Monthly Archives: May 2013

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.

NHS will produce more GPs to ease pressure on hospitals

The London Times (Chris Smyth) reports 28th May 2013:

More flexible NHS to favour GPs over hospital specialists.

“Fewer doctors will be trained to become hospital specialists under plans for a  big boost in GP numbers.

Half of all nurses will also do part of their NHS training in the community as  ministers aim to create “a more flexible workforce” that can treat patients  away from hospitals.

But more doctors are needed to relieve pressure on A&E departments and officials have been told to find ways to fill  the half of specialist emergency places that are now empty.

The £5 billion NHS training budget will be shifted away from producing  hospital specialists to create “a more flexible workforce with greater  generalist skills”, under a five-year plan launched today.

Half of all medical students should train to become GPs so that there are  2,000 more family doctors by 2018, while 100,000 NHS staff will have more  training on treating people with dementia. At least 50 per cent of nurses  will do community placements during training to encourage them to work in  local clinics rather than hospitals……”

A reflection on poor manpower planning. So many GPs are due to retire shortly (known since 2000, media coverage 2012). The professions wont believe this announcement until the money for training, recently reduced, is increased, and the profession agrees with manpower planning a realistic view of how many GPs will be full-time, how many part-time, how many will do Out of Hours (OOH) and how many will help with Accident and Emergency departments. (How many will go abroad and how many will be redundant?) There may well be two grades of GP – The truly Independent GP – those with overall skills including casualties, who can work single handed and anywhere, and the Dependant GP – those who only work in their practices from notes of patients they know well. I suspect the “man from the ministry” made the announcement with a smile at the thought of scapegoating General Practitioners.

So many of my school age patients have been refused Medical School training places when they were perfectly capable of the degree – if only they had been given the chance. This must have been repeated 20,000 times around the country and if the places had been offered there would be no crisis now!

The man who smiles when things go wrong has thought of someone he can blame it on. Jones’ Law quoted in Murphy’s  Law by A. Bloch 1979

The Any Qualified Provider decision

The DOH published its intentions in Jan 2012:

“From April 2012, patients in each primary care trust (PCT) cluster will have greater choice of who provides their care for at least three community or mental health care services. An online interactive map is now available to allow GPs, commissioners, and patients to see the local health services that will be covered by Any Qualified Provider (AQP) in each area of the country.

The map is published on the NHS Supply2Health website and was announced on November 11th 2012. The website also contains materials to support commissioners with AQP implementation, developed with support from clinicians and patient representatives…..”

Without a mandate, our politicians have implemented a service disintegration and an example of the services to be encouraged in this way is available from Bristol NHS Trust. UNISON have a perceptive and interesting critique.

By 24th February problems in structure were evident as reported in Pulse:

AQP U-turn ‘highly significant’ says Alliance chair

Specsavers was quick to realise the potential of AQP and piggybacking in to provide Hearing Aids. AN example is their “promotional” feature in GP magasine. They were already profitable enough, and now made more.. (See Daily Mail 2011)

AQP is Confusing Patients. (Commissioning GP 22nd May 2013)

“Any Qualified Provider (AQP) has been branded as dangerous to patient care and not in their best interests at the LMC Conference.

In a motion proposed by Merton, Sutton and Wandsworth LMC (Local Medical Committee) at today’s meeting in London, representatives from the UK’s LMCs have voted that AQP is “unnecessarily complex and costly to introduce, maintain and regulate”.

Amer Salin, from the Merton, Sutton and Wandsworth LMC, said, “The arrival of AQP is one of

the most dangerous parts of the new NHS.”

By 23rd May the BMA was saying “Competition will undermine care and increase costs, GPs warn”….

“Putting NHS services out tender will severely affect and undermine the continuity of patient care, according to GPs….”

It is a real challenge to continue to provide a joined up NHS when there are so many providers, BUT it does get control of the finances, and that was the priority for government. Standards are almost bound to fall while we work out a new way forward. I suspect inequalities will also be increased by AQP, as in any system those who work out how to play the game by the new rules do better – the informed.

Nothing is illegal if one hundred businessmen decide to do it. Andrew Young 1976

A reminder fm 2002 – The NHS Reality (and still 12 yrs later)

The London Evening Standard 22nd Jan 2002 reported:

“Placing often elderly patients in rooms adjacent to a casualty department is a common way for London hospitals to deal with overcrowding in A&E, a lack of beds on wards and disguising long trolley waits.

The areas, sometimes called observation wards or admissions wards, are effectively used as holding bays for patients who doctors have decided should be on a ward getting specialist care.

But because no bed can be found, they are kept in accident and emergency and cared for by casualty nurses – and these patients are not recorded in official statistics as having been kept in the casualty department overnight, no matter how long they stay.

Geoff Martin, of pressure group London Health Emergency, said: “Accident and emergency is a place where people are supposed to be assessed. That assessment is supposed to take four hours at the most.

“People who need to be in hospital after that should be on a ward.

“What is happening is that NHS trusts across London are colluding with the Government to cover up a real crisis in the NHS….”

I felt so disappointed to realise that nothing has changed in 12 years. What have the different ministers of health been up to?

Nothing is impossible for the man who doesn’t have to do it himself. A H Weiler, in the New York Times, 1968.

Introducing “more patient reality’ into NHS spending decisions

Lynne Taylor in The Pharma online Times reported 28th Jan 2013:

“A study by health economists at the University of York has, for the first time, produced an estimate of the impact on other NHS patients of new and more expensive drugs and other treatments.

This research suggests the need for a refinement of the way the National Institute for Health and Clinical Excellence (NICE) gauges the cost-effectiveness of new treatments, say the researchers. It also has implications for the prices that the NHS can afford to pay for new drugs when the value-based pricing (VBP) scheme for all new drugs is introduced by the government in 2014,….” T

I suggested a “reform” after Blair and New Labour won their first election. I suggested all NHS paper had the appropriate real cost attached but making it clear that this was for information only. A phone call from the bureaucracy in the Labour Party informed me they would “run” with this idea. I disconcerted him by laughing out loud and said that I did not believe it would happen, and to come back to me in 7 years time if it did. The reform suggested has not happened…The “running” has been very slow. I would like to speak to him again now,,

Bureaucracy …. the giant power wielded by pygmies. Honore de Balzac, Les Employes, 1838

Health chiefs refuse to pay for lifesaving drug

The Times Martin Barrow Health Editor reports 27th May 2013:

“Patients with a rare and potentially fatal disease are being denied the only  drug that will save their lives because it is too expensive.

The Department of Health has overruled a panel of experts who recommended that  the drug Soliris should be given to all patients diagnosed with a blood  disease called aHUS that causes irreversible kidney failure.

Lord Howe, the health minister, has ordered another inquiry over concerns  about the affordability of Soliris, which costs around £250,000 a year and  is one of the world’s most expensive drugs. However, it is the only one  licensed to treat aHUS and is already widely available across the EU and in  the United States.

The decision has devastated patients, who can be dead within days if the  disease takes hold and whose only other chance of survival is being put on a  kidney dialysis machine. A kidney transplant is not an option because the  disease can quickly destroy….”

This is a clear example of technology advancing quicker than our ability to pay. Without rationing the low cost high volume services (and encouraging patient autonomy) we will be unable to supply equitably the low volume high cost treatments and services that patients are afraid of. We are “bringing back fear” because of our inability to discuss the pragmatic and politically unpalatable issue of overt rationing. It is perverse that politicians have more to gain by ignoring the “R” issue, and replacing it with platitudes to a “patient centred” service, or a “primary care led” service. Politicians reject anything that they cannot gain advantage on within one term of office. Health planning beyond 5 years is needed and is a good reason for Proportional Representation.

Five law firms make £35MILLION by suing the NHS

The Sun JONATHAN REILLY Published:  19th May 2013 reports: ‘No win no fee’ solicitors get rich in just one year

“FIVE law firms pocketed £35MILLION by taking the  NHS to court last year. All used the “no win, no fee” system in suing for clients over medical  blunders. It came as the health service paid out a record £1.2billion in compensation  in  2011-2012. Irwin Mitchell made £18.9million working on 522 cases, gaining a total of £43million for clients. The firm’s London boss Alison Eddy, 59, lives in a £2.3million home. Last night Irwin Mitchell said it took on many important cases, including a  six-year battle to win an £8million payout for the family of brain injury  victim Holly Woods, 10, of Chislehurst, Kent. It added: “If the NHS wants to save money, it must stop making the same  errors — and admit them earlier.”…..

No fault compensation is one way 0f rationing legal costs but the politicians don’t vote for it because its time horizon is longer than one term of office. The savings are evident from NZ and Scandinavia who have had this for 20 years.