NHSreality feels that the culture in Westminster reflects the culture in the nationalised industries as a whole, and the health service being the biggest. It is also the biggest bully, with most fearful staff, and who feel most gagged… Starting again using local pride may help, but some areas may fail to recruit… Perhaps these should be the first to be released from the shackles of Political Interference. Co-payments should be allowed.
We cannot address the culture of fear without better management and it cannot come from inside. Even if the skills were there, which they are not, the staff would not trust them. We need an outside provided HR company to do “Exit interviews” on all staff and board members, and to report dispassionately and in a depersonalised way, at regular intervals. Somehow this needs to be amalgamated into an annual public report for localities, and regionally, and nationally. We need to hear the views of all staff who leave a job, move departments, or retire, or emigrate.
But then, you and I know what the result will be….
So at the same time, because we know the outcome, we need to be planning the changes necessary to reverse the decline. I admit that I cannot see the way forward, especially when the official line is “everything for everyone for ever” and no overt rationing applies. We are creating a dependency culture. We are discouraging autonomy. In work with the GIG economy we are creating a slave culture. I see several “Spartacus” like revolts ahead, and the destruction of the whole state health and social care empire unless we have much more honesty and much better leadership.
If we apply zero budgeting and allow local trusts to run themselves without any government interference, restraints, or banal performance indicators, we will get large differentials in health care, but morale will rise. Staff can feel involved and “begin to enjoy themselves”. After a time best practices will emerge, and convergence of standards, but this will take a decade(s). Meanwhile we need to lift the restriction on medical school and nursing training places, so that we have an excess of staff, even allowing for the dropout rate. We need to acknowledge that no state cannot keep up with the advances in medical science, (see The NHS is being impeded by greedy drug companies ) and therefore we need to ration health care. Cradle to grave, without reference to means,……? The drug companies are out to make a profit, and it is not drugs which improve the health of populations. (See the USA) They do improve the outcome for individuals, but that is different.
How we do this is the big debate which has not even started. NHSreality suggests means related co-payments, both for health and social care. Then there is the litigation…. without no fault compensation, the combination of reduced resources, short termism and declining standards (see baby death rate) will ensure more and more opportunities for citizens to litigate. Reducing tax relief on pension contributions is another tempting short term fix…
BMA 20th September : Survey of UK doctors highlights blame culture within the NHS
BMJ October 12th: Creating joy in work is the only way to save the NHS
Once we accept that we have to ration health care, we can start discussing how. Prevention can be expensive, and so can a lifestyle. NHSreality feels that means related co-payments would address this issue well, and even the poorest should pay something for prevention. Commissioners are not allowed to do this, anywhere in the 4 UK health systems, and the official line is that there is no rationing , and indeed we can provide “Everything for everyone for ever for free”.
A charity has called for more gay and bisexual men to be given access to the HIV prevention drug PrEP, a year on from the start of a major trial into the treatment.
The National Aids Trust (NAT) said many men were being turned away from clinics, and some would contract HIV as a result.
Last year, a study funded by NHS England found that a quarter of new HIV cases in England could be prevented by giving high-risk men pre-exposure prophylaxis (PrEP) treatment.
The programme could save the NHS millions as a result of fewer men
getting infected and needing a lifelong supply of drugs to stop them
succumbing to Aids, researchers said.
The first clinic in the PrEP Impact trial opened on October 13 last year.
The three-year trial aims to provide PrEP to 10,000 people, but the NAT said all the allocated places for gay and bisexual men were filled by March.
Since then reallocation of places and a boost of a further 3,000 places on the trial has allowed clinics to reopen, but this provides only temporary relief, and it is expected that most clinic places will be filled up by early next year.
NAT chief executive Deborah Gold said: “PrEP is 100% effective at preventing HIV when taken as prescribed.
“NHS England’s decision-making process concluded that PrEP should be commissioned and just last month the cost of the drug has substantially reduced as a result of court judgments on the patent.
“It is therefore completely unacceptable for people in need of PrEP to be denied it by the NHS.
“NHS England and local authorities must urgently agree a national PrEP programme to start as soon as possible in 2019.
“The Government should play its part by increasing funding to public health so that we maximise the sexual health benefits of the PrEP programme.”
NHS England initially refused to pay for PrEP, arguing that responsibility for HIV prevention lay with local authorities.
It agreed to fund the study at selected clinics after a High Court judge upheld a judicial review application challenging the legality of the original decision.
The treatment involves a pill containing a combination of two anti-HIV drugs, emtricitabine and tenofovir, taken daily or around the time of sexual activity.
A spokeswoman for NHS England said: “While it would be wrong to prejudge the PrEP Impact trial, it is already expanding with the number of places available increasing this year by 3,000 to 13,000.
“The NHS will look at evidence from the trial to expand prevention services in the most effective way.”
Just as we need to change the onus of proof on Agricultural products, we need to do the same with non drug medical products. The licensing of the mesh repair products is a case in point, and all 4 health systems should be ashamed of not reporting side effects and complications systemically (all together). The reporting of such problems is just one reason for a large mutual in health. Devolution means smaller numbers and lower standards. The commissioners and the Trust Boards are all to blame, but so is central government. Will any careers be finished? They should be.. Mesh is a foreign body, and as such the default is rejection, and possible infection.
Up to 170 000 patients who have had hernia mesh operations in the past six years could be experiencing complications, yet NHS trusts in England have no consistent policy for treatment or follow-up with patients, an investigation by the BBC’s Victoria Derbyshire programme has found.
Around 570 0000 hernia mesh operations have taken place in England over the past six years, figures from NHS Digital show. Leading surgeons think that the complication rate is between 12% and 30%, meaning that between 68 000 and 170 000 patients could have been adversely affected in this period.
Patients who had had hernia mesh operations told the programme about being in constant pain, unable to sleep, and finding it difficult to walk or even pick up a sock. Some patients said that they felt suicidal.
The Department of Health and Social Care and the Medicines and Healthcare Products Regulatory Agency (MHRA) continue to back the use of mesh for hernia repair. The use of surgical mesh for stress urinary incontinence is under ongoing review after it was suspended in July in response to pressure from campaigners and MPs.1 Campaigners are calling for a similar review into the use of hernia mesh.
Owen Smith, a Labour MP who chairs the all party parliamentary group on surgical mesh implants, said that he feared the UK could “potentially have another scandal on our hands.”
He added that the MHRA was not doing enough to listen to the experiences of patients affected. “It reflects the flawed system we have in place,” he said. “Neither the regulators nor the manufacturers have to follow-up on problems.”
Ulrike Muschaweck, a private hernia surgeon, told the programme that she used a suture technique instead of mesh for most hernia operations, but this method was dying out because young surgeons were rarely taught it. She said that she had performed 3000 mesh removals because of chronic pain—after which only two of the patients had not gone on to become “pain-free.”
Suzy Elneil, a consultant urogynaecologist who was a leading voice in the campaign to halt the use of vaginal mesh, said that the mesh used in hernia was the same product. She estimated that treating those who have had complications with hernia mesh would cost a minimum of £25 000 (€28 000; $33 000) a patient—a similar amount to that predicted for vaginal mesh complications. This includes the removal of the mesh, a further operation to treat the hernia, and follow-up care. She said that the manufacturers should be covering the cost rather than the NHS.
The Royal College of Surgeons pointed to a 2018 study, which found that both mesh and non-mesh hernia repairs were effective for patients and were not associated with different rates of chronic pain.2
A spokesperson for the college said that “complications range dramatically from minor and correctable irritations to the more serious complications highlighted [on the] programme. Complications can also occur with non-mesh hernia repairs and by not operating on a hernia at all.”
They said that the college and regulatory authorities would continue to listen to patients’ experiences. “It remains vital that surgeons continue to make patients aware of all the possible side effects associated with performing a hernia repair,” the spokesperson said.
Kath Sansom from campaign group Sling the Mesh told the programme that a lot of the studies into complications were flawed or had short follow-up times. Quality of life questionnaires, for example, asked only about whether the hernia was fixed and not about new onset pain or other complications.
In a statement, the MHRA said: “We have not had any evidence that would lead us to alter our stance on surgical mesh for hernia repairs or other surgical procedures for which they are used. The decision to use mesh should be made between patient and clinician, recognising the benefits and risks in the context of the conditions being treated and in line with NICE guidance.”
An MHRA spokesperson added, “We encourage anyone—patient, carer, or healthcare professional—who is aware of a complication after a medical device is implanted, to report to us via the yellow card scheme, regardless of how long ago the implant was inserted.”
Most GPS will be too busy to read or reply to Mr Darzi. As a retired GP I feel I have to reply. The letters from the Times’ replies are in the pdf below.
It seems a little ironic for a surgeon, who deals with operations and definitive outcomes, to comment on General Practice. The good GP uses time as a diagnostic tool, lives with uncertainty and handles patients with multiple symptoms and often multiple diagnoses.
Failure to train enough doctors is one problem. Training a disproportionate number of females to males is another. Making the job more and more desk bound and administrative is another. The shape of the job has changed a lot, but given time, appropriate training, and backup of a good team it would still attract. GPs need broader training especially so that all of them have the same opportunities in Paediatrics and Psychiatry, and Old age medicine and rehabilitation.
Doctors are trained to think laterally and make a diagnosis. The training takes a long time but why has only 2 out of 11 applicants been successful over the last two decades? Rationing places at medical school has now killed the goose that laid the golden eggs of efficiency. Nurses will probably refer more, request more tests, follow up more, and may well make more mistakes. The litigation will follow…
And will this mean that unpopular areas retain GPs, whilst unpopular ones have Nurse Practitioners? A health divide if ever there was one, and an encouragement for private practice.
Primary care and public health are becoming even more important as the population ages, diseases change and the need for long-term community care grows. Yet at the same time, this work is becoming increasingly unpopular with doctors.
To add to the problems of retaining GPs, a survey of general practice trainees carried out this summer by the King’s Fund, a health think tank, found that only a fifth planned to be working full-time a year after qualifying. The proportion planning to be working full-time after ten years was the same.
This is an astonishing vote of no confidence. Like many of their generation, young GPs want a portfolio career. They want to be involved in research and education; the prospect of owning and running the same practice for the next 30 years is a million miles from what most hope to do with their lives. They are not alone. Surveys show a similar trend across the world, with fewer than 10 per cent of physicians choosing family medicine in some countries.
Here, then, is an opportunity for nurses. Advanced practice nurses, also called nurse practitioners, are as effective as doctors at many tasks and, according to one study, could take on 70 per cent of GPs’ workload. Their main areas of expertise are in the management of long-term chronic conditions such as diabetes; they can diagnose, treat, prescribe and refer patients to hospital, and admit them if necessary. There are limits to their responsibilities (they don’t treat children under five or expectant mothers and they can’t sign sick notes) but they are acceptable to the public, take less time to train and cost less than GPs.
A report by a group of international experts, to be presented at the World Innovation Summit for Health in Doha next month, which I chair, will argue that nurses are poised to become the dominant force in primary care. They tend to live in the communities they serve, understand the local customs and culture and are well placed to detect early signs of disease and help tackle the wider social determinants of health.
There is a growing recognition that nurses are well suited to provide the sort of patient-centred care that is needed to look after the rising numbers of people with chronic diseases such as cancer, heart failure, diabetes and dementia.
There are barriers. Improved education, recruitment and commitment from employers will be required. But if we are to solve the crisis in primary care, we must urgently look to positioning nurses as the new gatekeepers of the NHS.
Professor Lord Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London
If there were an excess of GPs trained, then even allowing for emigration and part time working, there could be competition to work in practices. Long term rationing of medical school places is responsible.
A scheme to bolster the number of GPs in the North of England has recruited just two doctors so far, a meeting has heard.
Recruitment firm ID Medical has been signed up to help find 100 doctors to plug the gap – with 60 doctors lined up for Teesside and Darlington by 2020.
But so far just two GPs have been recruited over an area covering Greater Manchester, Cheshire and Merseyside as well as the North-east and the Tees Valley.
Health leaders shared their thoughts on the figure at Tuesday’s (October 9) meeting of two Tees Valley Clinical Commissioning Groups (CCGs).
The GP recruitment drive began in May and Sue Greaves, head of strategy at Hartlepool and Stockton (HAST) CCG, told panel members two GP candidates had got through to their “second stage” interviews last month.
Meanwhile, three others were “awaiting results” of English language exams.
But there were questions about whether doctors from overseas would even want to settle in the Tees Valley.
Ms Greaves added: “Will people naturally want to migrate to Newcastle?
“First of all, will they want to come to the North-east? Would it be Manchester or London?
“We don’t know the answer to that – but not everyone wants to be in a big city and there will be people who want to come to the North-east.”
Surgeries in the Tees Valley are short of doctors – a trend which is mirrored on a national scale.
Papers for the latest Tees Valley joint health scrutiny committee showed there were three GP vacancies in Darlington, three in Stockton, two in Hartlepool and 11 in South Tees.
Meanwhile, 10 Darlington GPs and 27 full time GPs in Hartlepool and Stockton are older than 55 and eligible to retire.
Candidates from overseas have mainly come from Bulgaria, Romania, Portugal and Spain so far.
But panel member Hannah Herron said the numbers “seemed quite low”.
“At first look we would be quite disappointed with the numbers – it’s just understanding what the projected numbers are,” she added.
Karen Hawkins, from HAST CCG, said the health bodies wouldn’t be able to attract doctors on their own.
“We need our partners to help and there is a push at local authorities,” she added.
And Ms Greaves told the committee the recruitment company’s prospectus was very “north-centric” with little mention of Darlington or Teesside.
Jean Golightly, head of nursing at HAST, said “getting home quickly” was important during her time as a medical professional overseas.
“We do have Durham Tees Valley Airport – I know Newcastle has an airport but we have one on our doorstep with a link to Schiphol,” she added.
“We are not Stansted but it’s very easy to get to a lot of places.”
South Tees CCG is trying to arrest the fall in numbers by using grant money to encourage older doctors to stay on for a little longer.
It has also launched a “local career start scheme” to encourage young GPs to come to Teesside.
When it came to overseas recruitment to the Tees Valley, committee chairwoman Hilary Thompson wanted to know how long it would take to get international GPs in place.
Average number of patients per GP
Darlington – 1,865 per GP
Hartlepool and Stockton – 1,741 per GP
South Tees – 1,569 per GP
North East average – 1,414 per GP
Ms Greaves replied: “Lincoln did this and it took them 18 months to get two GPs into practice from start to finish.
“But it does depend on the GP and the language barrier is often the bigger issue.”
The one thing a Doctor does, which others don’t do, and for which he is indemnified for mistakes, is to make a diagnosis. The first consultation is the important one, and afterwards, follow up can be done by many others. Physiotherapists, psychologists (or cheaper and less trained nurse counsellors) , Parkinson’s or Macmillan nurses etc. The achievement of a diagnosis involves examination, usually physical, but often psychological as well. Many patients present with “vague” or multiple symptoms, and some poor practices have demanded only one symptom per consultation!
The follow up rate of GPs differs according to their ability and willingness to live with uncertainty. Achieving a full diagnosis in physical, psychological and spiritual dimensions may take more than one 10 minute consultation, but this is unusual in todays accelerated world. All GPs need to know their follow up rate compared to their peers, but remember it needs to be adjusted for age and complexity of patients, and older GPs see older patients. Not many practices know their follow up rates, and very few GPs know theirs.
One technique to reduce uncertainty is to refer everyone. Nobody complains, but they do wait! Consultants used to know the GP, and after reading their letter, would often prioritise the referrals from those who sent patients infrequently. This unofficial form of rationing was reasonable. What happens today? Are letters sometimes handled by administrators and then treated equally?
Wriggleing on the hook of rationing health care in different ways, means that we will see many experiments until the numbers of diagnosticians increases. if a GP is needed for a 2 hour group surgery he could have seen 12 new 10 minute appointments in that time, along with the opportunity to examine and personalise the consultation. The old definition of a GP giving “personalised continuous care to patients and their families” has been abandoned in the modern world, but this does not mean we should not aspire to it. But if a GP practice follows up so many patients that they personally need to see groups, then that is not good use of resources. Others can do the follow ups. Leave doctors to diagnosis…
I found several current definitions (I have excluded those that focus on the negative (a doctor who did not specialise) and none of them mention the ability to live with uncertainty or to use time as a diagnostic tool. The GP was the goose that laid the golden eggs of efficiency in the original health service. No longer, and the fox is at the door..
a medical doctor who attends to the everyday medical needs of individuals within a community.
a doctor based in the community who treats patients with minor or chronic illnesses and refers those with serious conditions to a hospital.
A physician whose practice is not oriented to a specific medical specialty but instead covers a variety of medical problems in patients of all ages. Also called family doctor.
A fully registered medical practitioner in the UK who provides general medical services to a particular group of patients or “list”, either in partnership with other GPs, as a salaried GP in a group or, less commonly, as a single practitioner. GPs may also provide inpatient care in community hospitals. A GP will refer patients “forward” to a consultant (hospital specialist) when the patients’ needs cannot be addressed locally. GPs in the UK are not NHS employees, but rather contract independently with the NHS.
Both the Telegraph and the Mail last weekend reported on the shortage of GPs, and that they were looking at solutions whereby GPs see patients together. Obvious confidentiality issues – but also a group support ethos…. GPs to see groups
Group consultations of up to 15 patients are likely to be made “the default” for the NHS in its ten-year plan to tackle waiting times, it was claimed last night.
The scheme has been promoted as a strategy to ease the strain on family doctors and cope with growing shortages of GPs, and been piloted in areas including London, Birmingham, Manchester and Sheffield.
Doctors involved in the pilots said that they had reduced the time spent repeating advice and that patients were given as much as 90 minutes to discuss their condition with fellow sufferers. The longer sessions could also help doctors to develop closer relationships with patients and their families. They said that the consultations had proved more efficient at tackling health complaints including obesity, diabetes, arthritis and erectile dysfunction.
NHS England describes group consultations as medical appointments provided by a clinician in a peer-group setting that “potentially doubles productivity and access to routine care”. The clinician may be a receptionist, clerk or healthcare assistant with one day’s training who would be able to direct the group towards advice on their condition. Patients are asked to sign confidentiality forms to ensure that what is discussed remains within the room. In some sessions test results are posted on a board and a consultant, GP or nurse leads brief discussions with each patient.
However, Joyce Robins, from Patient Concern, said: “This is a ghastly idea. GP appointments are supposed to be a private matter where you can openly talk about your most personal health issues. If you’re discussing things in front of a group of strangers, you might as well tell the local town crier.” Rachel Power, of the Patients Association, said that the sessions would be helpful in some cases but added: “We are concerned that these group consultations are said to replace traditional appointments, apparently without exception.”
Letter in the Times 9th October:
SHARED GP VISITS
Sir, I thought my eyes were deceiving me when I read your article “GP surgeries to see 15 patients at a time” (Oct 8). I was also surprised by the Patients Association being reported as saying that this move “would be helpful in some cases”.
Are we now all to believe that Samuel Butler’s work of fiction, Erewhon, is likely to become a reality? He wrote about an imaginary visit to a topsy-turvy country where it was a punishable offence to be physically ill but where criminality and immorality were looked kindly upon as treatable diseases.
Wrexham, north Wales
Sir, In deeply rural villages, we all have the same doctor. Now I love my neighbours, but do not yearn to know the condition of their nether regions, or to recount my symptoms to the butcher, the baker or the gossip maker.
NHSreality agrees. It is illiberal to deny choice. I would like the choice. Whether I have the determination and strength of purpose to carry through is my concern, and should not concern society, other than to ensure that the decision is made by “informed consent”, that the patient is of sound mind (has capacity) and that a two trusted professionals agree.
I was recently reminded of something I said five years ago that has taken on a special resonance for me. At the time there were two separate but equally controversial pieces of legislation at Westminster and in the Scottish parliament.
Lord Falconer of Thoroton’s Assisted Dying Bill was beginning its passage through the house and the Assisted Suicide Bill in Scotland, drafted by the late Margo MacDonald, MSP, was well into its journey. Both failed.
Writing in a newspaper column at the time, I said: “Now I am convinced not just that I do not have a right to object to assisted suicide, but, further, that I have a duty to do what I can to win the freedom to choose that option for those that want it.”
Those words were used to introduce me at a fringe on assisted dying at this year’s Liberal Democrat conference. They stung. My words came back to remind me what I had promised and, so far, failed to deliver.
Sitting in that room I was moved to tears by the stories of what some individuals, denied the right to end their lives when they believe it is right, are forced to endure.
But it was made all the worse by the fact that in the intervening years I have also had to watch my family suffer as a loved one endured a long, painful and unavoidable death that I fear could have been made so much easier.
It was early May and he had been diagnosed shortly after Christmas with motor neurone disease. His closest family had been told that 14 months was the average time from diagnosis to death, but he was going downhill so quickly that it might not be that long. It wasn’t. He died before the next Christmas after less than a year.
In that time the disease had stolen from him not only his successful career, not only the years he should have enjoyed with his wife and sons, not only his ability to walk, talk or communicate. It had stolen his dignity, his choice.
I am not ashamed to admit that, at the time, I wondered whether it would be less cruel to end the pain for him and his family. I do not know what his choice would have been. I still have no idea what mine would be in those circumstances. But we should each be allowed to have one. We should all have the choice.
But of course assisted dying also provokes controversy, conflicting emotions and moral dilemma. Who decides when it’s OK to take the decision? How do we stop it being abused by unscrupulous relatives or evil Harold Shipman-like murderers? And how do we protect those people who don’t want it? Well, I have a question too: why are we not even trying to offer answers?
The organisation Dignity in Dying points to numerous and consistent opinion poll results over three decades showing support for assisted dying, most recently an 82 per cent backing for Lord Falconer’s 2015 bill. That support is generally for those with a terminal illness, where safeguards are in place to ensure that it is their consistently expressed will. And certainly it is before those other issues and questions come into play.
But surely it is not beyond the wit of politicians to recognise that there is a need to act and bring Britain into line with a growing international consensus.
Switzerland has been a world leader, but in the United States the state of Oregon has allowed assisted dying for terminally ill, mentally competent adults for more than two decades. Belgium, the Netherlands and Luxembourg offer euthanasia. Canada legalised assisted dying after a similar legal case to the one fought in this country by Noel Conway. His human rights case is challenging the blanket ban on assisted dying, and since being rejected by the Court of Appeal in June is being appealed to the Supreme Court.
It saddens me that many of us with responsibility have shied away from the challenge, preferring instead to leave it to an individual. That case may yet prove to be the turning point, but I believe it’s time that those of us who cherish freedom of choice and the rights of the individual took up the challenge once more.
With parliament returning after the conference season, and an embarrassing lack of non-Brexit legislation on the agenda, it is time to redouble efforts. I am already writing to the secretary of state for health to request a meeting on the subject and will press at every opportunity for that choice for those who are terminally ill. It will take time, but I have the luxury of being able to assume that I have it. Not everyone is so lucky.
Christine Jardine is the Lib Dem MP for Edinburgh West