Yes, targets used in professional health care are not constructive. The gain in Hospitals has been negated by their continuance, and managers responsible moving in such short times that they are never accountable. The gain from “performance related pay” in General Practice has halted (QOF – the Quality and Outcomes Framework is a silhouette, a shadow of its former self) , and at the expense of a disillusioned and disengaged workforce. In the Telegraph .NHS targets ‘have had their day’ says health service chief as he claims they encourage ‘gaming’.
The good Lord describes staff in the NHS as “disempowered” and having a mindset of “learned helplessness”. All we disagree with him is that there is no NHS any longer.
NHS staff suffer from “learned helplessness” in a dysfunctional system, the chairman of NHS England has said in an attack on 25 years of flawed health policies.
As accident and emergency units reported their worst waiting times on record, Lord Prior of Brampton gave a scathing assessment of the system over which he presides. He said that such targets had “had their day” and that they contributed to the erosion of the vocational culture of the NHS.
He said that targets, competition and reliance on inspectors had all led to a disjointed system and demoralised staff.
A series of NHS reforms that have broken up the health service into autonomous hospitals “makes driving an integrated strategy across the NHS almost impossible”, he added. “You could not have designed something that had at its heart more dysfunction. It’s truly remarkable.”
Lord Prior, whose role is guiding the health service’s strategy, said that the main aim of a ten-year plan was to overcome organisational divides that had “riven the NHS over the last 25 years”. He said that chaotic organisation and overuse of targets “led to a disempowered culture, a learned helplessness culture, a top-down looking-upwards culture, a very hierarchical culture”.
He told a conference organised by Reform, the think tank: “How we address these cultural issues is fundamental, how we bring back that vocation. I remember talking to many junior doctors who say, ‘At the end of our day when we’re about to go, we’d always walk back to A&E to lend a hand if there was a problem. Now we go home’.
“The number of GPs who want to leave when their pension plan hits their maximum, who historically would have worked for another couple of years; the number of nurses you meet who say, ‘I’m 60, I’m going’, who might have worked for another couple of years in the past. If we just recapture that kind of engaged spirit, that vocational engaged spirit, then I think so many of our other issues would be taken care of.”
Official figures yesterday showed that only 84.4 per cent of A&E patients were dealt with in less than four hours, the worst since records began in 2010.
About 330,000 patients waited longer than four hours last month, beating the previous worst last March. A record 83,519 patients spent more than four hours on trolleys because beds were not available. The NHS Confederation of managers said that the system was “buckling under the strain” of rising patient numbers.
Criticising the “unnuanced” pressure on hospital bosses to hit targets, Lord Prior argued that they led to widespread “gaming” of the system.
A&Es “run around like headless chickens” trying to get people out at three hours and 55 minutes, only to stop caring once the target is missed, he said. “Targets have had their day. Of course they achieved
great things for a short period of time in the mid-2000s, when we had to get waiting times down, but they have had their day.”
Taj Hassan, president of the Royal College of Emergency Medicine, said that hospitals had become “normalised in crisis mode”. “Policymakers and governments that believe targets have ‘had their day’ will need to be held accountable for the impact on patient safety and the added risk of harm or avoidable death if they choose to scrap them,” he said.
GP shortage threatens long term plan. Gareth Iacobucci in the BMJ
Patients and the professions are ready to ration health care strategically, without devolution. It’s the politicians and the managers who won’t hear of it because the strategy might mention rationing.
Chronic staff shortages in key areas such as general practice are jeopardising the NHS’s long term plan to strengthen primary and community care in England, experts warn. New research by the Health Foundation has found “ongoing deterioration” in workforce numbers in primary and community care, nursing, and mental health services, with staff numbers failing to keep pace with demand. Shifting care out of hospitals and closer to people’s homes was identified as a priority in the long term plan, published in January. But Anita Charlesworth, a director at the Health Foundation, said, “If [the NHS] can’t recruit and retain more professionals in primary, mental health, and community care, this will continue to be an unrealised aspiration. There is no sign that the long term downward trend for key staff groups, most notably GPs, will be reversed.” The number of GPs in England fell by 1.6% (450 full time equivalent staff) in the year to September 2018, the report said, despite ministers’ pledge to recruit 5000 extra by 2020. The report also highlighted the continuing decline in numbers of community nurses and health visitors, falling by 1.2% (540 FTE staff) in the year to July 2018. It noted slow progress in
mental health recruitment. Psychiatrists saw the smallest percentage increase (0.6% or 50 FTE) among doctors, and numbers of mental health nurses rose by less than 0.5% (170 FTE) in the same period. The importance of international recruitment was being hampered by broader migration policies and Brexit uncertainties, the report said. Although the number of doctors from other EU countries had risen by 5.5% since 2016, recruitment of EU qualified nurses and midwives had fallen respectively by 8.5% and 3.1%. Charlesworth said, “So much now hinges on the workforce implementation plan. But to bring an end to chronic workforce shortages for good, action must address the underlying major fault lines in the current approach, particularly the lack of alignment between staffing and funding.” A Department of Health spokeswoman said some of the report’s figures were out of date. Latest statistics, from October 2018, showed 2564 more health visitors, 473 more mental health nurses, and 233 more psychiatrists than a year ago, she said, adding, “Last year a record number of doctors were recruited into GP training.”
The irony of the lack of doctors, and insufficient access to Primary Care is that it is government who is responsible, and it is successive governments who have ignored the advice of the profession. The Inverse Care Law as defined by Julian Tudor Hart, used to apply to citizens in poorer and deprived areas who got less resources when they needed most. Now it is government who are responsible for the inverse care law as applied to health. As private practice becomes more evident, it will be most available in those areas where people can afford it, and the people living in deprived areas will have to put up with a second class service. Doctors, knowing they are rare commodities, can choose where to live, and will mostly choose where infrastructure and education and housing are best. Most of them come from suburban and inner city schools and these doctors when qualified would rather work part time in their home city than full time in a challenging area.
Daniel Weaver, a GP in Milford Haven, has sent this out on facebook, and has been interviewed for the Milford Mercury. Dr Weaver is an experienced and altruistic GP. His cry for help comes too late in many ways. NHSreality has been highlighting the demise of the “Goose that laid the Golden Eggs” of efficiency and avoidance of overtreatment for 6 years. NHS reality has also pointed out the problems with GP recruitment on many occasions, and asked for more graduate entrants to medicine. NHSreality has also reported on the rejection of 9 out of every 11 applicants when they were all recommended to apply because they were good enough. Rationing of places to medical schools, uninformed manpower planning, and an over dependence on females as doctors (because they are better at undergraduate entry) have all conspired to get us to arrive at this point. The short termism of the First past the post electoral system means there is no incentive to plan capacity over 20 years. Obviously we need to address recruitment, but the shape of the job also has to change. Golden Hellos are not enough… The heartfelt letter below is a cry for help on one level, and a daming indictment of government at another. NHSreality only disagrees in that there is no “N”HS any longer. Here is Dr Weavers Post: “If anyone is in the Milford Haven area feel free to share this post”:
I wouldn’t normally do this but I feel compelled to put a message out in response to the increasing levels of aggression and abuse towards staff over recent months. Hopefully this will work as something of a FAQ about recent issues relating to the surgery. This may be a long post, stick with it though and hopefully it will give some clarity.
Currently Robert Street is effectively short of 2 doctors (which is 40% of our manpower) & this is less then ideal. This is in part because of maternity leave, and in part because despite spending thousands of pounds on advertising we haven’t had any success in recruiting since a doctor left a couple of years ago. Why haven’t you had success? Multiple factors including a national shortage of GPs in UK and especially in Wales. Wales is seen as less appealing to work in compared with rest of UK and Canada, Australia as earnings tend to be lower and due to harsher social service cuts problems with social care, social problems end up reaching general practice, and longer out patient waiting lists mean that people are seeing GPs more frequently so there is a harder workload. We are further west than most people want to work, and our practice area is one of relative deprivation, so any GP applying knows they will be busier then those working in more affluent areas.
I came to back to work in Milford because I enjoyed working in the town during my time training in Barlow house surgery and I have a family connection to the town, but unless someone has a connection to the area it’s not easy to get people to relocate from other areas. Many international Doctors in the NHS have families overseas and want to settle in a location with good access to airports etc. or to live in larger cities with people of similar faith or culture. We have up to 3 weeks less annual leave then several other local practices which has been cited as a factor when I’ve chatted to doctors who’ve moved elsewhere, especially doctors with children. We have specifically resisted increasing amount of annual leave we allow ourselves because it would pressurise appointments further.
There are higher paid practices in the region. (practice income is complex depends on multiple factors, like if practice is a dispensing practice or has branch surgeries etc) I have medical friends with whom I have discussed about working in Pembrokeshire. Feedback from them often revolves around issues like the above but more locally uncertainty about local hospital services making doctors nervous about possible knock in increased general practice workload in the region.
The loss of maternity services in the county and loss of 24 hour paediatrics is deterring younger doctors who either have children or are planning to have children. Also the state of the secondary schools in Pembrokeshire at the moment puts some off. Locum rates being paid within our health board and elsewhere mean that potentially a GP could earn more money in a week of locum work then if they were in a stable salaried or partnership role for a month. Locum doctors don’t have to follow up patients or results and usually will cap themselves to a limited number of consultations eg 12 in morning or afternoon and 1 home visit. Existing locums have low incentive to get permanent jobs with a practice. There is ironically also a shortage of locum doctors. We are continuously looking for locums, and getting them when we have a chance. We cannot compete with health board for locums as their rates far exceed what a normal general practice can pay.
Another factor is we are not a training practice, I will come back to this later. Would it be financially beneficial and better for work life balance for doctors to leave and do locum work? Yes in short, but if another doctor left it would cause the practice to collapse entirely and we feel a duty to each other, staff and the local area. This is the danger about locum work being so lucrative in the current climate, it actually risks destabilising things further. Why aren’t we a training practice? We’ve been desperate to get training status since I joined the practice, it’s something I’ve always wanted to do, I’m passionate about training and this is something I’ve always been involved in in different forms from my time in medical school. Aside from wanting to train there is also evidence that the surgeries that cannot recruit and have to close are much more likely to be non training practice. Why is that? GP training practices have a registrar or registrars who effectively work as a doctors while completing their GP training, this increases number of doctors available to see patients in training practices. It also allows doctors to test working in a practice. Many trainees will end up in taking a job in a practice they trained at if they had a good experience. The good news is that we have had the first indication that can start the process of becoming a training practice which gives possibility of progress in the next year towards this goal.
Why is it so hard to get routine appointments? Unfortunately at the moment we are often down to 2 doctors a day, as we are frequently seeing 40-60 emergency appointments daily there is limited capacity for routine appointments. This is entirely manpower related. We are working harder then ever. We have effectively close to 3000 patients per full time equivalent GP currently. To put this into perspective a Nuffield Health study in 2011 showed national averages for Scotland was 1400 per GP, England was 1500 and Wales a little over 1600. We are short staffed at the busiest time of the year without locums. If there are 3 doctors in, the routine slots are put on in addition to emergency but these obviously go quickly especially if people are trying to see a particular doctor.
Why don’t you see more patients? During the average day which is usually 10+hours, often the only break is to go out and get food to eat at desk while going through results or letters or for toilet. Although I was not on call today I didn’t get a chance to have lunch so when I got home at 6:45 I ate for the first time since breakfast. This isn’t unusual. I am on call on average 3 or 4x per week either in the AM & PM during an on call there is a continuous stream of messages, script requests queries etc. In addition to usual duties emergency surgeries and home visits and things are often very frenetic and pressurised. Apart from seeing patients in the surgery GPs have do go through letters from hospital, amending medication and arranging tests and referrals. We will often have many letters daily, for example I went through a little over 70 letters this morning. GPs have to write letters for referral or to other agencies, appeals, DWP forms, forms relating to end of life, death certificates, cremation forms. GPs have to also go through Emails from NHS/health board/and check safety updates on medications which get posted through. Review results, bloods results get reviewed and often require further action, same with scans, we will often get results for around 30 patients each daily to go through more if someone is away and we are covering them.
Home visits: these are the least time efficient part of the day. Often if spread out a GP can spend over an hour driving between houses and nursing homes which takes time away from doing other jobs. Phone calls: I can have up to an hour of phone call requests or more in a day. Prescriptions and sick notes. In a typical week each GP is signing several hundred repeat medication prescriptions, along with sick notes. OK, I get that you are busy, what else have you tried? We have tried employing a physiotherapist to see patients presenting with muscular/joint problems to take pressure of the on call, allowing GPs to see other patients. Did it work? No most patients refused to see a physiotherapist and they insisted on seeing a GP.
GP Triage: this is a service which exists due to pressurised situations. A lot of issues can be managed over the phone and potentially saves an unnecessary appointment being used on the on call which can be used for someone else. The GP can access the notes and takes a history/arranges investigations or a face to face appointment if required. We pay for this out of practice budgets. It’s not ideal but it is better then nothing and there is no alternative option at this moment in time.
What about health board? in June we applied with Barlow House and Neyland surgeries for some existing Welsh assembly sustainability money to go towards employing a paramedic practitioner who could take some pressure off the home visits situation. Nothing has been forthcoming. We, on a temporary basis, have attempted to close our practice list although the health board have resisted this. This is given current intense pressure a logical step to try to preserve our resources and time for existing patients as we are aware of the access issues. They are not offering help. What else are you doing? We have been training a practice nurse to become a nurse practitioner, meaning she will be able to see some of the simpler emergency appointments.
Why can’t I get through on the phones? It’s not ideal but we have a finite number of reception staff. At peak times we have up 100 people trying to get through and without a call centre there are likely to be delays. Being on hold is common for doctors too and I often have to wait 20 minutes+ when contacting the hospital to refer a patient in for other reasons.
The NHS in general is struggling to deal with the amount of people who use the service, it’s far from ideal but there is no obvious solution, and no additional funding to help with this. Why do routines only come out on a Thursday? If everyone who wanted a routine appointment phoned up every day it is going to increase phone traffic and difficulties getting through, in other words it would make the problem worse. It’s the same reason why people are encouraged to put in repeat medication requests through via their pharmacy or by dropping a slip in. There is the option of signing up to request repeats online which is super useful, but not many people do this. Thursday is traditionally the quietest day of the week so that time in the PM is least worst time of the week. Why don’t you just abandon all routine appointments and just do book on the day system? This gets discussed periodically but when it has been trialled before people complain about it. Why do reception staff ask me about my symptoms if I want an emergency appointment? They are not being nosy, sometimes people phone to get an appointment with a GP when actually it would be unwise & they should call 999 or go to A&E, for example if having a stroke or suspected fracture. Sometimes the issue is something that can be better dealt with by a pharmacist, a dentist or is completely non medical. Additionally if I am doing an on call, I need to be aware who the likely most ill people are, eg if someone is doubled over in agony with a possible appendicitis or acutely suicidal, I will need to see them before I see someone with mild earache or trapped wind. Will shouting at staff or being abusive help? No, please try and be patient and don’t take frustration out on staff. Everyone is working hard and it’s not an easy time for anyone. Taking it out on staff increases the likelihood of people walking away which makes the problem worse. I still want to complain! Feel free although hopefully this will help put your concerns into perspective. We are very stretched and this entirely relates to staffing issues beyond our control along with a difficult local healthcare environment. I am a doctor, I am not a politician and I have no influence on the larger, complex problems facing our county or country. There are multiple practices in difficulty in the county and elsewhere in Wales, and increasing numbers of doctors handing practices back to health boards due to being unsustainable and impossibly challenging working environments. In summary we are working hard and have been trying things. Why aren’t Barlow House having the same issues? It is harder to get an appointment with us then Barlow House Surgery but this is resource linked. They are fully staffed with permanent GPs and usually have between 2-3 GP trainees giving them roughly double our capacity, despite this they are still busy and working hard as well, as demand continues to rise in part because of problems in social care and secondary care being moved onto general practice. We get continuous complaints about difficulty getting appointments and problems with the phones but hopefully this gives extra insight into reality on the ground. Positive aspects for future are: more trainees coming from local scheme in next few years increases chances of us recruiting in a year or two. Dr Skitt won’t be on maternity leave for ever. We may be able to have trainees in the next 12 months which will help. We and another practice in Pembrokeshire will hopefully soon have a CPN attached to the surgery who may be able to help out with mental health related issues. This is a Welsh assembly funded pilot and hopefully will be positive. Age wise there are no doctors coming up to retirement soon unlike some other practices around the region. My colleagues are grafters and work as hard as any clinicians I’ve ever worked with in my entire career. If we do recruit and become a training practice Milford Haven is will be in an advantageous position compared with most of the rest of Wales with full compliment of relatively young doctors. I appreciate in the short term this isn’t much consolidation but at moment priority is survival. I apologise in advance but I’m not planning to respond to comments on this post as I made a decision some months ago to try and avoid social media and to try to prioritise spending any free time I have with family and friends rather then online. This was a decision ironically I took because of how late I tend to get home from work and the impact my job has on the people around me. Feel free to share this though.
I had some unsolicited mail this week. The company was advertising a Peoples Postcode Lottery. You can easily find their website saying how many good causes they support: many medically related. Why in a comprehensive and free health service are such charities needed at all? The flyer does not say what overhead is taken out for admin, and the distribution as a percentage, and the rules are unclear. Just like the 4 health services. It is covert. And they make profit as well… also not stated in the flyer. On Sky TV I watched the Test Match and between each over there was an advert for at least one and sometimes two gambling outlets. The “profit” for the health services is missing. The overhead is mainly on staff. Capital investment is missing.
There have been a number of “news” items in the last few days/weeks which are as depressing as Brexit. The denial and obfuscation on the 4 UK Health Services is similar to that on our relationship with the EU. There are “hard truths” to be discussed but the informal collusion between he media and the politicians means that no honest debate is possible – until it gets much worse. Infections that used to be rare are now commonplace. Access and recruitment are becoming so difficult that private GP practice will start to spread. The cost of care in homes (Usually residential, but Nursing and EMI as well) is escalating as the owners are unable to make ends meet. Staff are mainly from overseas, so restraints on immigration will hurt and escalate costs further.
Surely we all have a right to know what will not be covered, and this void should be national and fair?
Lynn Davidson in the Sun 23rd Jan 2019 reports: Children in Care face post code lottery with some areas spending 10 times as much as others – A ten fold increase in children in care!
Tom Martin in the Express 30th Jan 2019 (Scotland) calls for “An end to the post code lottery of Hospital Cleaning” – Getting at the number of infections in state run DGHs (District General Hospitals)
Stephen Matthews for the Mailonline 8th Feb 2019 reports: The Post code lottery of seeing your GP. Shocking map reveals the 10 areas of England where most patients are waiting over two weeks for an appointment.
Because there are multiple health service hospitals disintegrating, there is no one big scandal such as Chernobyl. The failures will affect individuals and families in the form of delays, Iatrogenesis, and early deaths.
Ministers have been raiding the buildings budget to cover NHS day‑to‑day spending, putting patients at risk
problems such as burst pipes and failing heating systems.
The “alarming” scale of a crisis that means many hospitals are “falling apart” can be disclosed today after an investigation by this newspaper.
The total sum needed to eradicate the NHS maintenance backlog of “high-risk” and “significant-risk” problems jumped to £3.06bn in 2017-18, according to our analysis of official figures. This represents an increase of 102% in three years.
In the same period the Department of Health and Social Care took £3.8bn from NHS capital budgets to “plug holes in day-to-day spending” across the service.
Doctors, patient groups and MPs this weekend expressed concern and called on the government to invest urgently in the NHS’s infrastructure.
Britain’s most senior doctor, Dr Chaand Nagpaul, chairman of the British Medical Association, said: “Many of our hospitals are crumbling. These figures illustrate this very clearly.”
He added: “Doctors are painfully aware of the significant impact this can have on patient care and safety, as well as staff morale. The fact that ministers have repeatedly raided capital budgets — meant for building repairs and renewal — to plug holes in day-to-day spending is clear evidence of the damaging effect that years of underfunding and short-term thinking have caused.”
John Kell, head of policy at the Patients Association, described the maintenance backlog as “alarming”.
Jonathan Ashworth, the shadow health and social care secretary, added: “Years of austerity and cuts have left hospitals crumbling and reliant on outdated equipment. It’s shocking that the high and significant-risk maintenance bill facing hospitals has now soared to £3bn after years of ministerial neglect.”
The NHS definition of its high-risk repairs are those that “must be addressed with urgent priority in order to prevent catastrophic failure, major disruption to clinical services or deficiencies in safety liable to cause serious injury and/or prosecution”.
Significant-risk repairs are issues that “require priority management” and “risk healthcare delivery or safety”.
Three west London hospitals — Charing Cross in Hammersmith, St Mary’s in Paddington and Hammersmith Hospital — are most urgently in need of repair, with a total bill for high-risk and significant-risk repairs of about £650m.
In September last year problems with the lifts at St Mary’s affected its maternity services, forcing women hoping to give birth at the hospital — where the Duchess of Cambridge had her three children — to make alternative arrangements.
The Imperial College Healthcare NHS Trust, which runs the three hospitals, said: “Our staff are still managing to provide very advanced care in buildings that are simply not fit for purpose.”
Siva Anandaciva, chief analyst at the King’s Fund, the health system think tank, said: “For too long now, capital funding which should have been spent on NHS buildings and equipment has been raided to pay for the day-to-day running costs of services.
“This means patients are increasingly being put at risk as doctors and nurses are forced to cope with faulty or unreliable equipment in buildings that in some cases are falling apart around them.”
The health department said it would give the NHS £3.9bn in new capital funding by 2022-23: “We expect trusts to use their existing capital budgets and assets effectively to prioritise safety and ensure the best possible care for patients.”
The health service could face a shortage of senior doctors as new research found that a large proportion of consultants were planning to leave the NHS before they reached retirement age.
A survey by the British Medical Association (BMA) found that around 6 out of 10 consultants intended to retire at or before the age of 60, with more than two-thirds citing difficulties balancing life with work as their reason.
The BMA warned that the situation for the NHS was “untenable” and would jeopardise the Government’s recently announced 10 year plan for future health provision.
Dr Rob Harwood, BMA consultants committee chair, said: “During a deepening workforce crisis, the NHS needs its most experienced and expert doctors now more than ever.
“I struggle to understand how the Health Secretary can talk about increasing productivity in hospital care, while allowing the NHS to be a system which perversely encourages its most experienced doctors to do less work and, in some cases, to leave when they do not want to.”
The research, based on 4089 responses from hospital consultants in November and December 2018, echoed a recent survey by Medscape UK which found that 32% of doctors polled reported feeling burned out at some stage of their career, while 14% said they were depressed.
…Life, Work, and Pensions Concerns
Among consultants considering early retirement, the BMA survey found that 69.7% had problems with work/life balance….
The results also showed that:
- Only 6.5% of consultants expected to remain working after the age of 65
- Over a third of all respondents expected to reduce their work commitments by up to 50%.
- Almost 18% were in the process of planning to reduce their working time even further, including a complete withdrawal from service….
…Last December’s survey of 968 doctors by Medscape UK found that among those who reported burnout, 52% said they were considering early retirement as a solution, while 37% said they would leave medicine to pursue a different
In the past NHSreality has called for new legislation around assisted dying. Canada and Holland have both led the way in this aspect of individual liberty. The numbers in those countries are not enormous, and they have peaked. The number of people using the “Dignitas” service in other countries (Switzerland) is increasing and is now approximately one per week. The law as it stands is divisive, and gives a choice to those with enough wealth and family support to receive a service which is not available to everyone else. The medical profession is divided on this issue, but that does not mean that those who shout loudest. The current law is divisive, but then, any change will take years to change attituded universally, so it may be equally divisive at first. It should not be left to local post code or regional (Wales, Scotland, N Ireland) commissioners, but a national solution.
“The law as it stands mandates excruciating suffering and potentially criminalises compassionate acts. It is natural that those who face such suffering will crave the ability to determine the manner and timing of the end of their lives. Public policy needs to catch up with that humanitarian need.”