Monthly Archives: May 2013

Royal Glamorgan hospital could lose specialist services

BBC Wales news reports 22nd May 2013:

The Royal Glamorgan hospital in Llantrisant could stop treating the most serious accident and emergency cases as part of a major NHS shake-up in south Wales.

Health officials say the “best fit” is to locate specialist services in Cardiff, Swansea, Merthyr, Bridgend and in a new hospital near Cwmbran.

But a consultation will include options involving the Royal Glamorgan.

NHS leaders believe services are currently spread too thinly.

They have warned some specialist hospital services are “on the edge” and could “collapse” unless big changes are made to the way they are delivered.

NHS 111 non-emergency helpline for Wales set to progress

BBC news Wales reports 29th May 2013:

“Plans to launch a new NHS non-emergency helpline service in Wales look set to go ahead despite problems in England.

The 111 line would replace NHS Direct as a “gateway” to all kinds of different services.

The Welsh government hopes it will ease pressure on accident and emergency departments said to be “at the point of meltdown”.

Medical staff have mixed views as to whether the 111 line will ease or add to pressures on A&E services.

The line is intended to allow access to services such as out-of-hours GPs, district nurses, and eventually social care too, so that people will be less likely to end up taking themselves off to hospital.

“To expect this to reduce pressure on emergency departments is delusional”

Dr Aruni Sen Wrexham Maelor Hospital

The 111 service was fully launched in England in April but has been beset by problems, with reports of patients struggling to get through.”…

History ….is a nightmare from which I am trying to awake. James Joyce.  Ulysses.

History repeats itself — the first time as tragi-comedy, the second time as bedroom farce. Private Eye Magasine. 1978

Will Healthwatch give patients a better deal?

Dick Vinegar in The Guardian 29th May reports:

The community watchdog will have to work hard to realise the patient-centric  dreams of Andrew Lansley and Jeremy Hunt

“Trying to provide a channel for patients to engage with their local  healthcare providers is not new.

Indeed, it has been going on for decades. In 1974, Community Health Councils  (CHC) were set up.

In 2003, they were abruptly replaced in England (but not Wales) by Patient  and Public Involvement Forums (PPIF), reporting to the Department  of Health. In 2005, these were replaced by Local Involvement Networks  (LINks), which were funded by local government, and were aggressively local,  with no central controller. Now, there is yet another change, the fourth in  eight years, towards Healthwatch, the community watchdog  which really is going to realise the patient-centric dreams of Andrew Lansley,  Jeremy Hunt, and me.

I am not sure. All the previous iterations worked only in places where the  local CHC or LINk were uncharacteristically well-run, knowledgeable, and, above  all, stroppy. The rest failed, and the patient’s voice was ignored, ending up in  Mid Staffs-type disasters. At a recent Westminster Health Forum about  Healthwatch, Sir Steven Bubb, who runs the Association  of CEOs of Voluntary Organisations (ACEVO), admitted that when he sat on a  CHC, he was patronised by doctors. That is the big problem. Will doctors and  hospital CEOs ever take patient groups seriously?…..

Patient centric means trying to win votes, but does patient centric mean individuals or community? Is there a need for utilitarianism – Which means rationing out?

An NHS led by laggards

In an astute article in BMJ Careers May 2013 by Yasmin Akram, a specialist trainee GP registrar in year 2 in the West Midlands Deanery says that the “Slow uptake of innovation in the NHS heaps frustrations on working doctors” and then “looks at the health services exasperating technological failings.

She divides the acceptors of innovations into five groups:

Innovators, Early adopters, early majority, late majority, and laggards.

She says that “Unfortunately, most people in the NHS are, in my opinion, laggards. There seems to be a major reluctance to take up any new technologies and, more importantly, to move on from dated ways of working. I agree that “if it isn’t broken don’t fix it”, but the NHS is broken.”

…and then she goes on to give examples, and quotes Neame R – Smart Cards – the key to trustworthy health information systems. BMJ 1997; 314: 573

Commissioning groups would like real-time accurate information, especially regarding referrals and patient notes. Any business needs this, from the high street shop to petrol distributer and the pharmaceutical company. The NHS Trust Management and the DOH are managing blind without this. The history of government IT systems is one of persistent failure. They have made the mistake of trying to take giant strides forward rather than incremental steps. General Practices have wonderful IT systems and information, and there is no reason why this should not be available in Hospitals, and then updated by them. The barriers to change are that GPs are reluctant to change their systems, and that there is no thought given to persuading and compensating them if they do change. If a region chooses one GP IT system, and uses it for Out Of Hours and Casualty cases then any GP without it will soon move to it. The opportunity to have their notes updated for them is too good. There will be computer hygiene and confidentiality issues but nothing that cannot be overcome.

IT leads in the Health Service and other government departments are usually forgiven their sins, and the recent removal of the BBC digital project manager is refreshing. The way to success in IT whilst reducing risk is incremental improvements, with backup ability to reverse a few steps if needed. Evolution rather than revolution. But the culture of the NHS rewards revolutionary strategic managers with promotion before their work can be criticised, and gives no incentive to the operational managers (More appropriately called administrators?) to take risks. They are therefore unenthusiastic.

Yasmin is right, and more: it is a disgrace that my practice (By no means the first) computerised in 1985 and yet the Hospital Service has yet to do so in any way meaningful to patients.

Command is getting people to go the way you want them to go – enthusiastically. Gen. William Westmoreland.

“Confidence in nonsense is a requirement for the creative process.” -=- M. C. Escher

Health Inequalities in Primary Care- Time to face justice

Update 3rd Nov 2013 Credit contraction offers opportunity to close gaps in health inequities

Professor Sir Michael Marmot, chair of the World Health Organization’s commission on social determinants of health, discusses the impact of the world’s financial crisis on global health.

In an article in the RCGP 2012 p 517 Christopher Weatherburn comments on Dr Moscrop’s review article “Health Inequalities in Primary Care”.

He commends distinguishing between inequities and inequalities and also points out that the original article omitted a 2 year update published by UCL Institute of Health Equity (Feb 2012) which finds that Health Inequalities have widened in most areas of England.

He says “The Equality Trust has been set up by the authors of “The Spirit Level” to gain the widest public and political understanding of the harm caused by inequality. The striking messages are that members of more equal societies tend to live longer, have less mental health illness, less illegal drug use, with lower rates of homicide and childhood violence….”

The whole letter/article along with references is here.(bjgp oct 2012 cwIn)

Surgery ‘has growing death risk through the week’

Chris Smythe in The Times and The BBC News 29th May report:

“People who have surgery towards the end of the week are more likely to die than those who have procedures earlier on, researchers say.

A British Medical Journal report into non-emergency operations in England, suggests the overall risk of death from such planned procedures remains low.

But it shows “unacceptable” variation in survival rates through the week, a leading body of UK surgeons says.

The government says it is committed to safe care for patients at all times. “It is not acceptable that there should be such a wide variation in the mortality rates according to the day of the week the operation takes place” said Prof Antony Narula Royal College of Surgeons

Researchers from Imperial College London gathered data from all non-emergency surgery undertaken by the NHS in England in 2008-11.”

The Daily Mail (Emily Payne 29th May 2013) slant is on Heart Disease

The BMA editor Fiona Godlee comments:

According to a BMJ paper, there is a higher risk of death for patients who have elective surgery later in the week and at the weekend, compared with those earlier in the week. Whilst previous research has suggested a significantly higher risk of death if admitted as an emergency patient at the weekend compared with on a weekday, this is the first national study to focus on the day of elective surgery to report a “weekday effect.”

In a BMJ video abstract to accompany the paper, Paul Aylin, one of the researchers, says that the findings do suggest a poorer quality of care at the weekend. However, as this is an observational study, he adds, “it is difficult to draw those kinds of conclusions from routinely collected data.” Watch the video abstract here.

I have said elsewhere that weak management has allowed part-time and flexible working people to take Friday pm off. The first thing to ensure is that Friday, Saturday and Sunday are fully staffed working days, and that there are disincentives to taking friday afternoon off. Routine phone calls to check “presence” at 16.45 on a friday and more departmental and strategic meetings on a friday would set the right tone. The union voice will object. That’s why it might be better to let the failing trusts go bust and that will allow staff changes. The Health Service could be reconfigured once a new working ethic and practices were accepted, and sickness and absence rates reduce to those of other industries. General Practice is at risk from a similar culture as the units get bigger encouraged by government. Staff often come from the Hospital and if GPs were salaried  rather than self-employed I guess their sickness rates would quickly become the same as the Hospitals! This on top of “Never fall ill at weekends – our Out of Hours Service is a disgrace.”

This post heralds near to 3 months of postings. It is a record of a service in disintegration, and I will reduce input to the main posts from now on as I feet my point is proven. I will sign off with “What I belive” – although I am really unsure about what is an acceptable solution, and how much worse it needs to get. Timing is everything in politics, and a “turnaround” strategy

Cap on number of GP visits being considered by Tories

The Independent Jane Merrick Sunday 26 May 201 reports:

‘Idea on website ‘breaches National Health Service principle of treatment based on clinical need’

“A cap on the number of times patients can visit their GP in a year is being considered by the Conservative Party, it emerged yesterday.

A Tory consultation document on local health provision asks activists whether they agree or disagree with the idea of an annual limit on GP appointments. The paper also asks whether evening and weekend appointments with GPs and consultants are a “luxury the country cannot afford”.

The proposals, which the document admits are “controversial”, were yesterday condemned for targeting the most vulnerable, who need to see their doctor more often than
others. They also fuelled the debate raging over access to GPs, out-of-hours
services, and the pressure on accident and emergency departments. Dr Clare
Gerada, chair of the Royal College of GPs, said the idea was “short-sighted”…..

At least this proposal has the virtue of being honest and open rationing…. The response of Clare Gerada is like the opposition parties in politics… Will she not make a proposal on how to limit claims and encourage autonomy on smaller things – will she ever speak in favour of the R word (thus ensuring professional support and re-election)? And of course whatever happens Wales Scotland and N Ireland will be different! So who defines clinical need? At the point of making an appointment the patient. And who decides if unnecessary? The Pareto effect says that 20% of the patients create 80% of the work. Assuming some of these 20% are genuinely seriously ill, can’t we have a debate about how to educate the remainder? Perhaps we should take advantage of Goodhart’s law says that when you start to measure something it changes: I expect attendance at the GP will be no different.

The duty of an opposition (is) very simple – to oppose everything and propose nothing. Lord Derby, 1841

It is dangerous to be right in matters on which the established authorities are wrong. Voltaire ,quoted in A Cynics Breviary, by J R Solly.

Update 29th May 2013: David Baggs through 38 degrees offers:

“This could be very serious. The Conservatives are floating plans to cap
the number of times we are allowed to visit our GP
. [1] If we run out
of visits – because we’ve got a sickly child or long-term health condition, for
example – we could be forced to pay to go elsewhere.

At the moment it’s
just a proposal. [2] But if the Conservatives don’t see a big public backlash,
it could soon be a grim reality. So let’s raise an outcry as quickly as
possible and push them to drop the idea immediately.”

Please sign the urgent petition now: tell health minister Jeremy Hunt to
rule out limiting our access to NHS GPs:

The trouble is, like Clair Gerada RCGP, he does not say what form of open rationing WOULD be acceptable.