Monthly Archives: May 2014

New NHS chief Simon Stevens backs more local hospitals and “must end mass centralisation”

BBC News reports 30th May 2014 an apparent change in direction: New NHS chief Simon Stevens backs more local hospitals

Smaller community hospitals should play a bigger role especially in the care of older patients, the new head of the NHS in England has said.

In an interview in the Daily Telegraph, Simon Stevens signalled a marked change in policy by calling for a shift away from big centralised hospitals.

The health service chief executive said there needed to be new models of care built around smaller local hospitals.

The NHS said he was not suggesting the return of 50s-style cottage hospitals.

In recent years the health service has emphasised the benefits of centralised services.

This has paid dividends in areas such as stroke care and major trauma where significant benefits have been gained by concentrating specialist care.

But this has raised questions about the future of the many smaller district general hospitals across the NHS.

In the interview in Friday’s paper, Mr Stevens said they should play an important part in providing care, especially for the growing number of older patents who could be treated closer to home.

He said: “A number of other countries have found it possible to run viable local hospitals serving smaller communities than sometimes we think are sustainable in the NHS.

“Most of western Europe has hospitals which are able to serve their local communities, without everything having to be centralised.”

In the home

He said elderly patients were increasingly ending up in hospital unnecessarily because they had not been given care which could have kept them at home.

Mr Stevens also told the Telegraph:

  • The NHS needed to abandon a fixation with “mass centralisation” and instead invest in community services to care for the elderly
  • Waiting targets introduced by Labour became “an impediment to care” in too many cases
  • The European Working Time Directive damaged health care in the NHS, making it harder to keep small hospitals open
  • Businesses should financially reward employees for losing weight and adopting healthy lifestyles

An NHS England source said Mr Stevens was saying that smaller hospitals had a part to play in shifting services into the community, not that there would be no closures of local hospitals in the future.

Mr Stevens, a former adviser on health to Tony Blair, will outline his vision for the NHS in a major speech at the NHS Confederation conference in Liverpool on Wednesday.

He took up the post of chief executive of the NHS in England after 11 years working for private health care firms in Europe, the US and South America.

It is reasonable to ration care by not sending everyone to super-specialist centres. Local care, especially for the commonplace non-technical is best, and most appreciated. Patients can often return to the local unit from technically specialist centres very quickly.. Commissioners in rural areas need to take note.. But this does not excuse Mr Stevens avoiding the “R” (Rationing) word so far..

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‘Do not resuscitate’ is doctors’ own choice for end-of-life care – but perish the thought to educate patients!

Billy Kenber reports for The Times 29th May 2014 on an issue that doctors are able to decide for themselves on. They have no longer got complete clinical freedom over their patients, but with planning, cooperative relatives and an “Advanced Directive” they can ensure a speedy release. This is something that most patients fail to address and the consequence is a higher percentage of prolonged deaths in the general public: ‘Do not resuscitate’ is doctors’ own choice for end-of-life care 

With apologies, as I believe this is important, I reprint the complete article below:

Most doctors would ask to be left to die if they had a terminal illness, rather than pursuing the aggressive treatments they recommend for patients, a study indicates.

A survey of almost 1,100 doctors found that 88.3 per cent would opt for a “do not resuscitate” approach if they had terminal cancer or another illness that would soon kill them anyway.

Dr V J Periyakoil of Stanford University School of Medicine, in California, who carried out the research, suggested that doctors’ decisions were influenced by regularly witnessing the impact of efforts to extend life, including resuscitation attempts that could break an elderly patient’s ribs but would not return them to their previous state of health.

She said there was a disparity between what doctors would choose for themselves and their pursuit of aggressive treatments for patients. Dr Periyakoil said this was not for financial reasons or because doctors were intentionally insensitive towards patients.

She said that the medical system was set up in a way that rewarded doctors for taking action, not for talking with their patients. “Our current default is ‘doing’, but in any serious illness there comes a tipping point where the high-intensity treatment becomes more of a burden than the disease itself,” Dr Periyakoil, a clinical associate professor of medicine, said.

“It’s tricky, but physicians don’t have to figure it out by themselves. They can talk to patients and their families and to the other interdisciplinary team members, and it becomes much easier. But we don’t train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed.”

The study examined doctors’ attitudes to a new law designed to give patients more control over determining end-of-life-care decisions. Advance directives, or so-called living wills, are documents which allow patients to indicate their preferences for medical treatment when they are terminally ill or otherwise incapable of making decisions themselves.

Although other studies have indicated that the majority of Americans would prefer to die at home without life-prolonging interventions, hospitals remain focused on aggressive treatment at the end of life.

Dr Periyakoil surveyed 1,081 doctors in California, of whom 60 per cent were between 30 and 39 years old.

The results showed that doctors’ attitudes toward advance directives had barely changed in 25 years and that women remained more supportive than men of patients being able to set out their end-of-life choices.

An advanced directive or living will – It’s important to specify, especially lying flat. Good news if you take action.

Nuffield Trust: changing health care services and living with less

Dead people don’t vote… End-of-life care ‘deeply concerning’

Death discussions ‘taboo’ for many in UK, survey finds

The NHS and ‘cradle to the grave’

at least the profession are able to “commission” their own “end of life” care standards, and ration themselves out of pain and distress!

 

 

Fat and Alcohol will bancrupt the Regional Health Services – So who believes in some form of co-payment and/or deserts based rationing?

Fat and Alcohol will bankrupt the Regional Health Services – So who believes in some form of co-payment and/or deserts based rationing? Of course we don’t officially ration health care, so the possibility is a non-starter under current rules…

Dominic Walsh  reports 29th May in The Times: Slimming firms set to make big profits on NHS

Oliver Moody reports 29th May: British girls have become the fattest in Europe

British girls are the fattest in Europe, a landmark study has found.

The UK has had one of the fastest rises in obesity among developed nations since 1980 and ranks among the lowest 40 countries in the world, according to the largest and most comprehensive study into global weight problems conducted.

With 29.2 per cent of British girls under the age of 19 obese or overweight, Britain has the 27th-worst record in the world, falling between Dominica and Mexico. Only Iceland and Malta have worse overall rates of obesity in Europe, while Switzerland, France and Italy are among the least overweight countries on most measures.

On present trends, Britain could fall well short of the government’s stated ambition to reverse the rise of obesity in adults by 2020.

Leading public health experts have called for the government to encourage big food companies to make healthy food more affordable, market fast food less aggressively and produce clearer labelling.

According to the 2011 census, there were 7.38 million girls in Britain, meaning that at least 2.1 million are obese or overweight. The problem is marginally less acute for boys in Britain, but more than a quarter, about two million, are clinically overweight. Among adults, two thirds of men and 57 per cent of women are overweight or obese.

John Newton, chief knowledge officer at the government agency Public Health England, said that the “worrying” prevalence of obesity among British girls was partly due to peer pressure to eat fast food.

“We have to look at the environment in which people are living, and the constant pressure to eat unhealthy food means things are particularly a problem for girls more than boys,” he said. “Speaking as the father of a teenage daughter, girls are particularly prone to peer pressure.”

He said that Britain’s obesity levels were made worse by Scotland, Wales and Northern Ireland because of their relative poverty and unhealthy diets.

The study is published today in the Lancet. Researchers led by the University of Washington in Seattle found that no country had recorded a significant fall in obesity levels since 1980.

Some of the most rapid increases in obesity among adults in rich countries have come in the United States, where a third of the adult population is obese, as well as Australia and Britain.

One of the most senior obesity experts in Europe said that labour-saving gadgets, from washing machines to computers, had made people sedentary….

Interactive Map graphic: Obesity among European girls

BBC news reports 29th May 2014: Prescription drugs to treat alcohol top £3m

There were a million hospital admissions related to alcohol last year in England and £3.13m was spent on prescription drugs to treat alcohol dependency.

The Health and Social Care Information Centre’s latest report shows that 65% of adults admitted were men, but more under-16 girls than boys were admitted….

 

 

NHS ‘would crash it if was an airline’ says Mid Staffs inquiry chief who calls for “genuine information” and more honesty.

Josh Loeb and Sonia Elks  report in The Times 28th May 2014: NHS ‘would crash it if was an airline’ says Mid Staffs inquiry chief – What could be clearer? – Perhaps it is that the Regional Health Services are crashing, and the Mayday message is not getting through, and that includes Alice Thompson.

If the NHS were an airline plane crashes would “happen all the time”, the chairman of the inquiry into the Mid-Staffs scandal has warned.

Robert Francis, QC, said that the public believed that the quality of care available through the NHS was much better than it actually is. While the majority of patients received acceptable care, he said that services were patchy and patients were too often being blamed for “crowding out” accident and emergency departments when they did not know where else to go.

He said that NHS chiefs had become “complacent” and should take their cue from the private sector, where the needs of the customer were paramount.

“The answer is not to get the people to fit in with the service – you need the service to fit in with the people,” he told The Daily Telegraph.

“The trouble is it’s no use being satisfied or complacent – if we ran our airline industry on the same basis planes would be falling out of the sky all the time,” the barrister said.

“We’ve just got to change the attitude that because it’s provided by the state it’s all right for a number of people to be treated badly; well it’s not. Airlines would go out of business very quickly if they worked that way.”

Mr Francis said that the public had not been given “genuine information” about how services were performing, leading to a perception that things were “rather better than the probably are”.

More honesty was needed about the need to close some health services in order to put more resources into others, according to the barrister.

He also raised concerns about funding considerations being used as an excuse for failing to provide acceptable levels of staff.

“All we are talking about is proving something that is safe, something that is effective,” he said.

“If you can’t afford that then why are you proving it at all?”

There was a danger of health professionals and politicians resisting essential major changes including the closure of some local services because of “knee-jerk reactions”, he said.

Are GPs overpaid? Ms Alice Thompson has no sympathy for General Practitioners.

In The Times 28th May 2014 Alice Thompson opines: These overpaid doctors must stop whingeing

Ms Thompson opines and I have no doubt her view will increase the correspondence to “the Thunderer.” GPs put the individual patient in front of them first, and their first duty as a doctor (GMC) is to put their patient at the centre of their concern. The plural, patients as citizens, and communities, is for the government to put first. The greatest good for the greatest number is a utilitarian duty of government, and only becomes the duty of a doctor in wartime or in a crisis. Perhaps she is arguing that we are in a similar catastrophic situation? There is certainly no NHS from the point of view of one who lives in Wales and wishes to exercise choice. In Wales, where there is no aspiration, there is unlikely to be excellence, and recruitment (strangely it seems to the politicians in Wales) is a problem. Would Ms Thompson opine on why General Practice, once the jewel in the crown, and certainly the one aspect of the Regional Health Services that most Ministers of Health in the world would like to emulate, is now finding it hard to recruit enough doctors?

With apologies I reproduce the article in full:

GPs profess to put patients first but they need to modernise and adapt to increasing demand, not just lobby for money

In our house there is a box of wooden bricks played with by generations of children. It was given to my great-grandfather, a GP in Manchester, in return for nursing, for free, a child through whooping cough. We also have a miniature Victorian doctor’s bag that a cobbler made for him after he stayed up all night to save the man’s wife and baby during a complicated birth, refusing to take any payment.

The British used to revere their GPs. During the Second World War when British bombers bombarded the continent with copies of the Beveridge report, the idea of free GPs obsessed those who read it, according to a new book by John Micklethwait and Adrian Wooldridge The Fourth Revolution: The Global Race to Reinvent the State. Everyone dreamt of free access to their doctors’ words of wisdom and, after the war, NHS GPs became the envy of Europe.

As the royal family, politicians, teachers, journalists, vicars and bankers seemed to lose their way, GPs were the one profession that, until the turn of this century, were still trusted by more than 90 per cent of the population. The family doctor remained the linchpin of the community.

Now GP leaders say the service is “teetering on the brink of collapse” and that the government needs to “save general practice”, and they have launched a poster campaign showing queues of patients waiting outside surgeries. The Royal College of General Practitioners suggests that GPs will soon have to treat people on a first-come first-served basis or that patients will have to wait three weeks for an appointment. They say that they need to increase their funding by 11 per cent in the next two years, almost £3.5 billion, and they want all their patients to sign a petition backing them.

A decade ago there would have been huge sympathy for these poor put-upon professionals, up half the night, struggling through the day on mediocre pay, keeping the NHS going. But not now. Most people don’t feel GPs are hard done by any more. They have done pretty well, even during the recession. In 2004, partners managed almost to double their pay, suddenly earning on average £113,000 a year, while often cutting back dramatically on their workloads. They were no longer expected to be responsible for out-of-hours care. More than a quarter now work part-time to their own schedule.

There are exceptions, those who are seeing up to 50 patients a day, but most cannot be said to be under undue pressure. According to a McKinsey report published in 2010, GPs spent an average of 22.5 hours a week face-to-face with patients. Locums, NHS Direct, the new 111 system, the ambulance service and A&E have had to pick up the pieces in the evenings and at weekends. At the same time, British GPs have become the highest paid general practitioners in the world, according to OECD figures, earning more than the average medical specialist; they just spend less on equipment than they do in other countries.

The posters are part of the royal college’s “Put Patients First” campaign but it has become clear that it is the GPs who now come first. They have designed a system that suits them, not the public. When they stopped doing out of hours, I wrote a piece about how my youngest son nearly died from meningococcal disease when he fell ill one Sunday evening and NHS Direct suggested a purple stain on his stomach was just a bruise. I received letters from devastated parents whose sons or daughters had not survived after their GP had been unavailable for a consultation when their child fell ill. I received even more correspondence from the elderly or chronically ill, explaining that they see a different GP every time they visit, which they often find confusing and embarrassing.

More than 34 million requests for GP consultations will fail to be met this year, according to the GP Patient Survey, while hospitals are inundated by those with coughs, stomach bugs, ingrowing toe nails or migraines, and those requiring repeat prescriptions that they can’t get at their doctor’s. A&E staff see four million more patients a year since GPs changed their contracts in 2004.

Meanwhile other healthcare professionals are increasingly angry at GPs’ special pleading. Emergency staff, neurosurgeons, paediatricians and gynaeocologists may be on the same pay but are working longer, more variable hours.

GPs can’t carry on whingeing. They are desperately needed to help shape reform. David Cameron has pledged that an extra 1,147 surgeries will open between 8am and 8pm seven days a week. This government has already increased their number by 1,000. Ed Miliband, too, has promised that if Labour gains power he will provide the money for patients to be guaranteed an appointment in 48 hours.

The NHS budget is still ringfenced. The amount given to GPs since 2004 has risen from £7.2 billion to £9.2 billion, slightly more than inflation. Last week when the possibility of charging for appointments was raised, many GPs shouted it down without suggesting any alternatives.

The royal college is supposed to focus on training and education. It should be discussing how to modernise and adapt to increasing demand rather than continually lobbying for extra money — and working out where it can take the strain from A&E and be at the forefront of preventive medicine. “For we have agreed”, as Plato once said, “that a physician, strictly so called, is a healer of bodies, and not a maker of money, have we not?”

Update 30th May 2014 … Times correspondence:

Funding is falling, patients are getting older and iller, GPs are feeling the strain

Sir, I have been a GP in Devon for 22 years. The first 20 years were very rewarding, but the last two have been different (Alice Thomson, “These overpaid doctors must stop whingeing”, May 28). I work from 7.30am to 6.30pm without a break. The consultation rate has increased from 3-4 contacts a year to 6-7. Our population is getting older and more frail, further adding to workload. Increasingly our time is taken up by paperwork. The work transfer from secondary to primary care has been huge in the past few years.

Yes, GPs are well rewarded but we are also at point of collapse. We are asking for more money to pay for more doctors so we can offer a safer and better service to our patients.

Dr Elizabeth Brown

Teignmouth, Devon

Sir, Alice Thomson is correct that I see patients for about 24 hours per week but I spend at least that long again on filing, visiting patients at home and running a business (my surgery). We are being paid less and less for doing more and more work.

It should be pointed out that people need to take more responsibility for their own health. A&E departments are full of people who’ve drunk too much. Obesity is causing ever greater problems.

Dr J Hobman

Roundhay, Leeds

Sir, The workload has risen beyond recognition during my years as a GP. My practice’s funding is being cut by one third, yet I will still have to give the same level of care to the same number of patients (12,500).

All the Royal College of General Practitioners asks is that primary care is funded sufficiently so that there are enough GPs to see the patients, to ensure the recruitment crisis stops, that GPs don’t retire on grounds of ill health due to burn out.

Dr Michele Wall

Colchester

Sir, If general practice really is such an easy ride for overpaid GPs, why are older doctors retiring early in droves and why are young doctors shunning it in favour of working in hospitals or going abroad?

The numbers of young doctors choosing to become GPs went down 15 per cent last year. To quote Dr Chaand Nagpaul from his recent conference speech, “these doctors are not shunning the discipline of general practice, but the intolerable pressures that GPs are subject to, together with relentless attacks that devalue what we do, and which has butchered the joy and ability of GPs to properly care for our patients”.

Virginia C Patania

& Dr Naomi Beer

London E1

Sir, We should be sceptical of the RCGP’s demands for more money. British GPs are paid 3.4 times
the average wage in the UK, compared to 3 times in Canada, 2.7 times in Denmark and 1.7 times in Australia.

The National Audit Office found that between 2002 and 2006, GP partners enjoyed an astonishing 58 per cent pay increase despite working seven fewer hours a week than they did a decade earlier. Having such highly paid GPs means we can afford fewer of them.

In England we have 6.8 GPs per 10,000 persons compared to 20.2 per 10,000 persons in Australia.

It’s no wonder that it takes
people so long to get an appointment, a situation which is only exacerbated by the lack of GPs working at weekends and in the evenings.

Alex Wild

Update 1st June – Letter from Dr Maureen Baker RCGP and Patricia Wilkie NPA from 31st May 2014:

Investing in general practice will enable surgeries to deliver shorter waiting times

Sir, Further to Alice Thomson’s blistering critique of our call for more funding for general practice (“These overpaid doctors must stop whingeing”, Opinion, May 28, and letters, May 30), we are not asking for higher GP pay. We are asking for an increase in the proportion of NHS funding for general practice so that more GPs and practice nurses can be employed. In recent years there has been a cut in funding to general practice — to 8.39 per cent of the NHS budget — while the population is increasing and ageing, leading to higher demand for GP services in particular.

Investing in general practice will enable surgeries to deliver shorter waiting times, longer consultations and better continuity of care.

Workloads for family doctors are ballooning, and 84 per cent of GPs worry that they might miss something serious in a patient. According to a poll in March, 62 per cent in Britain think GPs’ workloads are a threat to standards of care.

Dr Maureen Baker

Royal College of General Practitioners

Dr Patricia Wilkie

National Association of Patient Participation

Update 2nd June 2014. Times letters:

Sir, Virginia Patania and Naomi Beer (letter, May 30) ask why older doctors are “retiring early in droves”. Part of the answer lies in a pension provision which is excessive by many standards and unaffordable by the nation. The solution lies not in paying doctors more, which would allow even earlier retirement, but in training more doctors and paying them less.

About 30 per cent of doctors in the NHS qualified abroad, rising to 50 per cent in the hospital service. In some parts of the country even locums are unavailable to fill service gaps. This is a shocking failure of leadership in what used to be a fine service.

Professor Michael Joy, FRCP
North Curry, Somerset

Sir, I strongly disagree with the claims made by Alex Wild of the TaxPayers’ Alliance (letter, May 30). At the moment there are advertisements for GPs in Canada (Alberta) for £162,000 to £270,000 per annum and Melbourne (Australia) for £140,000 to £220,000 per annum. Open the BMJ and British Journal of of General Practice to see the constant advertisements for overseas jobs.

Its no wonder that Australia has 20.2 GPs per 10,000 people and we have only 6.8, given the poor remuneration that is evident on an international scale.

Carry on complaining and you will speed up the retirement and emigration from — and loss of — new entrants to the specialty.

John B Ashton (retired GP)
Norton sub Hamdon, Somerset

We have to plan for “overcapacity” in all medical specialities because of drop out and emigration. It is common and appropriate for doctors to get experience abroad. This helps their overall development and if they return to UK is of benefit to us all. However, we can reduce the risk of permanent emigration, and of the drop out rate, by training less undergraduates and more graduates. Graduates with debt are really focussed and few drop out or emigrate. They are equally likely to be men as women (c.f Undergraduates) where women dominate. Overall they will give more service to the Regional Health Services, but they will tend to concentrate on attractive popular areas with good schooling. Regions with poor attraction to the profession (e.g Wales) need additional policies of help recruitment, possibly with housing and education subsidies….

 

Another Doctor with his head in the sand.. Deadliest cancers more likely to strike the poorest people

 

Dr Mark Porter in The Times 27th May 2014 opines against a “pay to see your GP” introduction. He fails to address any change in values to allow for the cost of new technologies. It is the post code and opaque nature of the rationing of these services, most of which are very expensive, which is bringing back fear. The values of 1948 were all very well in 1948. (“I remain committed to the three core principles laid out on July 5, 1948, when Bevan launched the NHS: that it should meet the needs of everyone, be based on clinical need rather than ability to pay, and be free at the point of delivery.” ) Dr Porter claims introducing charges will be like Saskatchewan 40 years ago, but then there were non-reclaimable charges for everyone including the poorest. In NZ 20 years of experience in giving back the charge to the poorest has addressed this. The debate continues – without a debate on the issues that would really make a difference…

Dr Mark Porter: Charging patients is not the answer – Another Doctor with his head in the sand..

General practice needs more money but the NHS will only survive if we use it responsibly and deliver it efficiently

Doctors may have overwhelmingly rejected the idea of charging patients up to £25 to consult their GP, but the mere fact that they were debating…

..The think tank Reform has suggested that raising prescription charges and charging for frontline services such as GPs would reduce demand by encouraging us all to use the service responsibly. It also says it would bring in much needed extra revenue of up to £3 billion a year. ..

…France is often held up by pro-charge campaigners as an example of good practice. The French currently pay about £20 to see a GP and a state-backed insurance scheme then reimburses the fee (or most of it at least). Patient satisfaction is high but it comes at a cost — France spends 11.7 per cent of GDP on healthcare, while we spend just 9.4 per cent. And herein lies the nub of the problem. It is not how you pay, it is how much you pay. …

Alexi Mostrous reports in the same paper: Deadliest cancers more likely to strike the poorest people so despite equal opportunity and access there are some people who won’t be helped.

Poor people are more likely than the wealthy to develop the more deadly types of cancer, an American study suggests.

Out of 39 types of cancer examined, 32 showed a significant association with poverty. Cancers associated with “lower incidence and higher mortality”, such as those of the larynx, cervix, penis and liver, were more likely to occur in the poorest communities, the US study found.

Cancers with lower death rates, including melanoma, thyroid and testicular cancer, were more prevalent in richer communities.

“The cancers more associated with poverty have lower incidence and higher mortality,” Francis Boscoe, of the New York State Cancer Registry and joint author of the report, said. “When it comes to cancer, the poor are more likely to die of the disease; the affluent are more likely to die with the disease.”

Dr Boscoe and his team investigated records of nearly three million tumours diagnosed between 2005 and 2009 in 16 US states, dividing them into four categories based on the poverty rate in the area….

 

It has to change. Listen to the effect the publicity of the NHS had on world economists at the Olympics.

ALTHOUGH the British National Health Service is under fire at home for its poor record, its model has drawn great interest from emerging economies

Listen to Sophie Delap, Home affairs correspondent interviews Anne McElvoy, Public Affairs Editor, in The Economist print edition Aug 5th 2013.

Values and philosophy seem “unlikely to change” according to Anne McElvoy. If the most influential elements of our society think that we cannot change where it really matters, what hope for the NHS? Covert rationing and a post code lottery with frontier issues will continue..

Here are original and the follow up articles from the economist.

The NHS – Health reform in a cold climate

And here are some other viewpoints:

Bitter Medicine – Reforming the NHS

Competition in healthcare a UK perspective

NHS tourism – Free for all – and growing

It makes sense to limit care

The NHS – Change at the top