplication and waste. These factors need scrutinizing and improving to ease unnecessary burdens. They are a result of how services have historically been set up, how the budgets have been divided and how care is organised across Health and Social care boundaries. If we were to consider only healthcare, then Primary and Secondary Care have both been treated as separate branches of one system and the many structures, governance and management arrangements that have developed across each branch have done so in silo. ‘The left arm doesn’t always talk to the right arm’. Now Introduce Social care into the equation, and once again the differences in their structures, governance and management arrangements become even more apparent. In the past little thought, if any, has been given in relation to the impact that these services have on one another. Often there has been no risk assessment of the impact changes to one service will have on the other, especially if it crosses professional boundaries. This is a fundamental design flaw and one which must be addressed if we aim to provide services that focus on quality, are less fragmented and have improved channels of communication that enhance care.

There have been many attempts in the past to integrate services, none of which have yielded any lasting and positive results. The fact that previous attempts have failed will act as a significant barrier to reform and this ‘elephant in the room’ will need to be addressed by Leaders and Clinical staff before any redesign work can proceed. Other barriers to Integration include:

– Separate budgets in key care areas, for example, between Primary and Secondary care, and between budgets for Health and Social care.

– Institutional separation between Primary Care – independent small businesses generally owned by GPs, Secondary Care – entities owned by the NHS, and Social Services – owned or commissioned by local authorities.

– Professional separation between the staff working in all three domains, resulting in different cultures, pensions and contracts.

– Lack of integrated data and information systems between major care providers.

– Repeated reforms of NHS commissioning bodies that have disrupted efforts to develop effective joint commissioning.

The approach considered by the vast majority of professionals as now being able to deliver on integrated care, is through the creation of Integrated Care Organisations. Various models of the Integrated Care Organisation are now being piloted across England, with their primary goal being to improve coordination of care, prevent avoidable ill health and provide more cost effective services.

So, why then is this approach more likely to deliver than previously explored approaches? The driver for change now centres on an unsustainable system and finally the realisation that if Organisations continue to work in silo, they will just bankrupt each other. Health and social care therefore need to come together and look at the system as a whole and work out how to spend the whole system budget collectively to create a sustainable system. This is driven out of the fact that the system was designed to cure ill health, not manage long term disease.

Now that leaders finally agree that they need to work this way, we are in a much better position than in previous years to design a new integrated model of care. The blockers to this work can also be identified and this is where ICOs are especially useful, as they facilitate the removal of blockers, especially when these are people working for and within different organisations. With this in mind, there is a real potential that the use of expensive hospital services will be reduced by redesign of current services. Collaboration provides the opportunity to overcome the fragmented responsibility for the commissioning and provision of care in the NHS – all with the patient at the centre of the chosen model.

The various models of these Organisations include:

– Networks of provider organisations operating under a single, integrated budget (‘virtual integration’).

– Organisational mergers (‘real’ integration) to bring together different care sectors (acute trust ownership of GP services, for example).

– Integrated commissioner–provider organisations that combine commissioning care for a designated population with the provision of some or all of these services.

This is an exciting time for many working in Primary Care and Social services, as Secondary Care has in the main, always been the priority for funding and development. Whilst it is still too early to assess the impact that these Organisations will have, never has there been more of an exciting opportunity to be involved in improvement work that will promote whole system change. One can only hope that GPs are freed up from some of their clinical commitments so as to collaborate on the best possible designs for patients. Otherwise, a potential pitfall is they will be under represented and whichever model is introduced will be rebuffed through fear that it is another model imposed by the hierarchy and professionals feel forced rather than engaged and empowered.


GP workloads are now at saturation point.

During recent years, there has been a widespread and shared belief, amongst many GPs and others working in Primary Care that workloads have increased exponentially. The Government has failed to resource adequately for this and, as such, not only is this having an impact on the health and wellbeing of GPs, it is also at times affecting their ability to provide safe and consistent levels of care.

It is now commonplace for the media to sensationalise issues occurring within Primary Care concerning the supply and demand of services and the impact that this has on other frontline services. Most GPs want the best for their patients and, as such, the increase in workloads has been raised repeatedly and consistently with the Government, only for these concerns to be rebuffed, by both NHS England and the Department of Health, with promises of thousands of extra staff in Primary Care by 2020.

Despite the attractiveness of thousands of more staff in 2020, a new study in the Lancet led by researchers from the BMA and the Royal College of GP’s, provides clear objective evidence of what GPs have been saying for years and demonstrates that action must be taken now.

The key messages from the study, which covered over 100 million GP and Nurse Consultations at 398 practices in England during 2007 and 2014, include:

– ‘There is a substantial increase in practice consultation rates, the average duration of the consultations being given and the total patient-facing clinical workload.

– GPs are facilitating more consultations than ever before for patients who are living longer, who often have multiple long-term conditions resulting in a complex presentations of symptoms that cannot be dealt with in the previously allocated time.

– Due to the change in nature and volume of workloads, GP practices and their teams are working harder than ever before, but struggle to provide basic levels of care as services are overwhelmed.’

The impact of inaction in the face of such significant objective data could be disastrous not only for staff but for patients also. With many GPs now facing the prospect of burnout or feeling the impact of being overworked, over tired and exhausted the results could be damaging for patients especially if this results in substandard care, harm or misdiagnosis.

Compounding these issues are figures released from Health Education England, who have revealed that one third of GP training places still remain vacant. Despite this representing a 1% increase on last year’s figures these results are second lowest recruitment results of all the specialities. This is not unsurprising as in 2015; GPs in England reported having the lowest job satisfaction rates since records began in 2001.

The solution for many of the problems reported across the NHS, according to the Government, is a greater shift towards ‘place based care’, a new model being explored to reduce the burden on the acute care system. However, without a serious focus on patients’ and communities abilities to self-care and make the most of non-traditional services, such as the extended pharmacy offer, the ‘place-based model’ will only once again serve to shift the burden from acute to primary care and resulting in further pressure to under-resourced and overworked GPs, and once again endanger the whole system of collapse.


Fallout from EU Referendum.

On the 24th June 2016 the people of the UK made the decision to leave the EU, a decision that has since sent shockwaves across the entire global community. Politically, this has sent the country into chaos with changes and challenges of leadership across the three main political parties. Economically, the impact is widely expected to result in recession in the UK, which could then have a knock on effect and force other EU countries down the same path.
With the decision to leave predicated on strong views concerning NHS Funding and Immigration policies, it now seems ironic that these two issues, along with economic gloom, once again plunge the future sustainability of the health service further towards uncertainty. Furthermore, with the ‘Leave’ campaign distancing themselves from claims that were made indicating that funds previously sent to the EU could be reinvested into the NHS, this is an uncertain time for many of the 110,000 EU healthcare workers who already work tirelessly to deliver more with less resources.
Previous estimates relating to shortages in both the future Medical and Nursing workforces may potentially pale in comparison to the reality, especially when one considers that the UK has traditionally tried to fill existing gaps in healthcare workers from abroad. A huge majority of these workers – 10% of Doctors and 20,000 Nurses, have come from other EU countries. With already rising social unrest and concerns over existing immigration policies the current challenge of motivating, recruiting and retaining an already disenfranchised GP profession will continue to escalate, especially if no help is perceived to be coming from anywhere other than inside the UK. The GMC is currently exploring how doctors from the EU will be granted access to the UK medical register once the UK is no longer a member state. As it stands, the EU vote will have no impact on the current registration of any doctor on the register, but there may be implications relating to regulation in coming years.
In the aftermath of a heavily sensationalised and manipulative leave campaign, many of us now ask if it was right to trust such an important decision to the people, especially when the outcome now stands to jeopardise so much. Should this have been left in the hands of people with the power, knowledge, experience and understanding to assess the impact on our services, our economy and our health care system? It’s too early to be able to ascertain with any great certainty, but one thing is for certain there is an ageing population. By limiting free movement of skilled workers, we are widening the gap concerning demand and supply for our health care services and we are pushing our already heavily burdened finances a step closer to the brink of destruction.


Unified DNA-CPR

End of life and palliative care symptom control can be some of the most fulfilling aspects of the GP role, but huge variations still exist across the whole of the UK. Getting it right every time for every patient is the ultimate goal in these situations, and supporting people to live well before dying with peace and dignity in a place of their choice can be incredibly satisfying for all involved, despite the bleakness of the situation.
A number of strategies have arisen in recent years to help GPs and other professionals to facilitate the wishes of patients approaching the end of their lives, and they have ensured that care is uniquely tailored to the patient. This has resulted in their needs increasingly being met and care is often managed in a much more collaborative and coordinated way. Ironically, the ultimate goal of healthcare, which is to save lives, can be a barrier in these circumstances and can prevent patients from achieving a peaceful and dignified death, especially when we consider the issue of CPR.
Discussions relating to resuscitation can be one of the most sensitive and difficult that GPs, patients and family members may ever have to be involved in. It is essential to identify patients for whom cardiopulmonary arrest represents the terminal event in their lives and for whom CPR will fail or is inappropriate. It is also essential to identify those patients who would not want CPR to be attempted and who competently refuse this treatment option. Some patients may wish to make an advance directive about treatment. Such directives must be respected as long as the decisions are made by patients with the mental capacity to do so. These decisions should be informed, current, made without coercion and should apply to the current clinical picture. All of these variables have to be considered and should include the patient where appropriate. With emotions high in these situations, unsurprisingly there are still many reports detailing when patients have been excluded and decisions made in their best interests, with some of the worst cases reaching the media. This does nothing but create a culture of fear and results in further anxiety around such discussions. There needs to be convincing reasons not to involve patients in these discussions, or as seen with the Tracey Judgement, there is a risk to patients under Article 8 of the European Convention on Human Rights.
Once the decision concerning CPR is made, it is absolutely essential that inappropriate, futile or unwanted attempts do not occur. This is not to say that decisions cannot be reviewed and amended accordingly, if it is appropriate to do so. Variations in local policies can cause further misunderstandings and can lead to distressing incidents for patients, families and staff. The increased movement of patients and staff between different care settings makes a single integrated and consistent approach complex and difficult to achieve. The caution for Locums is that this can be very confusing, especially if they work in one area of the UK where there is a unified approach in place and then they choose to work in another area, where this approach is yet to be implemented and the policies once again differ significantly.
The introduction of the ‘Unified-Do-Not-Attempt-CPR-Form’  represents a significant step in the right direction for standardising the approach relating to decisions concerning CPR. The concept is quite simple but very effective and just involves the appropriate professional completing a resuscitation form. Ideally this form should be initiated in the Primary Care setting, and therefore should be a GP, but it can be commenced when the patient is still in the Secondary Care setting. Its significance comes from the fact that once the decision has been made it doesn’t mandate the process be revisited just because the patient may move between different settings prior to their death. Of equal importance, is it is recognised by the Ambulance Service and will therefore prevent inappropriate CPR if the service is contacted, when previously Paramedics would have been duty bound to act. The paperwork is transferable to all services.
It isn’t without its criticisms. The decision is only applicable if the lilac form stays with the patient at all times (or can be easily found) regardless of their setting. There are reports that this is much easier said than done, and forms often get lost and need re-writing. The fact that it is currently only available in a paper format when most services are working towards an Electronic Patient Record is also another area of weakness and a potential pitfall.
The introduction of the Unified DNA-CPR Form is in varying degrees of implementation across the UK. Due to the positive impact the process can have on patients and their families, there needs to be increasing amounts of pressure from all healthcare professionals to ensure that there is rapid roll out in those areas that are lagging behind, or have yet to embrace the idea.


CQC – A hindrance or a help?!

For many employed within Primary Care the very mention of a pending CQC inspection is enough to trigger anxiety, panic, fear and frustration. These emotions can be felt by every member of the team regardless of their professional roles and responsibilities, even more so when there is an overwhelming feeling that we just don’t have the resources to do what we do currently any differently. With recent news that the Organisation intends to increase the amount of unannounced visits over the next couple of years many are left pondering whether clinical staff will ever get an opportunity to see patients again or just be forever lost in a constant and never ending sea of paperwork?
The CQC prides itself on monitoring, inspecting and rating health care providers, making bold claims that this is done in partnership with the teams who deliver those services. A rating is given in accordance to how safe, caring, effective, responsive and well-led that service is and then this is published nationally. Why then, when most of the Primary Care workforce take such pride in our work and when nobody gets up in the morning to go to work and do a bad job, is this Organisation able to illicit such negative emotions in the run up to an inspection? Why does the very mention of the Organisation unite the profession into calling for its immediate dissolution?
Here at we have put together a few potential reasons why:
– The amount of preparation and work required for a Practice to survive an inspection is substantial, and heavily bureaucratic. Despite what the Organisation claims, it is not always reflective of a diverse and modern health care system with many inspections being reported as being undertaken with an autocratic ‘we know best approach’ rather than a collaborative approach to dealing with real issues.
– The inspections are dependent upon data being readily available, up to date and correct in order to make a rating. Often, data comes from multiple sources, is difficult to collate and across England transparency in dealing with data and presenting it varies significantly, with the reasons why being multifactorial.
– Poor ratings often result in job losses and staff replacement, rather than addressing root causes of problems and working with leaders to resolve the system problems which are often out of the control of the staff leading the services.
– CQC inspections are often the ‘final nail in the coffin’ for struggling Practices and can destroy the last vestige of hope and morale currently keeping that Practice afloat. Surely an injection of resource, support and leadership is much more effective than an injection of inspectors telling disillusioned staff what they already know? If this results in the closure of a Practice then this causes additional pressure to other Practices who have to pick up this work and as such, care if often compromised.
– Ratings should not be issued on the basis of a single visit and some consideration should be given to how responsive that Practice is in dealing with any identified issues and what systems and processes are put in place to deal with them.
– Some GPCs have called for the CQC regime to be abolished and replaced with a proportionate and fair system that empowers and supports Practices to improve without recourse to an unachievable action plan.
– The CQC does not take into account resource allocations when considering ratings. When the BMA reviewed CQC ratings from 2814 GP Practices in England from 2015 they found that practices with the highest ratings received more funding per patient.

  • Practices rated as ‘outstanding’ received on average £152 per patient
  • Practices rated as ‘good’ received on average £140 per patient
  • Practices rated as ‘needs improvement’ received on average £128 per patient
  • Practices rated as ‘inadequate’ received on average £111 per patient

The correlation between performance and funding per patient are not shock findings, they are common sense. The CQC does not take this into account when issuing ratings, but maybe now that so much importance is being placed on finances driving our services influencing their sustainability, this is the time that funding should be published. This may in some way act as some consolation that at least people may have some ideas of the real pressures that Practices face.
For Practices who have an inspection pending then the BMA have released advice and guidance in relation to this and this can be accessed via this link


Medical Revalidation – Under the Microscope

Revalidation started on 3 December 2012 and the vast majority of Doctors are now reported to have undertaken the process at least once. Opinion on Revalidation is extremely divided and this can be a contentious topic of discussion, especially when one considers how much time, energy and effort GPs and their partners have to invest in order to work through the process and demonstrate the requirements. It is absolutely essential that GPs provide up to date and evidenced based treatment to patients. Nobody can argue that this should be done by competent, compassionate and resilient GPs who are caring and sensitive in their approach to patients and their families. What many GPs are disgruntled about is where they are finding the time to complete Revalidation. With constant pressure from rising workload demands, attempts to ensure quality is never compromised and the rising expectation to undertake non-patient facing work and additional roles, many GPs are having to tackle Revalidation in the evenings after an exhausting day in the Surgery or during their downtime.

If Revalidation creeps into social and leisure time then surely this will have an impact on the resilience of GPs, their ability to deal with stress and may bring about one of the conditions the process has been brought in to root out, unstable Doctors! For Locum colleagues the process can be even more daunting with concerns being raised in relation to finding not only time, but a Responsible Officer to undertake the review. One only hopes this process is not having an impact on the current poor recruitment and retention rate across the whole of the medical profession. Is it just becoming too difficult to maintain one’s licence in the face of just wanting to treat patients?

Two significant reports have been published in recent months that aim to review the effectiveness of the process for both patients and for colleagues. The hope is the reviews will help to identify what doesn’t add value and what needs to improve.

The first report, a GMC sponsored evaluation, is a report by an independent collaboration of researchers referred to as UMbRELLA. The survey reveals some encouraging feedback that the process may be having a positive impact on practice especially when used in line with appraisal. Other important findings include:
• 90% of doctors have had a medical appraisal in their career; of this group, 94% have had an appraisal in the past 12 months
• 42% of doctors agreed that appraisal is an effective way to help improve clinical practice
• 32% thought that revalidation has had a positive impact on appraisal, with a small number saying that the impact has been very positive
• Doctors who got feedback from patients said it is the most helpful information to support reflection on their practice
• Some specialty doctors have highlighted difficulties with collecting patient feedback.
The Department of Health commissioned the second report and the main findings include:
• Revalidation has led to important changes in the way that medical performance is managed and assured
• It has helped to integrate sources of information within organisations, therefore giving the Responsible Officer the authority and scope to bring together information on performance and to act upon it
• There are issues around variation, especially from organisation to organisation, and as such there are still considerable areas of the process that could be more efficient and effective.
In short, the jury is still out as to how much value this process adds to safer and better quality of care for patients. The process is full of good intentions but there is still considerable work required to make it user-friendly and less time consuming. Currently, countless hours are not accounted for when referring to guidelines online, discussing cases with colleagues and referring to the BNF. One useful tip is to ensure that you use the GP Notebook  CPD tracker when you are quick referencing guidelines during Surgery, as this may add up to a few hours through the course of the year.


CVD risk calculations error

Following a statement issued by the MHRA, an investigation has been launched into how a digital calculator (QRISK2) used by GPs to assess the potential risk of cardiovascular disease, has resulted in incorrect risk estimation scores being calculated. The SystemOne’s version of the QRISK2 calculator is used in more than 2,500 practices across the country and it is now thought that incorrect scores could have been determined for potentially hundreds of thousands of patients, dating as far back as 2009.

The MHRA confirmed that it was only the interaction between QRisk2 and SystemOne that have caused the alert and this must be reiterated to patients when concerns are being raised. Having said that, this is a major system error, one that could potentially result in a loss of confidence in the tool and one that could create a lot of additional work to already excessive GP workloads.

The risk to patients can vary and includes:

– Thousands of patients may have been prescribed statins when they are not indicated.

– Patients who should not be on statins may suffer unnecessary side effects from being on them.

– Patients may choose to stop their statins because of a loss of confidence in the decision making process. This may cause cholesterol to return to dangerously high levels in just a few weeks.

– The risk of a cardiovascular event from not being on a statin, when in actual fact one should have been commenced.

The numbers of patients affected by use of the tool are thought to be low because this is a tool to aid to clinical decision making. Therefore, the hope is that only a small number of patients will require changes to their CVD management plan. If only one patient is affected by a software system error this, however is one patient too many. GPs and the company that manufactures the SystemOne software system, TTP, are therefore working frantically to enable practices to identify patients to ensure that they receive accurate risk estimation scores and treatment where necessary is altered accordingly.

TTP have temporarily, but only recently suspended the use of their tool until the glitches within the system have been identified. The MHRA are working closely with the company to get to the root cause of the problem. One thing is certain, it is going to take a lot of time and reassurance from TTP before many GPs find confidence in this particular brand of the tool, especially in the face of so many other competitors whose end product is much more reliable. In the meantime GPs are advised that if it is necessary to use an algorithm to assess a patients risk then QRISK2 is available at