Monthly Archives: July 2015

Building from nothing? A workforce for the Regional Health Services and rural areas…

Maureen Baker, the Chairman of the RCGP sent around a newsletter last week…

By the time the Roland Commission report is actioned, and makes a difference will we be building from nothing? A workforce for all the Regional Health Services is only possible with deliberate overcapacity and some sort of adverse selection. No mention of the rationing in selection where only 11:2 applicants are accepted to medical school..

Dear colleague,   The long-awaited Roland Commission report into the state of the primary care workforce, which was chaired by Professor Martin Roland of Cambridge University, was released this week and if the recommendations are adopted, it will spell good news for general practice, and our patients.

Particularly welcome is the Commission’s recognition of the severe shortage of GPs and the call to reverse longstanding under-investment in general practice.

The report echoes and supports a lot of the objectives of our Put patients first: Back general practice campaign. It calls for the rapid implementation of the College’s 10-point plan to build the GP workforce, which we launched with NHS England, Health Education England and the BMA earlier this year.

The report also advocates broadening the skill-mix in general practice, something that the College also supports.

We have already secured £15m NHS England funding for a pilot scheme of practice-based pharmacists, an idea we launched jointly with colleagues at the Royal Pharmaceutical Society back in March, and which we know already works in some areas of the country. We now want to see a pilot scheme to see how a new medical assistant role – successful in the US to help relieve the administrative burdens that GPs face in our daily practice – translates to UK general practice.

I understand that ideas about broadening the skill-mix in primary care has led to concerns amongst some of you, so I want to reiterate that this is not about replacing us – that will never happen. If properly piloted, evaluated, and then implemented appropriately, these schemes could provide much-needed support to help us meet intense demand.

New GPs can’t be created overnight and we need to take safe, innovative steps, to make our working lives a bit more manageable, both short-term and long-term.

Another recommendation in the Roland Commission’s report is an emphasis on new models of care, particularly GP federations, which the College pioneered nearly a decade ago now.

We are currently working with the Nuffield Trust to map out where federations and other ‘at-scale’ models of general practice are currently in place, so that we can learn about what works and what doesn’t. Please take a few moments to complete our survey to help shape this important piece of work, being led by Mike Holmes. There are two surveys; one for individuals and the other for Clinical Commissioning Groups.

The Roland Commission report provides further ammunition for us to persuade politicians and decision- makers that backing general practice really is in the best interests of the NHS and our patients, now and in the future.

We must particularly thank Vice Chair Amanda Howe, who sat on the Commission, for her considerable efforts in ensuring that the GP voice has been heard loud and clear.

Government plans inquiry that could mean end of NHS free at point of use – about time

It seems to have slipped under the radar somewhat but when NHSreality looked carefully there were references and comment on the article in the BMJ 21st July 2015 by Ingrid Torjesen (BMJ 2015;351:h3971).: Government plans inquiry that could mean end of NHS free at point of use . No other country in the world tries to pull the wool over it’s voters as much as the UK, and no other country tries to be free and comprehensive and cradle to grave! The The Information Age means that citizens will not be content with covert rationing..

Funding Black Hole NHS

The Department of Health for England is considering an inquiry to look at how the NHS should be funded to ensure its future sustainability, which some doctors fear could put in jeopardy a founding principle of the NHS: that it is free at the point of use.

The inquiry was suggested during a House of Lords debate on the “sustainability of the National Health Service as a public service free at the point of need,” which took place on 9 July.

At the end of the debate the parliamentary undersecretary of state for NHS productivity, David Prior, said that he was interested in meeting Narendra Patel, who moved the Lords debate, and “two or three others” to discuss how an independent inquiry looking into the long term sustainability of the health service might be framed. He did not think that the inquiry would need to be a royal commission but that an organisation such as the health think tank the Nuffield Trust or the King’s Fund could be commissioned to examine the issues.

Commenting on the potential inquiry, Clive Peedell, co-founder and co-leader of the National Health Action Party, said that the proposal seemed to have “slipped by very quietly.”

He said, “Premiums, charges, and, potentially, insurance schemes are obviously completely against the ethos of the NHS, and the public deserves to be involved in the debate, if that is what they want to talk about.

“All the evidence suggests that we should be sticking with a tax funded system—progressive taxation. That’s the fairest way to fund healthcare. If you bring in charging and insurance systems, that just transfers risk from the wealthiest in society to the poorest in society in terms of bearing the burden of healthcare costs.”

In the House of Lords Patel pointed out that close to 9% of gross domestic product was spent on the NHS, that 89% of NHS trusts were forecasting deficits, that outcomes, including those relating to cancer and avoidable deaths, were poor, and that the NHS needed to achieve productivity gains far in excess of the 0.4% year on year that it had attained historically. “In this scenario the NHS will need an annual budget of nearly £200bn [€290bn; $310bn] by 2030 and one fifth of the nation’s entire wealth by 2060,” Patel said.

“The history of the past two and a half decades tells us that political parties will continue to manage the health service according to their ideology—managing scandals and giving a bit more money—but with no long term planning, as there will be no political consensus,” he said. “We need a national consensus that recognises and accepts that individuals, communities—including employers—and the state have a role in health and contributing to it.”

The former Labour health minister and peer Norman Warner backed an inquiry, saying, “Our tax funded, largely free at the point of clinical need NHS is rapidly approaching an existential moment. The voices of dissent and outrage will no doubt be deafening, but a wise government should begin now the process of helping the public engage in a discourse about future funding of the NHS. To do that requires a measure of cross party consensus on some form of authoritative independent inquiry that could produce analysis and a range of options for a way forward.”

The Conservative peer Patrick Cormack added that all forms of funding must be looked at. “We have to have a plurality of funding if we are to have a sustainable NHS. Whether the extra funding comes from compulsory insurances or certain charges matters not, but it has to come,” he said

Prior said that, having looked at many other funding systems around the world, he was “personally convinced” that a tax funded system was the right one. “However, if demand for healthcare outstrips growth in the economy for a prolonged period, of course that premise has to be questioned,” he said.

The health secretary for England, Jeremy Hunt, last week refused to guarantee that the current system of funding would remain. After a speech at the King’s Fund in which he set out a 25 year vision for the NHS,1 Hunt was asked whether the budget would continue to be funded by taxpayers for the next 25 years. He replied, “I am confident, but I don’t have a crystal ball.

”Iacobucci G. Hunt promises more transparency and fewer targets in “more human” NHS. BMJ2015;351:h3885.

The Health Services need a new electoral system – Sudden swings in direction, funding, and organisation are killing health systems..

Rationing a Global Perspective

Rationing and Models

Waiting lists are rising: Marie-Louise Conolly 22nd July 2015: Musgrave Park Hospital’s waiting list rises by 75%

The Budget is under duress: Hugh Pym 22nd July 2015: The health budget – under strain again and care of the elderly is impossible to fund (Nick Triggle 24th July 2015 – Is the cap on care costs doomed?)

Jon Stone in The Independent opines 17th July: The principle of a free, taxpayer-funded NHS ‘must be questioned’, says Tory health minister

and Cory Doctorow in BoingBoing 16th July remains in cloud cookooo land: UK Tories launch quiet inquiry into privatising the NHS

NHS’s financial problems need one solution, not many

No mention of rationing or co-payments… this means the eventual solution will be more knee-jerk and less debated, and NHSreality feels the solution proposed will not be based on philosophical and moral/ethical criteria. Meanwhile denial will continue.. and rural areas will suffer….and the charities will deliver more core services

Image result for financial problems cartoon

Chris Hopson reports 24th July 2015: NHS’s financial problems need one solution, not many – A collaborative approach is needed between local and national systems to ensure the NHS stays within its 2015-16 budget

The latest evidence, such as the King’s Fund Quarterly Monitoring Report (QMR) published last week, shows that the NHS faces a significantly more difficult challenge to stay within its budget this year than it did last year.

There are a number of possible responses from NHS frontline leaders to this problem. One would be, “The only way we can manage 2015-16 without the system crashing is for the government to inject more money and admit the current challenge is undeliverable”. Another might be, “Making the NHS numbers add up is a system level responsibility of the department of health and the arm’s length bodies, not ours”. A third would be, “We can only deliver by forgetting about everyone else and sorting out our own problems”. These responses are understandable and justifiable, but they ignore the risk the NHS runs by missing its 2015-16 targets. The NHS, along with social care, is the only public service to experience 4% increases in demand annually. But it’s also the only one to have the combination of its budget being ring-fenced; an extra £2bn-ish for 2015-16 in the autumn statement; and the promise of real terms growth for the remainder of the parliament. Other Whitehall departments have had to contribute £3bn of in-year savings in 2015-16, admittedly boosted by a £200m raid on public health budgets. So the government has said there is no more money for the NHS in 2015-16.

Failure by the NHS to stay within its 2015-16 budget would risk a crisis of confidence in central government and across Whitehall. We need to be alert to the arguments that others will make. If the NHS can’t deliver financial balance with all these advantages, why put more money in? Why frontload the NHS’s extra £8bn (which we desperately need)? Let the NHS demonstrate appropriate financial discipline first. Why bother investing in an NHS transformation fund if the health service will always be a bottomless money pit that cannot transform? There have already been mutterings of this kind in the national media.

So there is a strong argument for the need for a concerted one NHS solution to a large one NHS problem – a collective responsibility and shared endeavour to ensure the health service stays within its budget. Our members tell us they need a number of things from national system leaders if they are to apply the in-year spending handbrake quickly and sharply.

They note that in many places there is a significant gap between commissioner and provider activity plans and budgets, which suggests that not all the extra autumn statement money is reaching the provider frontline as planned. This needs to be bottomed out quickly. System leaders are placing a lot of reliance on new agency staffing controls to reduce staffing spend but the QMR shows this may be overoptimistic. Our members tell us they need clearer and more obvious signals around the staffing/finance balance if they are to recalibrate in favour of the latter. They need to know that they won’t be at regulatory risk if they make sensible judgments to ensure this recalibration while continuing to deliver the right quality of care.

Our members tell us they could also look at delaying capital expenditure, which could be turned into local revenue. They also say it’s important for system leaders to be role models for the right behaviours – for example, by rapid vacancy control and delaying non-essential spending across the department and its arm’s length bodies.

The Five Year Forward View talks about the importance of a new relationship in which the national NHS system supports local leaders. A collaborative local-national partnership to ensure the NHS delivers its 2015-16 budget would be a great place to start.

OOH GP services – A Shameful reduction in standards, and increase in expense

ITV enquiry by Alice McShane and Produced by Sam Collins reported 22nd July 2015: ‘Shocking failures’ of after hour care

What happens if you fall ill out of hours? You’d hope you’d be able to access the same standard of treatment as you would during the working day. But is this really the case? A recent undercover investigation of our NHS Out of Hours service for ITV’s Exposure series has alleged “shocking failures ” in patient care. The programme sent Mark Austin and undercover reporter Alice McShane to a privately run Urgent Care Centre in West London and today they join us to tell us what they saw.

Nothing is shocking to us GPs who provided both normal and OOH (out of hours) services during most of our working lives. Some of the best and most rewarding years of my professional career as a GP was when we had a local GP co-operative. All the GP principals were involved, and we met to exchange ideas on improvement and treatment protocols, and helped each other with cover for sickness etc. When Mr Blair and the Labour government offered us “exit” in 2004 (BBC news 30th Jan 2007) without significant financial hardship we were stunned but grasped the offer… But the service for patients now is not as good as it was 10 or even 20 years ago.. And it costs a lot more in real terms… A shameful reduction in standards, and increase in expense… politicians are the guilty ones. They have created the system which is driven by lies and perverse incentives. Combined with rationing of doctors and nurses, It will lead to more litigation..

The program has some jargon on Key Performance Indicators (KPI) being fudged, and the evidence that OOH is more target friendly than patient friendly. Dr Mike Smith (A Hammersmith locum and also director of Haverstock Health, another OOH provider in North London) says “We have reached a point where disregard for basic processes to ensure basic patient care and safety are being ignored……. The whole thing only works if you have a GP trained in risk management at the front door.. Attitudes to patient care are questionable..”

It is not a requirement to have A&E experience to qualify as a GP, although it is desirable.. Nor is it a requirement to be able to read X rays, but there are few doctors willing to do this job, so relatively untrained personnel are appointed.

In the OOH centres, failing to meet targets means less cash, and less profit if the targets are not met. Therefore, the targets are “gamed” to ensure profit.. E.g. Early discharge within 4 hours, with unofficial follow up afterwards seemed commonplace..

A barrister, Simon Butler said “there are serious concerns about what Care UK contracted to do, and the reality of the service”… There is good evidence of understaffing at an average of 20% and as high as 50% undercapacity at peak demand times..

Catch up with the last week of This Morning on ITV Player

22/03/2013: Patients Association Criticise GP Appointments and Out Of Hours Service

Caring for your elderly and “continuous care”

2/5/2013: NHS watchdog severely reprimands Serco – a private company providing out of hours (OOH) GP services in Cornwall

3/10/2013: GP crisis. Out of Hours (OOH) and Out of Doctors – A&E Attendances

27/06/2015: OOH (Out of Hours) is very variable, and a disgrace. There is “No effective oversight”.

It was the best job in the world – for me 1979-2012 – but now there are not enough of us to cover the country

Setting sail in a boat already holed. The new government will fail unless it rations health. Proportional representation would be better than the inevitable mess to come..

Why are we not controlling cancer pain adequately in the community?

The True History of GP Out of Hours Services | A Better NHS

The NHS and reckless election promises. How about posthumous voting?


The media does publish “good news” – but far too early, raising expectations unreasonably…. Do you know what is not covered in your Regional Health service?

The media does publish “good news” – but far too early, raising expectations unreasonably. Eastern researchers are not held in great esteem and this work on prevention of cataracts needs to be validated and confirmed in the West. Meanwhile, for many years to come, second cataracts will be rationed out by some post-code administrations, and prevention of the speed of dementia onset will suffer the same covert rationing… Do you know what is not covered in your Regional Health service?Oliver Moody in The Times 22nd July 2015 reports: Cataract eyedrop treatment offers thousands hope

Eyedrops that may cure cataracts have been developed by scientists in a breakthrough that could eliminate the need for surgery. British doctors carry out an estimated 300,000 operations to remove clouded lenses each year, making it the most common surgical procedure in the country.

Although the operations are cheap and take as little as half an hour under local anaesthetic, a drug that can sort out the condition without the need for patients to go under the knife would be a significant advance.

A team of Chinese scientists studied the DNA of two families with a genetic predisposition to cataracts and found that they shared mutations of a gene called LSS, linked to the production of an important structural molecule.

The lens, which refracts light on to the retina at the back of the eye, is made up of millions of slender, fibrous cells containing proteins called crystallins, whose density plays a role in determining the clarity of a person’s vision.

Cataracts form when these proteins become damaged and the cells make opaque clumps that scatter light. Lanosterol, an enzyme produced by the LSS gene, appears to break these structures down in the healthy eye and keep cataracts at bay.

Tested on cloudy lenses taken from rabbits and on live dogs with cataracts, the compound was found to make their eyes significantly clearer and to break up the clusters of proteins on a molecular level. Scientists hope that it will have the same effect on people.

“Cataracts are the leading cause of blindness and millions of patients every year undergo cataract surgery to remove the opacified lenses,” they wrote in Nature. “The surgery, although very successful, is nonetheless associated with complications and morbidities. Therefore, pharmacological treatment to reverse cataracts could have large health and economic impacts.”

In an accompanying editorial J Fielding Hejtmancik of the US National Eye Institute said that the drug showed great promise. “The potential for this finding to be translated into the first practical pharmacological prevention, or even treatment, of human cataracts could not come at a more opportune time,” he wrote.

Because it has to bend light with such precision, the lens is one of the most delicately structured parts of the body, and the crystallin proteins that govern its shape are some of the densest human tissues.

As people age these proteins are not replaced and the fibre cells in the lens lose their alignment, often leading to a natural clouding effect in the eyes of old people. The cells can also be damaged by ultraviolet light from the sun.

Dr Hejtmancik said that a drug for treating or preventing cataracts would be of particular use in places where surgery was not cheaply available.

“Although surgery to remove cataracts is efficacious and safe, ageing populations around the world are predicted to require a doubling of cataract surgery in the next 20 years,” he wrote.

“The same population demographics suggest that the need for surgery could be reduced by almost half.”

Tom Whipple in the same paper reports: New drug could slow progress of Alzheimer’s

….After decades of failed attempts costing pharmaceutical companies billions of pounds, a manufacturer has released the results of a human trial that it says shows that it is possible to slow the rate of decline in patients with the disease.

…Although the effect of the new drug, solanezumab, was small, researchers said that it could have exploited a crucial chink in the disease’s armour, pointing the way to better treatments. However, others cautioned that the trial was too small to consider the results a breakthrough in what remains a poorly understood neurological illness….

Gone, but not forgotten | The Economist




New plan to develop frontline NHS Wales workforce

Recruitment to Wales is a problem because the aspirations of doctors and surgeons are for excellence. They hope their children will aspire as well, and the infrastructure and the attitude of the politicians needs to support such aspiration. This used to be the case, particularly in Education, where teachers from Wales were highly valued and sought after in the first half of the last century. With the WG elections next year, the last thing the assembly will want is Hospitals closing because of lack of applicants. Perhaps some are considering Australia? (Australia offers free weekends to lure NHS consultants)

The Aneurin Bevan Health Board on Friday 17th July announces yet another move to help recruitment. “New plan to develop frontline NHS Wales workforce“…

A new plan to strengthen the primary care workforce to deliver new models of care and look after more people close to their homes has been published by Health and Social Services Minister Mark Drakeford today
The primary care workforce plan will be backed by an extra £4.5m of funding as the Welsh Government continues to invest in primary care to recruit, educate and train the wide range of healthcare professionals who are key to providing health services in local communities.The majority of patient contacts with the Welsh NHS are in primary care services, such as GP surgeries; NHS dentists or local opticians. The plan outlines how the Welsh Government will continue to invest in GPs, community nurses, pharmacists, healthcare support workers and other clinical staff to provide more care closer to people’s homes and move services out of hospitals.

The plan supports the continued development of the 64 primary care clusters across Wales, which include GPs working with pharmacists, dentists, optometrists, therapists, nurses and healthcare workers.

It calls for a more robust and joined-up approach to workforce planning, including greater sharing of information, which will help redesign ways of providing care outside hospitals.

The strategy also includes a number of actions to stabilise core sections of the workforce, including GPs and nurses, by supporting people who want to return to practice or work part-time; exploring how training and working in general practice can be encouraged in areas of greatest need and communicating the opportunities afforded by general practice in Wales.

Measures include:

  • Increase the number of Welsh Government-funded places on return-to-nursing practice courses
  • Investment in advanced and extended skills, including non-medical prescribing and advance practice education
  • Working with health boards and universities to develop an education and training programme for physicians associates in Wales
  • Establish how Wales can move to a position where multi-professional training becomes the norm for centrally-funded NHS education programmes
  • Expand the range of care settings in which training can be carried out and build on the experiences of learning wards in community settings
  • Analyse existing and future Welsh language population needs and the support needed by the workforce to meet those needs
  • Establish a national programme of organisational development for the 64 primary care clusters
  • Expand the GP retainer scheme, which offers flexible working opportunities to encourage professionals thinking of retiring to stay in work part-time
  • Reimburse medical school fees when a newly-qualified doctor commits to a career in general practice
  • A national GP recruitment campaign promoting the benefits of a career in Wales
  • Changing the law to make it easier for GPs registered to work in England to work in Wales for short periods of time without the need to make a full application to join a Welsh health board’s performers list
  • Working with medical schools to increase the proportion of general practice and community placements medical students experience.
ProfessorDrakeford said:“Our goal is to meet the rising demand for healthcare by making the most of the skills our dedicated primary care workforce already have and supporting them in their continued desire to innovate and improve the services they provide every day.

“This can be achieved by bringing together teams of people with the necessary skills to meet the needs of people and the local communities they serve. It is also important that everyone in those teams works at the top of their clinical competence – they only do what only they can do.

“This prudent healthcare approach to developing our primary care workforce will improve access to care and the continuity and quality of that care.  It is also central to rebalancing the workload of all those who work in primary care so roles and services are sustainable and can adapt to meet future demand.”

Australia offers free weekends to lure NHS consultants

Government should not be surprised or offended. After all, we have been stealing doctors from Africa, and the Indian subcontinent for years, and only allowing 11:2 applicants to have places to train in Medical School here in the UK. (Medical Schools: your chances – applications-to-acceptance ratio was 11.2.) Who would want to be a consultant in the UK when the minister derides their contribution …?

Improving safety needs a “buy in” by professionals. Scapegoating and denial, and causing antagonism are not the way to treat professionals.. but they might start a war.

Kat Lay in The Times 22nd July 2015 reports: Australia offers free weekends to lure NHS consultants

Australia is sending a message to NHS consultants: come and enjoy our glorious sunshine and beaches and we will not make you work seven days a week.

Health recruiters are trying to lure British consultants with big salaries and promises of a better “work-life balance” after the health secretary’s threat last week to impose seven-day contracts.

An email advertising six-figure salaries for consultant radiologists said that the weekend working contract might mean that it was “time to start thinking about a new life in Australia”.

The BMA said that it showed that Jeremy Hunt’s speech last week, in which he said he would remove opt-outs of weekend working from new consultant contracts, had been “a spectacular own goal”. Two online petitions against Mr Hunt continuing as health secretary have amassed more than 200,000 signatures between them.

The email sent to doctors last week from the Head Medical recruitment agency based in Edinburgh promised that in Australia “the work/life balance not only genuinely exists as a way of life, but is also promoted by the employer as a unique selling point.”

Mr Hunt, speaking at the King’s Fund last Thursday, said: “No doctors currently in service will be forced to move on to the new contracts, although we will end extortionate off-contract payments for those who continue to exercise their weekend opt-out.”

He accused the BMA of being “a roadblock to reforms”, adding: “Be in no doubt: if we can’t negotiate, we are ready to impose a new contract.”

A BMA spokeswoman said: “His attack on the profession is being used as a recruitment tool to lure doctors away from the NHS at a time when many parts of the health service are facing a recruitment and retention crisis.”

The pay scale for consultants in England starts at £75,000 and goes up to £101,000 after 19 years. In contrast, there are adverts for a £190,000 general surgeon post in Queensland, a £165,000 psychiatry post in Queensland and a £118,000 emergency medicine consultant job in New Zealand.

The email from Head Medical sought consultant radiologists with salaries from £125,000 to £400,000.