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Tag Archives: GPs
Patients less satisfied by GPs who refuse to prescribe antibiotics
December 7, 2015 News and Interestantibiotics, GPsaoadmin
GPs who prescribe fewer antibiotics have less satisfied patients, according to a new study by researchers at King's College London.
The study, published in the British Journal of General Practice, compared the prescribing rates of more than 95% of all GP surgeries in England to a survey of patient satisfaction.
Those satisfaction scores are used to determine how much GPs get paid.
Patients' satisfaction rose when they were listened to or carefully examined.
A study last year warned that up to half of all prescriptions of antibiotics could be inappropriate – given to patients suffering coughs, colds, sore throats and the flu – none of which can be treated with antibiotics.
The overuse of antibiotics has led to antibiotic resistance, when bacteria and infections can no longer be killed off or treated with strong drugs.
In this study, doctors who prescribed 25% fewer antibiotics saw a modest reduction in patient satisfaction with them or with their surgery.
The General Practice Patient Survey, which invites nearly three million adults registered with GPs in England to comment on the quality of their care every year, is also a factor taken into account in GPs' performance-related pay.
Dr Mark Ashworth, GP and lead study author, from the King's College London division of health and social care research, said: "GPs often feel pressured by patients to prescribe antibiotics and find it difficult to refuse a patient who asks for them.
"GPs who are frugal in their antibiotic prescribing may need support to maintain patient satisfaction."
Although the authors say they can't show cause and effect in this study, other studies in other countries have come up with similar results.
But they also point to research that indicates it is possible to offset any feelings of dissatisfaction if patients feel they have been listened to or carefully examined.
Dr Tim Ballard, vice chair of the Royal College of GPs, said the findings were concerning.
"It is frustrating that GP practices that are working hard to reduce inappropriate antibiotics prescribing face falling patient satisfaction ratings.
"It truly is a case of being damned if we do and damned if we don't.
He added: "Public perception needs to change – our patients need to understand that when diseases become resistant to antibiotics, it means that antibiotics will cease to work and as it stands, we don't have an alternative.
Source BBC News
How your GP is paid to stop you going to hospital
October 1, 2015 News and InterestGeneral Practitioners, GPsaoadmin
GPs are being offered bonuses to reduce the number of patients sent to hospital, including those with suspected cancer, an investigation has found.
Family doctors are being paid bonuses worth thousands of pounds to keep within targets for outpatient referrals and follow-ups, which can include two-week cancer waits and emergency admissions.
The British Medical Association's general practitioners committee (GPC) said such schemes could be "ethically questionable" while Macmillan Cancer Support said it was "very worrying" that GPs could be put under pressure not to refer people against their clinical judgment because of targets.
The schemes are also at odds with the recently announced NHS Cancer Strategy which promised an 80 per cent increase in tests for cancers. The UK has the worst survival rates for cancers in Western Europe, largely due to late diagnosis.
The General Medical Council (GMC) has already looked into one such scheme and raised concerns that the payments could be regarded as inducement if it was felt they had influenced a GP's behaviour.
The research, by Pulse magazine, found that Clinical Commissioning Groups (CCGs), the NHS bodies responsible for the planning and commissioning of regional healthcare, in nine parts of the country were offering GP practices financial incentives to cut referrals.
GMC guidance states that doctors must not accept any "inducement, gift or hospitality" that affects or could be seen to affect the way a doctor treats or refers patients.
But as the NHS in England attempts to save £22 billion by 2020, the Freedom of Information study indicates how standards in routine, front-line care are being jeopardised.
It found that the NHS North-East Lincolnshire CCG is offering the average practice the equivalent of more than £6,000 to reduce outpatient referrals, including two-week urgent cancer referrals, to the same level as the 25 per cent of practices with the lowest referral rates in 2014/15.
NHS Birmingham South Central CCG is offering the average practice the equivalent of more than £11,000 to reduce new outpatient attendances, follow-ups, A&E attendances and emergency admissions by one per cent, compared with last year.
The CCG said it had considered the "full impact" of the incentive scheme and was "confident that there is no conflict of interest".
"These (schemes) may, at face value, potentially be ethically questionable and conflict with GMC guidance."
Dr Robert Morley
In London, at least six CCGs offer incentives for practices to reduce referrals.
Among them, NHS Hammersmith and Fulham CCG has made available a total of £107,600 across all practices for reductions in referrals.
NHS Lambeth CCG is offering payments to practices which move towards the average 2014/15 referral rate per 1,000 patients.
The CCG claimed that urgent care and two-week cancer referrals "cannot be separated" from the overall numbers.
But Dr Emma Rowley-Conwy, a Lambeth, south London, GP, warned that such targets were "counter to other initiatives that encourage GPs to refer earlier for suspected cancers".
NHS Bolton CCG sought guidance from the GMC over its "quality contract" which pays practices for reducing referrals for procedures of 'limited clinical value' by 20 per cent and for reducing first outpatient appointments and follow-ups by 1 per cent.
Dr Rosie Loftus, joint chief medical officer at Macmillan, said: "This is yet another sign of an NHS which is seriously over stretched and not giving GPs the resources and support they need.
"England's cancer survival rates are already amongst the worst in Europe and a key reason for this is the inadequate access to cancer tests and treatment. If this is rationed further it could make survival rates and quality of life for people with cancer worse. This isn't something the NHS can afford to do."
Dr Robert Morley, chair of the GPC's contracts and regulations subcommittee, told Pulse that schemes incentivising practices to reduce urgent cancer referrals were "extremely concerning".
He added: "These may, at face value, potentially be ethically questionable and conflict with GMC guidance, on the basis that they might conceivably influence individual management decisions."
Former Royal College of GPs chairwoman and Lambeth GP Professor Clare Gerada said such schemes risk "interfering with the doctor-patient relationship".
She added: "Once we start incentivising to reduce activity, then it puts a conflict within the consulting room."
The Patients Association also warned that such incentives posed an inherent risk to patients.
"If we start incentivising so that we can achieve targets, but actually we are not providing the most appropriate care, then it brings into question good practice guidelines," a spokeswoman said.
"We should never focus on targets and financial gain over clinical outcomes."
In July, the NHS pledged major reforms to the way it diagnoses and treats cancer, leading to an 80 per cent increase in the number of cancer tests, with all patients given a definitive diagnosis within a month by 2020.
Simon Stevens, chief executive of NHS England, said the £2 billion initiative would also replace a range of outdated equipment and mean that the UK has a "world class" cancer service within five years.
The largest ever cancer study revealed last month that the UK's cancer survival rates are a third lower than those in Sweden.
The report, presented to the European Cancer Congress in Vienna, showed that despite investment in attempts to diagnose cases earlier, and speed up access to treatment, there has been no narrowing of the gap between Britain and other developed nations.
Experts said the major differences reflected poor rates of early diagnosis in this country, with one in five cancers not spotted until a patient arrives at Accident & Emergency departments.
Some of the CCGs said they were focused on cutting "unnecessary" referrals. Others had much broader targets to cut referrals for "high activity" specialties.
Some argued that the incentives represented no conflict of interest for doctors and that they were simply reducing the huge variations in referral rates between practices.
Some of the CCGs that provided details to Pulse said they were focused on cutting "unnecessary" referrals. Others had much broader targets to cut referrals for "high activity" specialties.
They have not yet responded to requests for comment from the Telegraph.
Source The Telegraph
Cutting trainee GP pay subsidies will put patients at risk, doctors tell Jeremy Hunt
August 10, 2015 News and InterestGPs, Jeremy Huntaoadmin
The Secretary of State for Health, Jeremy Hunt, has been told by family doctors that proposals to strip trainee GPs of thousands of pounds' worth of salary supplements could have a "catastrophic" impact on the workforce and compromise safe patient care.
The Government is considering plans to scrap pay subsidies worth between £14,300 and £16,200 a year to GPs in training, which were originally introduced to address pay discrepancies between GPs and hospital doctors.
Withdrawal of the subsidy could mean GP trainees' pay falling to a rate 31 per cent lower than their hospital counterparts.
GP leaders fear medical students will be deterred from choosing general practice at a time when the profession is already in the midst of a workforce crisis and is struggling to attract new recruits.
Dr Maureen Baker, chair of professional body the Royal College of General Practitioners (RCGP), has now written directly to the Secretary of State for Health, to warn him against the plan, which she said would make the Government's own goal of recruiting 5,000 more GPs by 2020 "impossible" to achieve.
The Department of Health says the proposals, recommended by the independent Review Body on Doctors' and Dentists' Remuneration (DDRB), would give trainee doctors a higher basic salary and reward them according to hours worked. GP trainees often work fewer hours than hospital doctors.
There are also proposals for the subsidies to be replaced with pay premiums designed to incentivise young medics into entering undersubscribed specialities.
However, the RCGP said the premiums, whose value has yet to be decided, did not offer the kind of guarantee required to attract medical graduates into general practice.
Stripping away the subsidies without any replacement would leave trainee GPs with a basic salary of £31,838, rising to £35,952 in their third year of training. Around 4,000 GPs would be affected, the RCGP says.
In her letter to Mr Hunt, seen by The Independent on Sunday, Dr Baker writes: "I am extremely concerned that this proposal, if implemented, would have a catastrophic impact on GP recruitment, leading to a worsening of the current workforce pressures that general practice is under and compromising the ability of GPs to continue to provide safe patient care.
"I therefore strongly urge you to reject the DDRB's proposal to remove the GP-trainee supplement, and to enter into discussions with the British Medical Association (BMA) with a view to agreeing a way forward that recognises the need to ensure that disproportionate pay does not discourage junior doctors from joining the profession."
Dr Baker's decision to write to Mr Hunt represents a rare intervention by the RCGP into a pay dispute with the Government. Doctors pay negotiations are carried out by the BMA, the doctors' union.
The RCGP said their intervention reflected the scale of concern about the negative impact of the proposals on recruitment and the long-term future of general practice. Despite a Government target for half of all medical graduates to enter general practice, more than one in 10 new training placements were left unfilled in England last year, rising to almost one in three in the North-east and the East Midlands.
There fears that GPs will move abroad to seek fewer hours and greater pay There fears that GPs will move abroad to seek fewer hours and greater pay
There are fears that this year's recruitment round will also leave many places unfilled. New trainees began work on Wednesday last week, but the recruitment body, Health Education England (HEE), has not released fill-rate figures.
However, figures released by HEE's Scottish counterpart show one in five GP training places in the UK remained unfilled at the end of June. A third round of recruitment is under way, with candidates likely to start work in February 2016.
In her weekly message to RCGP members, Dr Baker said: "It's extremely rare for the College to be commenting on contractual matters, which is why in my letter I have asked Mr Hunt to enter into negotiations with the BMA …. We cannot sit back and stay silent on something which is a threat to the future of our profession and, ultimately, the care we deliver to patients."
Increasing the GP workforce has become a priority for the Government as rising demand from a growing and ageing population puts the profession under strain and drives a rise in waiting times.
NHS England has set itself a target of saving £22bn by 2020 to keep the health service sustainable in a time of straitened Government funding.
Commenting on Dr Baker's letter, a Department of Health spokesperson said: "These proposals, endorsed by the independent pay review body, set out a fairer deal for all medical and dental trainees so that their pay relates to actual hours worked. We want to encourage trainees to take up specialities like general practice and these plans provide incentives to do so."
Source The Independent
GPs who put money before patient care and who is really to blame for the dawn queues outside health centre
December 24, 2014 News and InterestGPs, Patient Care, Sunbury Health Centreaoadmin
One shameful statistic, if that is the right word, lies behind the dawn queues outside the Sunbury Health Centre in Surrey.
It is this: the surgery was originally designed for 6,000 patients, but now serves nearly 19,000.
Had the building in which the practice is based been a block of flats, say – and not part of the beleaguered NHS – it would surely have been closed down by now on the grounds of overcrowding.
Instead, the sick and the elderly find the phones at Sunbury continuously engaged (a fifth of those using the centre had to wait more than ten minutes for someone to answer their call, according to a patient survey) and, even if they do get through, it is impossible to book a same-day appointment, and face up two weeks to see a doctor.
Hence the reason why nursery teaching assistant Talitha Taylor, 34, foster carer Georgina White, 58, and retired Ray Samphire, 68, were among those who, once again, were waiting in the cold and dark outside the centre from 6.18am yesterday; a scene repeated at GP surgeries up and down the country. 'Crazy',
Mr Samphire called it.
Nevertheless, the surgery passed a recent Care Quality Commission (CQC) inspection with 'flying colours', which perhaps tells us more about the CQC than the Sunbury Health Centre.
So what has gone wrong, or rather who is to blame for the scandal?
Not the doctors who run the centre, it seems, if a newsletter issued by the centre is taken at face value.
The extra demand is a result of new housing developments springing up in the area, the doctors say, and the 'very old and tired' health centre simply cannot cope with the influx.
They applied to NHS England for permission to redevelop the building, but 'we still have no news'.
They applied for a grant to improve the centre 'but, again, we have not heard anything more!'
They have had meetings with the local council but 'despite our concerns, the council continues to grant
planning permission and allow "new builds'' in the area with no consultation.'
The bottom line? Sunbury Health Centre is 84 per cent undersized (the surgery's phrase.) All this is true and has undoubtedly contributed to the crisis.
Indeed, the surgery – now one of the biggest in Britain – occupies less than half the existing building (the other half is occupied by Virgin, a private health care provider, which is responsible for the district nursing team.) But is this the whole story?
The fact remains that more patients equals more money – for GPs. As its patient roll has increased, so has the NHS money flowing in to the surgery, which, like other practices, is paid £73.56 per patient a year.
Or, to put it another way, 6,000 patients means £441,360, for Sunbury, but 19,000 patients means £1,397,640. Nor is this the full extent of the financial incentives for GPs
Under the latest GP contracts, they are also paid £7.64 for vaccinations such as flu and MMR jabs and £55 for every patient diagnosed with dementia; GPs qualify for the payment if they diagnose the patients themselves (with no checks as to whether their assessment is right), or if they update their records when their patients receive diagnosis in hospital.
Some GPs have condemned the scheme as an 'ethical travesty' which amounts to 'cash for diagnosis'.
Either way, it means that a practice such as Sunbury – where patients have to queue at dawn to see their doctor – is also extremely lucrative.
The council would be very keen to support new or improved health facilities in Lower Sunbury
This is the perverse irony at the heart of this scandal. Once upon of time, of course, the NHS – and, in particular, the service provided by GPs – was the envy of the world.
But under the new system, introduced by the last Labour government in 2004, doctors were allowed to opt out of evening and weekend work – which nine out of ten practices, including Sunbury, did.
This brought the average GP's basic salary down to £55,000, but, at the same time, new rules on bonus pay contained in the deal pushed their average pre-tax pay above £100,000.
The new rules stated that GPs would earn bonuses for meeting certain performance targets – from distributing anti-smoking information to diagnosing illnesses such as depression. No cap was placed on the amount they could earn from the new contracts.
As for patients, well, the daily scene outside the Sunbury Health Centre speaks for itself. Behind those scenes are patients like pensioner Mr Samphire and other personal testimonies written, in black and white on the centre's own website.
'I called every ten minutes from 7am until 8.45am (when I finally spoke to someone to only be told that all the appointments had gone … looking to changing doctors. Wouldn't wish this practice on my worst enemy,' wrote one patient.Another added: 'Tried for two hours to get past the engaged tone then waited in a queue of five to wait to be answered.'
A third revealed: 'I have been on hold for 45 minutes, told I am caller number one for 35 minutes and still haven't spoken to receptionist. When I tried the automated system yesterday, soonest appointment was a week's time – even though the medical centre is next door to my house.'
The surgery has 12 GPs, four of them recruited in the past two years to cope with increased demand, and hopes to recruit more. But two new housing developments are also in the pipeline which are likely to place further strain on the oversubscribed health centre. The first of these, at the famous Kempton Park race track, could see more than 1,000 homes being built.
A second is an application to build 196 houses on the site of London Irish rugby club's former training ground in Sunbury, which is currently going through the planning process at Spelthorne Borough Council.
'The council would be very keen to support new or improved health facilities in Lower Sunbury,' said head of planning John Brooks. 'However, these need to be supported by the relevant health funding bodies. To date, they have not given us specific proposals and neither have they made specific funding requests.'
In fact, more GP practices than ever are reaching capacity and applying for permission to refuse new patients, with the number of requests to reject additional patients soaring by 160 per cent in three years, according to GP magazine Pulse.
Has the Sunbury Health Centre made such an application? After all, the surgery has blamed the crisis on a dramatic increase in the number of patients (19,000, remember) now on its roll?
A spokesman for the centre said no such request had been made 'because closing the list would be detrimental to local people who may wish to register with us as patients.'
Source Mail Online
NHS to discontinue dementia diagnosis payments to GP practices
November 26, 2014 News and Interestdementia, diagnosis, GPs, NHSaoadmin
The scheme to pay surgeries was introduced as part of a drive to raise the diagnosis rate from half to two-thirds of all those who develop dementia.
A controversial scheme to pay GPs' practices £55 each time they diagnose a patient with dementia is to be discontinued, the head of the NHS in England has announced.
GPs' representatives and patient groups fiercely condemned the payments, which are part of a drive to increase diagnoses of the condition, as ethically questionable and damaging to the relationship between doctor and patient.
Simon Stevens said on Wednesday that the scheme would end in March, describing it as a "one-time catch-up opportunity for practices who want to take it" and an unusual situation.
Despite the flak the scheme has received and the decision not to continue with it, he said there were no regrets about its introduction.
"I think it's too early for hindsight," he told medical website Pulse. "We need to look at the dementia diagnosis rate through the year before we do that. It is not driven by patient preference, but by different levels of focus on this topic.
"If people don't want to take the payment, that's entirely legitimate. The underlying point though is you have a lot of variation in your chance as a patient with early stage dementia in having that identified and getting the support, whether that is medicine or a care plan.
"There are quite a lot of people who are not having the opportunity to get that early information and support, so there's a whole range of things being done to address that, and this is only a small part."
The NHS says there may be about 400,000 people living with dementia who have not been formally diagnosed.
The payment scheme was introduced as part of a drive to get the rate of diagnosis up from about half to two-thirds of all those who develop the condition. GP practices that have registered will receive payment based on their net increase in diagnoses between 30 September this year and the end of March next year.
Responding to the news that the scheme would be dropped, Dr Richard Vautrey, the deputy chair of the British Medical Association's GP committee, said the NHS had "finally listened to GPs and the BMA, who have raised concerns about the government directly linking payments to specific targets.
"Decisions about an individual's care should always be based on clinical need, not financial imperatives, and while the diagnosis of dementia is important it should not be done in a way that could seriously undermine the doctor/patient relationship."
He accused the NHS of wasting money on "short-term, pre-election targets", when it should be investing properly in GP services.
Martin Brunet, a GP in Guildford, Surrey, who revealed the scheme's existence in an article he wrote for Pulse, said: "I like to think that they have listened. I think they were probably surprised by how unpopular it has been not just among doctors but also the public. I hope we can make it clear that we should never be paid on the basis of diagnoses."
An NHS spokeswoman said the scheme was always intended to be short-term, ending in March 2015.
Source The Guardian
Patients must be told if they have dementia: They have a human right to know about illness, says new NHS chief
September 11, 2014 News and Interestdementia, diagnosis, GPs, NHSaoadmin
Patients have a 'human right' to be told if they have dementia, the new head of the NHS has declared.
GPs should always seek to diagnose the illness and not make the assumption that sufferers would rather stay in the dark, said Simon Stevens.
He warned that there was an 'attitude of fatalism' about dementia in the NHS – and society – with both patients and doctors thinking 'nothing could be done'.
Mr Stevens is now issuing new guidelines for family doctors which set out the importance of diagnosing dementia, which is characterised by failing brain functions such as memory loss.
Figures suggest that 850,000 Britons have the syndrome but half have never been formally diagnosed.
And in some GP surgeries only 13 per cent of patients with the condition have been given a diagnosis – fewer than one in seven.
The low figure is partly because patients and their relatives are reluctant to tell doctors about dementia symptoms because they assume it is just old age – or pointless because there is no cure.
Some GPs are also unwilling to send elderly patients for scans as they want to protect them from the news that they have an illness for which there is no treatment.
But Mr Stevens said that once patients were diagnosed they could be offered medication to help stave off symptoms as well as crucial support and advice.
Devastating: Some 850,000 Britons are thought to have an undiagnosed form of dementia
Addressing a conference of the Alzheimer's Society in London, he said: 'Let's face, it there has been an attitude of fatalism about dementia which says, "there's nothing much that can be done and therefore I'd rather not know because when I do, no good can be done". That is the wrong way of thinking.
'Medication does help many people become more themselves for a useful period of time.
'There's an opportunity for individuals and families to maximise joyful activities, plan and mitigate against potential difficulties and crises. It's increasingly important that we diagnose and code patients with early dementia so that their risk of deteriorating may be understood when they go into hospital.
'Most importantly of all, it seems to be a basic human right for patients to know about their own medical condition.' Mr Stevens, who took up the post in April, added: 'We're moving away from the concept of protecting patients from the diagnosis because nothing can be done and towards offering timely diagnosis for patients.
'We should respect the decision of patients and their families to present themselves at a time that is right for them. But that should not excuse inaction on the part of the National Health Service.'
The Government says that by next year, two thirds of dementia patients will have been given a formal diagnosis.
Yet Professor Alistair Burns, the NHS's national clinical director for dementia, told the conference there were some surgeries in England where the rate was just 13 per cent. He said he would be visiting these practices to find out why they are failing to diagnose so many patients. One GP based in West Lincolnshire said she was reluctant to tell patients they had dementia because there was so little support and treatment on offer.
The doctor – who did not give her name – said: 'I'm not against diagnosing early, it's just what do I do afterwards.'
There is no cure for dementia, although there are a handful of drugs available on the NHS which can temporarily slow its progression by a few months.
Last year the NHS gave GPs new incentive payments for increasing diagnosis rates. All suspected dementia patients must be referred to memory clinics.
The NHS now compiles diagnosis data for every surgery and compares the figure to the number that would be expected given the surgery's population.
GPs dishing out MORE antibiotics just to treat colds: Number given treatment by doctors rose by 40 per cent between 1999 and 2011
August 5, 2014 News and Interestantibiotics, GPs, infections resistant to antibiotics, Superbugsaoadmin
The proportion of patients given antibiotics by GPs for coughs and colds rose by 40 per cent between 1999 and 2011, a study has found.
Antibiotics do not work against viruses, which are often the cause of colds and sore throats.
But researchers from Public Health England and University College London discovered that the proportion of patients prescribed antibiotics by their GP for coughs and colds reached a new high of 51 per cent in 2011 – up from 36 per cent in 1999.
And despite dire warnings about the dangers of antibiotic resistance caused by overuse, they suggested that GPs tend to prescribe them when they are put under pressure by worried patients.
According to the study, which was published in the Journal of Antimicrobial Chemotherapy, the 10 per cent of GP practices with the highest prescribing rates gave antibiotics to two-thirds of patients with the minor illnesses.
Researchers monitoring prescriptions in 537 GP practices across the UK found some gave antibiotics to four out of five patients with sore throats. One in ten GP practices prescribed antibiotics to at least 97 per cent of patients suffering from ear infections.
And use of the recommended antibiotic trimethoprim in women for cystitis increased from 8 per cent in 1995 to 50 per cent in 2011.
Last year 41.6million prescriptions were dispensed for antibiotics in England, according to figures from the Health and Social Care Information Centre, which do not show how many were handed out for coughs and colds.
The Government's chief medical officer Dame Sally Davies said last month that pushy patients have been partly to blame for the rise of deadly superbugs which are immune to the drugs.
And the Prime Minister has warned that Britain faces returning to the 'dark ages of medicine' where antibiotics no longer work.
Lead researcher Professor Jeremy Hawker, a consultant epidemiologist from Public Health England, said: 'Although it would be inappropriate to say that all cases of coughs and colds or sore throats did not need antibiotics, our study strongly suggests that there is a need to make improvements in antibiotic prescribing.
Gets rid of them: It was suggested some doctors prescribe useless antibiotics to stop patients returning
'Previous research has shown that only 10 per cent of sore throats and 20 per cent of acute sinusitis benefit from antibiotic treatment, but the prescription rates we found were much higher than this.'
He added: 'The worry is that patients who receive antibiotics when they are not needed run the risk of carrying antibiotic-resistant bacteria in their gut.
'If these bacteria go on to cause an infection, antibiotics will then not work when the patient really does need them.'
Professor Hawker went on to say that 'defensive medicine' could be partly responsible for some GPs prescribing them more often for coughs and colds to save them 'being caught out' by complications if the condition got worse.
And he suggested that GPs keen to cut down on their workload may give patients a prescription to stop them coming back to the surgery.
Dr Maureen Baker, chairman of the Royal College of General Practitioners, said: 'Antibiotics are very effective drugs, as long as they are used appropriately. But we've developed a worrying reliance on them.
'GPs face enormous pressure to prescribe them, even for minor symptoms which will get better on their own or can be treated effectively with other forms of medication.'
She added: 'Our patients and the public need to be aware of the risks associated with inappropriate use of antibiotics – and know how to use them responsibly.
'This study reinforces the message that we issued recently for frontline health professionals to resist pressure from patients for unnecessary prescriptions and explore alternatives to them.'
Phone consultations 'do not cut GP surgery pressures'
August 4, 2014 News and InterestGPs, phone consultationsaoadmin
Introducing GP consultations over the phone, rather than face-to-face appointments, does not reduce pressure in busy surgeries, a study shows.
The analysis of 42 practices, in the Lancet, found telephoned patients needed more contact with their GP.
The report's authors said phone consultations had a role, but were "no silver bullet".
The British Medical Association (BMA) said GPs were "under real pressure" from soaring patient demand.
It was hoped that using telephone consultations would relieve some of the burden.
Greater workload
An average surgery deals with 20 patients who need an appointment on the day.
Researchers at the University of Exeter Medical School investigated the impact of having a GP or nurse call those patients back instead of them coming into the surgery.
Rather than easing workloads, the number of patients being dealt with by practices increased by 33% when a doctor called back, and by 48% when a nurse was on the other end of the phone.
The study showed that telephone conversations led to more people needing a second consultation.
If the first meeting was in person, 50% of patients needed a second visit, but 75% of GP and 88% of nurse calls required a later visit to the doctor.
Lead researcher Prof John Campbell told the BBC: "This is not the silver bullet to dealing with workload.
"Introducing it in some settings will be very useful, but it needs to be introduced with caution."
He said phone calls were still a valuable and good service, especially for people who could not get away from work.
But equally they could harm the relationship with patients who like to come into the surgery.
'Direct examination'
Dr Richard Vautrey, the deputy chair of the BMA's GP committee, said: "A key problem is that general practice as a whole is under real pressure from soaring patient demand and falling funding, which often means that practices don't have enough GPs or nurses to operate these services in addition to managing their current workload."
He added that phone services increased demand from people who would not have come to an appointment, or would have managed their condition at home.
He said it was important to get the balance right and ensure face-to-face consultations were not completely replaced, as "there are many conditions that can only be safely treated by direct examination in the GP practice".
A spokesperson for the Department of Health said: "Most patients can get appointments and we're offering 7.5 million more people email, Skype and evening and weekend slots.
"GPs know what works best for their patients so can tailor their services as they see fit and based on what patients need."
NHS crisis: Tory health expert warns we have 'the wrong workforce' for the future due to 'huge bias' towards training specialists – and leaving surgeries crying out for GPs
July 7, 2014 News and InterestDr Sarah Wollaston, GPsaoadmin
The NHS has "the wrong workforce" to cope with the future health needs of the country, with medical schools training too many hospital specialists and not enough GPs to cope with overwhelming patient demand, the new chair of the influential Health Select Committee, Dr Sarah Wollaston, has said.
Dr Wollaston also warned that the health service faces a crisis in the GP sector and that more should be done to encourage those who have left the profession, particularly women, to return to help relieve the pressure.
Dr Wollaston, Tory MP for Totnes, Devon, and a former GP, said there was "a huge bias" in medical training for doctors to train for work in hospitals, despite a growing consensus that the future of the health service lies in caring for patients closer to home – with GPs seen as key to new models of care.
The Health Select Committee said last week that 15 million NHS patients with long-term conditions such as diabetes, arthritis and asthma now represent 70 per cent of the work the health service does.
Improving GP and community services will be crucial in preventing medical emergencies associated with these conditions that would require expensive hospital care.
The "closer to home" strategy is seen as key for ensuring that the NHS, which is facing a £30bn funding gap by 2020, will be sustainable for the future.
However, the MP warned that "a real workforce crisis" in the GP sector, particularly in rural and deprived areas, threatened to undermine patient care.
Dr Wollaston worked as a GP before entering Parliament in 2010 and also has experience of training junior doctors. She believes one way the NHS could "very quickly" begin to address the GP workforce crisis would be to attract women who have left work to have children, back into the profession.
"We've got the wrong workforce," she said. "What we do, still, is train too many doctors out of medical school, to become acute hospital specialists in specialities for which there are no jobs. They might have four or five years of training to become a particular hospital specialist when everybody knows there won't be a job for all of them. And yet in general practice we've got huge vacancies."
Only a decade ago there were 2,500 more GPs than hospital doctors in England. But by 2012 that balance had shifted, with 31,700 GPs against 38,200 hospital doctors.
Dr Wollaston said that much of the problem lay in the training doctors received in medical school. "There's not enough of their training focusing on where we need doctors in the future – generalists in primary care … we encourage them, through medical school, to think that the only show in town is becoming an acute hospital specialist. There is not enough prestige and not enough emphasis at medical school placed on primary [GP] care – some medical schools are better than others, some do focus on primary care, but others don't."
However, with patients reporting that it is becoming harder and harder to get a GP appointment, and doctors' leaders from the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) warning that the profession is approaching the limit of its ability to cope, Dr Wollaston said one short-term measure that would relieve pressure would be to clear the barriers which stop trained doctors who are not working, from getting back into day-to-day patient care.
"We've got a very large female workforce now in general practice," she said, "many of whom step out for childcare commitments. Let's very quickly try to bring those women back into the workforce through returner schemes. It takes four years to train a GP, it takes a very short time to get someone back in the workforce who's been out for three or four years."
NHS statistics reveal 65 per cent of GPs in training are women, but that 40 per cent of women who leave general practice are under the age of 40.
The RCGP is working on a campaign to encourage women who have left work for childcare, and other trained GPs who have taken time out, back into work.
The college has heard anecdotal evidence that "good quality and experienced GPs are being discouraged from returning to UK practice" – in particular by the cost of having to pay for their own re-training.
Dr Maureen Baker, the chair of the RCGP, called the "significant barriers" faced by GPs wanting to get back into work "ludicrous", saying: "We desperately need more GPs and practice staff. It is ludicrous at a time when we are seeing the general-practice workforce depleting that there are very significant barriers to [allowing] people to return to careers in general practice, caring for patients."
Dr Baker added that the RCGP was looking for funded schemes to support doctors, "so that they can have a safe, protected route back to practice and ease workforce pressures across the NHS". Surgeries are being encouraged to invest in "return to work" re-training schemes that are more cost-effective than training new GPs. It is estimated that there are hundreds of trained GPs who could return to practice.
Dr Chaand Nagpaul, of the BMA's GP committee, said: "It is unacceptable that female GPs who have taken periods of leave after having children face barriers when returning to work. It is important for GPs to be encouraged back into the workplace, particularly at a time when general practice is facing a workforce crisis.
"It is essential that the funding is ring-fenced for returner schemes, which allow GPs to return to practice, and retainer schemes which allow them to remain part of general practice during their time off. There is currently a huge disparity in the funding offered across the country, and highly skilled, dedicated GPs are being prevented from providing the care our patients need."
Cambridge GP Dr Fiona Cornish, a past president of the Medical Women's Federation, said the NHS was "missing out" on "hugely experienced, valuable GPs" by making it difficult for women who wanted to return to work.
"We need them more than ever," she said. "Younger doctors don't want to go into general practice, they see it as an unstable and demotivated profession because of the media bashing and constant denigration by the public and politicians."
A spokesperson for Health Education England said the number of GP training posts has been increased in 2014, with a target to provide a total of 3,250 GP training places.
"This work includes a review of the GP recruitment process, development of a pre-GP year for prospective applicants, and careers advice for foundation doctors and medical students," the spokesperson said. "We have also just started conversations with the Royal College of General Practitioners – in relation to a possible GP Return to Practice 'campaign' in the near future."
The cure that isn't working
Pressure on the Government over GP access increased last night as it emerged that it has produced an action plan to improve services in primary care which is already failing.
NHS England quietly produced the six-point "call to action" strategy a year ago to reverse the growing dissatisfaction with GP services. Yet figures released last week showed that, on all the indicators, approval among patients has fallen.
Access to a family doctor is threatening to become the next big crisis in the NHS, with patients' groups and MPs increasingly alarmed that waiting longer than a week for an appointment is becoming more and more common.
The strategy "NHS England: Improving General Practice", included six key indicators to highlight "growing challenges in relation to patient experience of access". These are: the overall experience of their GP surgery; overall experience of out-of-hours GP services; the ease of getting through on the telephone; ability to get an appointment; overall experience of making an appointment; and ability to see a person's preferred GP.
When the six indicators are compared with a published survey of patients, satisfaction with services are shown to have deteriorated.
The survey of nearly one million patients published last week showed that a quarter of patients are waiting more than a week, and one in 10 gives up trying to see their GP – instead heading to already overflowing A&Es.A third of people felt they had to wait too long for a GP in the evenings and at weekends, while a quarter found it difficult to contact a surgery by phone.
Labour said the revelation of the six-point plan showed that the Prime Minister's claims in the Commons last week that the NHS was better under the coalition were not true.
The shadow Health Secretary, Andy Burnham, said: "David Cameron will be embarrassed by this. It… shows that his plans are simply not working. The reality is that he's made it harder to get a GP appointment and there is now growing public dissatisfaction. Labour will scrap Cameron's NHS market and invest the savings in helping patients get a GP appointment when they need one…
"While the Government tries to claim that everything is fine, people know from their own experience that the NHS is heading downhill."
Last week, Dr David Geddes, head of primary care commissioning at NHS England, said that overall experience of GP services was good, but conceded: "We need to recognise the continuing trend in what patients are telling us about access to services, particularly out of hours."
Seeing a GP 'getting more difficult'
July 3, 2014 News and InterestBMA, GPs, waiting to see a doctoraoadmin
Getting to see a GP in England is getting more difficult, the official patient survey shows.
The poll of more than 900,000 patients found that, in the last two years, the proportion saying it was not easy to get through on the phone rose from 18% to 24%.
When they did get through 11% were unable to get an appointment, the Ipsos MORI poll for NHS England showed.
But overall 75% rated the experience of making an appointment as good.
When they did get to see a doctor, or for some a practice nurse, 86% said their overall experience was good.
'Waits will become normal'
It comes after the British Medical Association (BMA) warned last week that patients would face longer waits to see a GP because of a shortage of doctors and squeeze on funding.
Speaking at the BMA's annual conference, BMA GP leader, Dr Chaand Nagpaul, said waits of one or two weeks would "become the norm".
This survey does not measure that, but it does show that access is becoming a problem for a growing minority.
As well as 11% not being able to make an appointment, 8% of those getting an appointment felt it was at an inconvenient time.
GPs argue the problem is caused by rising demands not being matched with by a corresponding rise in resources.
The number of annual consultations carried out by general practice has risen by 40 million since 2008, hitting 340 million at the last count.
Meanwhile, figures from the Royal College of GPs (RCGP) show the amount spent on practices has fallen by £400m in real terms over the last three years.
In 2012-13, £8.5bn was invested in general practice, when everything from spending on pay, IT, tests and drugs was taken into account, the RCGP research found.
That compared with £8.3bn in 2009-10, which is the equivalent of £8.9bn in 2012-13 prices.
'Majority positive'
The Department of Health has already recognised access to GPs is an issue.
It has launched a £50m Challenge Fund to extend opening hours and make greater use of technologies such as Skype and email.
More than 1,100 practices – one in eight of those in England – have signed up.
Dr David Geddes, from NHS England, said: "Overall, these results show that the majority of patients are positive about their GP services, which is testament to the hard work of GPs and their staff.
"But we need to recognise the continuing trend in what patients are telling us about access to services."
However, Shadow Health Secretary Andy Burnham warned: "It is getting harder and harder to get a GP appointment under David Cameron.
"The next Labour Government will invest £100m to help patients to get appointments within 48 hours or on the same day for those who need it.
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Contract service for the apartment. The living room area is characterized by backlit onyx, the TV unit shows a vertical coplanar sliding system and a bio grain alcohol fireplace. The bar area is distinguished by its pull-out doors and leather insides. The kitchen presents American walnut doors and a Bronze Amani top. The bedroom wardorbe is carried out with Nabuck doors and cedar insides, a Nabuck bed and American walnut night tables with a steel nickel-plated finish lower part. The bathroom furniture is characterized by American walnut doors and a Bronze Amani top.


During May and June 2014, Victoria's Racing Integrity Commissioner (RIC), Sal Perna, will undertake a series of presentations in regional and metropolitan areas of Victoria.
These presentations build on those undertaken the previous two years to create a greater understanding and awareness of the role and responsibilities of the RIC, the work the office has undertaken and an overview of what is in place to ensure that the Victorian Racing Industry operates free from the influence of crime and corruption.
The sessions will be an opportunity to raise questions and hear first-hand of the Commissioner's perspectives on integrity in the racing industry.
All members of the public are invited to attend, whether racing industry participants or not.
All sessions will commence at the allocated time and will run for approximately 1 hour.
Those interested in attending any of the sessions are kindly asked to indicate their attendance online via the website or email rsvp@racingintegrity.vic.gov.au prior to the session.
Further queries can be directed to Lauren Clausen, Office of the Racing Integrity Commissioner, via the above email address or 03 8684 7776.


The difficulty with abstract expressionism like that of Barnett Newman is that it doesn't represent something (immediately) recognizable. That doesn't necessary mean there is nothing to relate to though.
Izzy was missing the other day.
We had started to let her out only a couple of weeks ago. Enough to get used to the gardens and not to get lost, but she isn't too bright. And she's fat, too.
Since our move to Holland and the purchase of our house A and I needed a sunny holiday.
Having been to the Greek islands of Lefkas and Samos before, this time we decided to go to the larger island of Lesbos.


Yale will become the first university member of the Carbon Pricing Leadership Coalition (CPLC), a private-public partnership among the World Bank, International Monetary Fund (IMF), governments, nonprofits, and private sector companies to strengthen carbon pricing policies through the development of a network for sharing best practices.
World Bank president Jim Yong Kim and IMF managing director Christine Lagarde launched the CPLC at the recent COP-21 climate summit in Paris. The CPLC coalition includes over 90 business and strategic partners as well as more than 20 governments, ranging from Germany and France, to Mexico and Chile, to Ethiopia and Morocco.
The announcement was made on March 14 in Mumbai, India during the World Bank's Corporate Carbon Pricing Leadership Workshop. Two recent Yale graduate and undergraduate students who work on Yale's Carbon Charge Project —Jennifer Milikowsky (a 2015 graduate with a joint degree at the Schools of Management and of Forestry and Environmental Studies) and Ryan Laemel (a 2014 graduate of Yale College) — gave presentations at this workshop as well as at the India Climate Policy and Business Conclave in New Delhi on March 15.
Daniel Esty, the Hillhouse Professor of Environmental Law and Policy, and Bradford Gentry, co-chair of Yale's Sustainability Advisory Council and associate dean for professional practice at Yale School of Forestry and Environmental Studies, both served on the Presidential Carbon Charge Task Force and were approached by the World Bank about possible CPLC membership for Yale. The two professors will lead a discussion on campus among students, faculty, and staff starting this spring on how Yale may best contribute to CPLC's global network.
"It has been an honor to work this past week with Indian officials, the World Bank, and member companies of the CPLC to share Yale's carbon charge pilot project," said Laemel. "The lessons we are learning are an important extension of our efforts on campus. The CPLC's network will be an invaluable resource as we continue to test and develop the concept.


– Chris Jericho actually flew to WWE headquarters in Connecticut a while back and met with Vince McMahon to map out his return, all while claiming that he would never work with WWE again.
The cryptic videos leading to Jericho's return were WWE's Social Networking Department's idea. Several in the company felt that the campaign as too smart for its own good before they started airing.
During Jericho's unique return at Monday's RAW Supershow, people backstage were noting the similarities to the Dynamic Dudes character that John Laurinaitis played years ago.
Most expect Jericho to begin feuding with WWE Champion CM Punk, leading to a WrestleMania match. There is no word yet on exactly how long Jericho is back for but there was speculation going around that he will be involved in a major program after WrestleMania 28 with a match at SummerSlam.


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Tumang is een bestuurslaag in het regentschap Siak van de provincie Riau, Indonesië. Tumang telt 1168 inwoners (volkstelling 2010).

Plaats in Riau

redpajama_set_name: RedPajamaWikipedia


text:
D16 Phoscyon
This oddly-monickered TB-303 clone aimes to bring back the halycon days of Acid House
By Future Music 2007-11-08T12:06:00.311Z
A TB-303 and then some. If that's what you want, get it.
Decent 303 clone. Interesting new bells and whistles. Good price.
Not exactly groundbreaking.
Phoscyon uses and interesting photo-real GUI
D16 Group Phoscyon
The manual isn't particularly helpful
Fans of the Roland TB-303's distinctive tones are spoilt for choice on the software emulation front. One can acquire the original ReBirth 338 for free via its sinister online mausoleum, and there are dozens of other versions available, including Audiorealism's elaborate mutation, Bass Line Pro.
Despite the crowded market, Polish newcomers D16 Group have seen fit to debut with Phoscyon, a curiously named TB-303 clone with a few tricks up its sleeve.
Though Phoscyon might not be a fantastically original idea, it does manage to pull a few surprises out of the bag. The most obvious, yet least consequential of these is the rather striking interface design. The photorealistic look works well and certainly sets it apart from the competition visually.
Despite the large number of new knobs and switches the interface is pretty clear, and everything is logically laid out. Anyone who's used ReBirth, or indeed a real TB-303, will feel right at home, although those unfamiliar with the intricacies of its step sequencer might feel a little lost at first.
Unfortunately Phoscyon's manual is rather poorly written, though it does at least feature a short but informative quick start section. Despite the manual's shortcomings, this kind of thing isn't exactly rocket science and it's not too hard to get the synth making some nice noises.
Much of the 303's individual style comes from its built-in 16-measure step sequencer. Phoscyon has its own step sequencer that has the same features, including some clever new tricks (including a row of LEDs across the bottom of the sequencer's interface that indicate what measure is currently being edited).
This is much clearer than the usual digital display, and as such it's a welcome addition. Other new sequencer features include the ability to pitch notes up two octaves instead of just the usual one, and the rather mysterious Threshold control.
The manual is a little confusing on this function, but it's actually a type of filter used for bypassing accent, glide and gate values. Not particularly exciting, but potentially useful for live work.
The patterns from the built-in step sequencer can be triggered in from the host sequencer via MIDI notes. The triggering mechanism can be configured to work in a variety of ways, depending on how the Note Off Clear and Self Reset switch are arranged.
Again these are non-essential functions when you're using Phoscyon with a sequencer, but they make jamming new parts easy and are ideal for the live performer.
As well the internal sequencer, Phoscyon allows users to enter notes via MIDI from the host program, which is well done.
Notes are accented by giving them a velocity over 100, and starting a new note before the last one has finished will cause Phoscyon to slide between the two values.
The system works well and is better at incorporating the synth into song-based tracks than the internal sequencer.
So Phoscyon is pretty flexible on the sequencing front, but it's the sound of the synth that'll sell it. Most 303 clones have a hard time with synth purists who are never quite satisfied with the quality of software copies, and it's unlikely that this attempt will convert them.
However, if you're not intimately familiar with the original hardware it's most likely that you'll find Phoscyon convincing enough. It remains pretty true to the original hardware; you're limited to square or saw waves, and there's a single filter with the 303's characteristic 18dB low-pass response.
There are plenty of new knobs to go round though, including envelope attack time, slide time, envelope accent level, and accent attack and decay times. These all work as you'd imagine, and techno-heads will appreciate the extra noodling possibilities, though there's nothing spectacularly unexpected on offer.
The final two additions to the classic 303 line-up are the built-in arpeggiator and distortion units. The distortion unit has six knobs and getting a decent sound requires more tweaking than ReBirth's equivalent, but the extra controls make it more flexible and a variety of suitably crunchy noises can be gleaned from it.
The arpeggiator is fairly sophisticated, and offers a selection of patterns, tempos and chords, including some user-defined ones.
There's also a repeat note mode that repeats each note of the sequence a certain number of times, and an octave selector that lets you turn up to four octaves on or off - a nice touch. The good news is that it works really well and integrates especially well with the external sequencer.
While this synth is by no means groundbreaking, it does offer plenty of bells and whistles, and the distortion and arpeggiator will endear it to the hard dance scene in particular.
Phoscyon definitely offers a lot over the standard 303 clone, and at the price it's the most attractive proposition in the field.
Acid-imitation aside, it's a fun synth with a mighty big sound that simply begs to be tweaked and then tweaked some more. It might not have an enormous amount of range, but it's great at what it does and is extremely reasonably priced. Definitely worth a fiddle.

redpajama_set_name: RedPajamaCommonCrawl


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Scotland > Lothian > Gazetteer of Castles
Lothian - Castles
This page Blackness Castle - Tantallon Castle
Map of Castles in Lothian
Map of ALL Castles in Scotland
Map of all attractions in Lothian
Blackness Castle
One of Scotland's most important military strongholds, Blackness Castle was built in 1440's, strengthened in the 16th century as an artillery fortress, and finally used as a Royal castle and an ammunition depot in the 1870's. The castle stands on a rocky promontory on the southern shore of the Firth of Forth.
Blackness, Linlithgow, Lothian, Scotland, EH49 7NH
Heritage Rating: ?
Nearest: Hotels - Self Catering - Bed and Breakfasts
Craigmillar Castle
Craigmillar is an early 15th-century L-plan tower house, expanded in the 15th and 16th centuries. Known for its historical connections with Mary, Queen of Scots, Craigmillar stands amid extensive gardens.
Craigmillar Castle Road, Edinburgh, Lothian, Scotland, EH16 4SY
Heritage Highlight: Mary, Queen of Scots Room
Crichton Castle
Despite the fact that Crichton Castle is only a short drive from the greater urban sprawl of Edinburgh, it stands in idyllic, secluded countryside, as if lost in time. One of the most appealing features of Crichton is the glorious setting on a hill above the winding River Tyne.
Crichton, Lothian, Scotland
Heritage Highlight: Superb 16th century Italianate Renaissance interior
Dirleton Castle
Visiting Dirleton Castle really gives you two historic attractions for the price of one. At the centre of the site is a fantastic medieval fortress, home to three powerful families. Set in the attractive grounds surrounding the castle is a much later garden, established after the castle had ceased to be occupied.
Dirleton, Lothian, Scotland, EH39 5ER
Dunbar Castle
Dunbar Castle was once one of the most important and most impressive castles in Scotland. It was begun as early as the Iron Age but the oldest ruins we see today date to the 12th century. The castle has close links to Mary, Queen of Scots.
Castle Gate, Dunbar, Lothian, Scotland
Heritage Highlight: Closely linked with Mary, Queen of Scots
Edinburgh Castle is one of the great castles of Britain. The oldest part of the castle dates from the Norman period. The Great Hall was built by James IV, and nearby are the Royal Apartments with pine panelling and gilded and painted plasterwork. The castle houses the Honours of Scotland, the Stone of Destiny and Mons Meg, a famous 15th-century cannon, plus several military museums.
Castlehill, Edinburgh, Lothian, Scotland, EH1 2NG
Heritage Highlight: The Honours of Scotland display
Hailes Castle
A beautifully sited ruin on the south bank of the River Tyne, Hailes consists of a 13th-century fortified manor house, extended in 14th and 15th centuries. The castle was probably built by the Earl of Dunbar and extended by the Hepburn family in the late 14th century. How the Hepburns gained Hailes is an interesting tale; apparently, the castle was granted by the Earl to an Englishman named Adam Hepburn as thanks for Hepburn having saved the Earl from an attack by a savage horse.
Brae Heads Loan, East Linton, Lothian, Scotland
Linlithgow Palace
The magnificent ruin of a Royal Palace stands in its own park. Linlithgow Palace was the residence of Stewart kings and queens from James I, and both James V and Mary, Queen of Scots were born here, as was Princess Elizabeth, better known as 'The Winter Queen'.
Kirkgate, Linlithgow, Lothian, Scotland, EH49 7AL
Tantallon Castle
A superb clifftop castle, a stronghold of the powerful Douglas family, Earls of Angus. The first fortress at Tantallon dates to about 1350. For the subsequent 3 centuries the castle served as one of the major strongholds of the powerful 'Red Douglas' family, the junior branch of the Douglasses. The Douglas family rose to power as allies of Robert the Bruce during the Scottish Wars of Independence.
North Berwick, Lothian, Scotland, EH39 5PN
Heritage Highlight: One of the most dramatically situated of all Scottish castles
Tantallon Castle Prints
National Trust for Scotland
National Trust for Scotland membership
Free entry to National Trust for Scotland properties throughout Scotland, plus free admission to National Trust properties in England & Wales.
About the National Trust for Scotland
Featured Historic Hotel
The Luib Hotel
Ardchyle, Central Scotland
Heritage Rating:
The Luib Hotel is an ideal place to stay for travellers needing to relax conveniently situated midway between Killin & Crianlarich with its backdrop of magnificent mountain sceneery. The Luib …
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Isle of Skye self catering
Strathpeffer (Self catering)
Larchfield Chalet 2
This custom-built timber chalet is an unusual, comfortable and spacious holiday property and sleeps up to four people.
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Uig (Self catering)
6 Totescore
This detached cottage situated on the north eastern tip of Skye, close to Uig, sleeps five people in three bedrooms.


If Serie A seems already played with the probable title of Juventus, we must head for the fight for fourth place to know much more suspense. While AC Milan is, for the moment, installed in this position, the Rossoneri have only one step ahead of the sixth place of AS Roma. The club Louve hopes to be able to recover this place in the coming weeks. Despite a difficult season, Edin Dzeko's teammates are still in the running. To continue to hope, the men of Claudio Ranieri must win at the reception of Udinese. If successful, Roma would chain a second win in a row, after that won on the lawn of Sampdoria (1-0).
Roma are still in the race in fourth place.
Udinese is only in the fifteenth position.
AS Roma have just won on the turf of Sampdoria (1-0).
Udinese has not won on the road for eleven days.
AS Roma have won their last five Udinese receptions.
AS Roma should be able to win in front of its public. A victory would allow the club Louve to stay very close to fourth place.


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Husky Basketball
Percy Allen
Adam Jude
Husky Football
Jon Wilner/Pac-12 Hotline
How former Husky Nigel Williams-Goss found a home at Gonzaga
Originally published December 2, 2016 at 7:00 am Updated December 3, 2016 at 5:34 pm
After two seasons as a starter for the Washington basketball team, Nigel Williams-Goss transferred to Gonzaga. He will face his former teammates Wednesday when the two teams renew their rivalry after a 10-year break.
Bud Withers
Special to The Seattle Times
Editor's note: This is an excerpt from "Glory Hounds," written by former longtime Seattle Times college-basketball writer Bud Withers. The book tells the stories behind the staying power of the Gonzaga men's basketball program. Washington and Gonzaga are resuming their men's basketball rivalry after a 10-year break, and one of the Zags' top players is guard Nigel Williams-Goss, who transferred from UW after two seasons.
Washington's 2014-15 team would likely intrigue sociologists. It blew to an 11-0 start, undefeated all the way past Christmas. Then it lost at home to Stony Brook, the first of four straight defeats. Late in January, coach Lorenzo Romar booted star center Robert Upshaw for rules violations — amid reports of failed drug tests there and at his previous school, Fresno State — and the Huskies plummeted to a 16-15 ending, 11th in the conference at 5-13.
Nigel Williams-Goss led the team in scoring at 15.6, while his shooting slipped to .442 and only .256 from the arc. He was second in the league in assists at 5.9 a game and third in assist-turnover ratio at 2.08. His superlative game came Feb. 1 against Cal, as he hit 11 of 17 shots on a 31-point afternoon, with six rebounds, five assists and no turnovers.
How Nigel Williams-Goss is doing in his first season with the Zags:
Points per game
Three-point shooting percentage
Note: Stats entering Saturday's game
When, on senior day at the UW, he had 28 points in 39 minutes to lead an upset of 13th-ranked Utah, no Husky fan, not even Romar, could have guessed what was coming next.
The team was fragmenting. Darin Johnson and Jernard Jarreau were outbound, and deep-reserve center Gilles Dierickx was dropping down to Seattle Pacific. A couple of seniors were done, and there was some continuing buzz that Williams-Goss might enter the NBA draft; he had contemplated it after his freshman year.
Williams-Goss points out that another element of the turmoil was assistant coach T.J. Otzelberger, who was leaving to return to Iowa State. Says Williams-Goss, "It was just a lot of change in the program. I was kind of at that halfway point. I kind of said, do I want to rebuild midway through my career or go elsewhere?"
It wouldn't have floored Romar to know that Williams-Goss was going to explore the NBA. Transferring was something else entirely. Williams-Goss recalls him saying, "You know, it's one thing to think you were going to leave to try to enter the draft. It's another thing knowing you're going to play for someone else."
Indeed, Williams-Goss was, and he obtained his release from Washington. He upped the ante considerably three weeks later when he announced his destination: Gonzaga, the school across the state, the place that had been a burr in the Huskies' backside competitively as well as in the public discourse after Washington curtailed the series in 2007.
"I mean, it was tough," Williams-Goss says. "One, telling coach Romar I was leaving the program in general was hard. And again, when I said I was going to Gonzaga. I didn't look too much into the rivalry or anything like that. I was making a decision into where I thought was best. It just so happened it was Gonzaga. At the end of the day, coach Romar has his career and his family he has to take care of, and my career is still young and I'm still developing mine."
Williams-Goss made it clear to me he didn't want to make his transfer from Washington to Gonzaga a noisy, contentious episode. Still, it was apparent that his departure was about more than just the attrition around him.
"I felt after my freshman year, a lot of the things we had talked about (that) were going to change going into my sophomore year, I didn't see a lot of that change happening," he says. "It's one thing, I feel like, to lose, but it's another thing when you're not doing everything in your power, or your capability, as far as preparation in trying to win. I just felt there were a lot of stones left unturned before games, and stuff like that. I had talked to past players, where they kind of had similar experiences … I just felt it was best for me to move on."
Was he saying that people weren't working hard enough? "I'm not saying guys didn't work hard," Williams-Goss says. "I just felt there are a lot of things that go into preparing and stuff at this level — the margin is so small at this level — and I just felt there were just a lot of things that weren't being done that could have been done. That (they) said were going to be done that weren't."
Naturally, he became one of the premier transfers on the market after the 2014-15 season. He spent a weekend sifting through feelers and phone calls – UNLV, Providence, Ohio State, Michigan State, Texas, Notre Dame, Georgetown, LSU, St. John's, Vanderbilt, Gonzaga.
"A big list," Williams-Goss says. "I remember being on the phone with like Tom Izzo, and Thad Matta would be calling, and John Thompson from Georgetown. It was kind of overwhelming."
What wasn't overwhelming, initially, was Gonzaga. Zags assistant Brian Michaelson was close to one of Williams-Goss' former AAU coaches, and Michaelson called during that hectic weekend. But Williams-Goss hadn't heard from Gonzaga coach Mark Few, while he was taking calls from head coaches around the country.
But Few got to Williams-Goss on Monday, and they set up a home visit. Accompanied by Michaelson, he made an impression.
"They completely elevated in my mind," says Williams-Goss. "Again, it was going back to the preparation, the workouts . . . like the amount of film they watch, just the preparation that goes into being successful. Again, like some of the issues I had leaving the UW, they were kind of on top of everything I was kind of looking for. Their whole thing was about developing and winning, those two things exclusively. It wasn't about the facilities or the location or the conference. It was strictly making me the best player I could possibly be, and having a chance to win at the highest level."
As Few puts it, "Literally, there isn't a stone that goes unturned here."
Going way back, even as far back as middle school, Williams-Goss had a saying: "I just want the platform." He just wanted the surroundings, the ingredients, to help facilitate his own initiative and ability.
It helped, no doubt, that Gonzaga was coming off an Elite Eight appearance, and could point to 17 successive years in the NCAA tournament. That's a platform. It had appeal, especially in contrast to Washington's growing tournament drought. After an extended run of success under Romar, the Huskies had failed to make the tournament four straight years, a number that grew to five in 2015-16.
Williams-Goss visited Gonzaga with his parents, did the campus tour and had a meeting with Few in his office. On the last night of his visit, he and Gonzaga players were gathered at Few's rustic home southwest of Spokane, and the Zags were glued to the television showing the long-awaited Manny Pacquiao-Floyd Mayweather fight.
Williams-Goss slipped away to the kitchen, where it was just him and Few. There, he told the coach he wanted to transfer to Gonzaga.
"Glory Hounds" is available forpurchase at amazon.com and will be available soon in bookstores.


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by Steve Ives January 14, 2023, 3:53 AM 13.5k Views
There are three big overlooked trends in the stock market now, and by tapping each one, we can set ourselves up for some very nice long-term gains in my favorite high-yield vehicles: closed-end funds (CEFs).
The 11.8%-yielding CEF we'll discuss further on, the BlackRock Innovation & Growth Trust (BIGZ), is a prime example of a CEF with loads of upside potential now. I've also got a collection of buys yielding up to 9.6% on average (with many paying dividends monthly) waiting for you in the portfolio of my CEF Insider service.
Inside 2023's "Double Discount" on CEFs
CEFs' high dividends are one reason why we favor these funds. Another is that right now CEFs are offering up a rare "double discount": one deal on CEFs' portfolios (many of which are bargains, due to last year's selloff) and another on the fund itself, thanks to its discount to net asset value (NAV, or the value of the stocks in its portfolio).
These discounts to NAV, as members of my CEF Insider service know, are unique to CEFs and a main source of profits in these funds. They stem from the fact that CEFs' share counts are mostly fixed from the time they're issued. That means CEFs can trade at values different from the per-share values of their portfolios.
Our strategy? Buy when discounts are unusually wide, then ride along as the discount narrows, boosting CEFs' share prices as they do.
And right now, we have some tremendous discounts in CEFs (and on BIGZ in particular) thanks to three overlooked shifts happening in the market right now.
Overlooked 2023 Trend No. 1: Inflation Is Ebbing
Inflation was the buzzword of 2022, as COVID-19 snarled supply chains, whacked productivity and permanently altered consumer spending.
But things are settling down on the spending and supply-chain fronts, causing the Fed's preferred measure of inflation, the personal consumption expenditures (PCE) price index to decline, too:
PCE Falls, Giving the Fed Breathing Room
The Federal Reserve favors PCE instead of the commonly followed consumer price index (CPI) as an inflation measure, and PCE's lower current level means that we went from a spike to the highest inflation in 40 years to a level a bit above what we saw in 2005 and 2008.
Overlooked 2023 Trend No. 2: The Fed Is Moving to the Sidelines
The PCE decline is why the Fed funds futures market hasn't priced in many rate hikes this year: 50 basis points in total, which is a big change from 2022.
Rate Hikes Shift to Low Gear
Source: CEF Insider
With rate hikes being about a tenth of what they were last year, it's clear that the Fed won't be the major market influencer it was last year, even though markets have priced in another year of rate-based stress.
Overlooked 2023 Trend No. 3: Recession Fears Are Ringing Hollow
There is one wild card that could stop the momentum in the market today: a recession.
While the data looks like things are getting better for the US economy, most on Wall Street and in the press believe a recession is imminent. This, again, is why stocks and CEFs are oversold, at least until (and if!) that recession happens. That's a big if, considering that, here again, the data differs from market perceptions.
Economy Shrugs Off Recession Fears
Using cutting-edge methods, the Atlanta Federal Reserve provides a real-time estimate of GDP growth that has a better track record than Wall Street economists. And the Atlanta Fed sees nearly 4% growth in the fourth quarter of this year.
This has been a pattern for months now. For example, the Atlanta Fed's measure saw 2.9% growth in the third quarter, versus a 1.2% expectation from Wall Street economists. The real number was 3.2%.
An 11.8% "Double Discounted" Dividend Built for 2023
When macro data is this bullish, investors easily make mistakes by picking the wrong stocks, or going with an ETF that is tied to an underlying index—and is therefore unable to steer around stocks with their own unique problems.
This is a major reason why CEFs are a better way to invest than ETFs. Not only do we get higher dividends than ETFs pay and our CEF "double discount"—we also get the expertise of a professional manager. And we often get those management services for free, to boot!
To see what I mean, let's swing back to the BlackRock Innovation & Growth Trust (BIGZ). As mentioned, this fund yields 11.8%. It also trades at an outsized 20.8% discount to NAV. Since that discount is much larger than BIGZ's 1.25% management fee, we're essentially being "comped" for the expert team from BlackRock, the world's largest investment firm.
BIGZ holds growth-oriented names like Axon Enterprise (AXON), a maker of security technology; Entegris (ENTG), a producer of systems that purify materials in the semiconductor space; telecom-equipment supplier Five9 (FIVN); and Bio-Techne Corp (TECH), which supplies products for pharmaceutical testing.
These are all top-quality techs that were hit hard in 2022 but have strong bounce-back potential in 2023, as the sector that gets hit hardest in a selloff is usually the one to lead the recovery—think financial stocks in the wake of the 2008/2009 meltdown. That, plus the high dividend and deep discount, makes BIGZ more than worth your attention now.
Buy These CEFs for 9.6% Yields—and Monthly Payouts—While They're Cheap
Now—before the next upswing in the market—is the perfect time to buy CEFs. Thanks to the 2022 market mess, these funds' discounts are deep, and their yields are through the roof!
We've been getting ready for this moment at my CEF Insider service for months, adding the most discounted funds to our portfolio, so we're ready for the next surge.
Now I'd like to give you VIP access to this portfolio, which yields a stout 9.6% today. You'll also get a Special Report revealing the 5 best monthly dividend CEFs to buy now. These 5 monthly paying cash machines yield an outsized 8.9%.
Click here and I'll show you how to download your FREE copy of my Special Report revealing these 5 reliable 8.9%-yielding monthly payers. Plus you'll get full access to CEF Insider—and its 9.6%-yielding portfolio—through my exclusive 60-day trial offer, too!
Before you make your next trade, you'll want to hear this.
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The ElectricAccelerator development team sits at desks less than 30 feet apart, but despite our close proximity, we don't often speak to one another. To an outside observer this may seem to be a sign of disfunction in the team — after all, developers have to communicate to work effectively. Some people think we're obviously not communicating, but the truth is that we're not obviously communicating! That's because we use instant messaging for most of our communications, including status updates, technical collaboration and even code reviews, rather than face-to-face conversations. I believe this has made my team more connected and more productive. Here are six reasons why instant messaging trumps face-to-face conversations for software teams.
The key advantage of instant messaging is that all conversations are logged automatically. As a result I've got records of every conversation with every member of my team for the past two years. That's proven invaluable on a few occasions, to provide additional context for decisions made weeks or months earlier. Obviously this is not a replacement for other types of project documentation, but it is a fantastic supplement.
The second most important advantage of instant messaging is that it's relatively non-intrusive, at least compared to a face-to-face conversation. We all know how important it is to get into and preserve a state of flow when programming. Spoken conversations, by social convention, command your immediate attention — effectively an interrupt of the highest order. When somebody comes to my desk to ask me something in person, they are implicitly saying, "What I have to say to you is more important than anything else you might be doing right now." Sometimes that's true, but many times it's not. And yet every time somebody initiates a face-to-face conversation with me, it destroys whatever flow I might have developed.
In contrast, instant messaging allows me to defer a response until I reach a good breaking point, so people can ask questions without interrupting me.
Our office has an open floor plan, which means that instead of individual offices or cubicles, we have a single big room. This layout worked very well when the company had only 6 people, who were all working on the same project. Now the company employs over 100 people, with two separate development teams working on completely different products, so the open layout doesn't work quite so well. Conversations between other people can be very distracting when you're heads down on a tricky technical problem. By using instant messaging instead of face-to-face conversations, we significantly reduce the distraction for our collegues.
Carrying on multiple face-to-face conversations on disparate topics is practically impossible, but doing the same via instant messenger is simple. Every IM client I've seen displays the last several messages of each active conversation, so you have context when a new message arrives. That signficiantly reduces the mental burden associated with each conversation, so it becomes possible to sustain several simultaneously. I often have five conversations "active" during the work day, and sometimes even more.
Unlike face-to-face conversations, IM works well regardless of the relative locations of the conversants. That means that it doesn't matter if my colleague is in the office with me, or working from home, or working from a customer site, or halfway around the world. I can use the same tool to communicate with them, which in turn means I don't have to change the way I work to accomodate changes in the way they are working.
One final advantage of instant messaging compared to face-to-face conversation is the versatility of the medium. I can trivially share a code fragment with somebody via IM, or a link to an online resource. Try doing that in a face-to-face conversation: "Yeah, you should check out the STL reference docs, at aich tee tee pee colon slash slash double you double you double you dot …".
If you're not already using instant messaging in your development team, give it a try. There are multiple free IM services out there, and there are good free IM clients on every platform, including smart phones, so you've really got nothing to lose — but you might gain a more efficient, productive team. It worked for us.


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In Power Integrations, Inc., v. Fairchild Semiconductor International, Inc., [2015-1329, 2015-1388] (December 12, 2016), a complicated action where each party claimed the other directly and indirectly infringed its patents, the Federal Circuit affirmed the jury's verdict that the asserted claims of the '876 patent were not anticipated; vacated the jury's verdict that Fairchild induced infringement of the asserted claims of the '876 and '851 patents; reversed the jury's verdict that the asserted claims of the '605 patent were not anticipated; and affirmed the district court's construction of the '972 patent.
On this issue of induced infringement, the Federal Circuit noted that induced infringement is defined in 35 U.S.C. § 271(b): "Whoever actively induces infringement of a patent shall be liable as an infringer." Fairchild's proposed jury instruction tracked the then-current Federal Circuit Bar Association model, while Power Integrations' proposal was a variation of an instruction given in a prior trial in the District of Delaware. The district court adopted an instruction that largely tracked the one proposed by Power Integrations:
Each party alleges that the other is liable for infringement by actively inducing others to directly infringe the patents in suit. The direct infringement may either be literal or under the doctrine of equivalents. A party induces patent infringement if it purposefully causes, urges, or encourages another to use a product in a manner that infringes an asserted claim. Inducing infringement cannot occur unintentionally.
A party is liable for active inducement only if the patent owner proves by a preponderance of the evidence that:
the party took some action during the time the patents in suit were in force intending to encourage or assist actions by others;
the party was aware of the patent and knew that the acts, if taken, would constitute infringement of that patent or the party believed there was a high probability that the acts, if taken, would constitute infringement of the patent but deliberately avoided confirming that belief; and
use by others of the party's product infringes one or more of the asserted claims of the patent.
In order to establish active inducement of infringement, it is not sufficient that others directly infringe the claim. Nor is it sufficient that the party accused of infringement was aware of the acts by others that directly infringe. Rather, in order to find inducement, you must find that the party accused of infringement intended others to use its products in at least some ways that would infringe the asserted claims of the patent. However, that infringement need not have been actually caused by the party's actions. All that is required is that the party took steps to encourage or assist that infringement, regardless of whether that encouragement succeeded, or was even received.
Intent to encourage or assist the acts that constitute direct infringement must be proven by evidence of active steps taken to encourage direct infringement, such as providing products, advertising any infringing use, or instructing how to engage in any use that is infringing. Proof of intent to induce infringement may be based on circumstantial evidence, rather than direct evidence.
The Federal Circuit said that this instruction left the jury with the incorrect understanding that a party may be liable for induced infringement even where it does not successfully communicate with and induce a third-party direct infringer. The Federal Circuit said that the Supreme Court in Global-Tech Appliances explained that the term "induce" as it is used in § 271(b) "means '[t]o lean on; to influence; to prevail on; to move by persuasion." Each definition requires successful communication between the alleged inducer and the third-party direct infringer.
The Federal Circuit noted that in Dynacore Holdings it held that "[t]o prevail under a theory of indirect infringement, [plaintiff] must first prove that the defendants' actions led to direct infringement of the [patent-in-suit]." And that in DSU Med. Corp. it held that the plaintiff has the burden of showing that the alleged infringer's actions induced infringing acts. The Federal Circuit concluded that under this precedent, a finding of induced infringement requires actual inducement, although this inducement may be proven via circumstantial evidence.
In other words, liability for inducement requires proof that: (1) a third party directly infringed the asserted claims of the patent; (2) the defendant induced those infringing acts; and (3) defendant knew the acts it induced constituted infringement.
Knowledge of Ex-Employees Working for Accused Infringer Makes Inducement Claim Plausible
Instructions Induced Prescribing Physicians to Infringe