What’s life as a GP really like down-under?

As the pressure on UK GP’s reaches breaking point many have already left for a new life Down- under. Here is the feedback from a few of  those who have already left …. The endgame as a result of rationing by undercapacity over many years..

‘Sydney is awesome. Living on the Northern Beaches near Manly now and absolutely loving it. Australia was a fantastic move and I haven’t looked back. Working as a GP here is very refreshing and would recommend it highly!’

‘Well city life won for me and I love Newtown. 15 mins to work in the city by car. Lots of great shops and cafes etc. In fact, I love Australia! Re GMC – I’m changing to no licence to practice as I’m not planning to move back.’

‘Adelaide is an awesome city for family – distances short, schools excellent and cultural as well…I’ve been here 7 years. The beaches are incredible and the wine rocks…‘

‘Cronulla for a beach life has lots of cafe shops. Rent for a 2 bed flat 5 mins walk to the beach and train to city about 55 mins costs $475 a week.‘‘I hear Mornington Peninsula is beautiful.‘

‘Melbourne is 5 times bigger than London with half the population so 10 times less dense…I live in Port Melbourne. Am at work….another writes ‘I’ve got my interview tomorrow am for a Melbourne post so hopefully join you soon.’ UK GPs seem to congregate in the same apartment block in Melbourne!

 From a doctor who made the move

“Clinically, general practice in Australia is not dissimilar to the UK. The types of cases are similar, but with potential for wider scope, for example minor injuries and plastering, particularly in rural areas.

The role of nurses here is much more variable and is evolving. The gatekeeping role of the GP has less of a focus in Australia and there is more clinical freedom in prescribing and making referrals. Access to diagnostics is also much easier.

The workload is less intense here, with most GPs offering 15-minute appointments and the demand for home visits not as great. The amount of paperwork GPs are required to do in Australia is significantly less in comparison with the UK.”

How much can I expect to make?

A recent job advert offered approx 40k more than the average GP partner pay for a lot less worry and hassle ( administration makes up a huge amount of the time spent at work  as a partner).

LocationGold Coast, Queensland

Salary65% of billings – Income approx $300k AUD (£140K)

Below are some comments from GP’s  working in Australia 

 

‘I was told via the practice partner the average is 250 after their 40% cut.‘

‘AUTONOMY is everything. You should work WHEN you want and HOW you want. The numbers for earnings will not easily come in the 1st year – once the patient base is settled and you have a long term client base and do all the chronic disease management, then it will be lucrative. The money will come but the ability to work when and how you want is worth its weight in gold.’

‘Una, it depends on the practice and percentage of earnings given to you by the business owner. One can easily make up to $8,000 ie £4,000 per week if one chooses to work 6 days. Some practices promise big earnings but do not deliver and some doctors can earn as little as £2,000 per week. Earning £100,000 annually is ok here without working too hard but without a pension, people here invest in real estate instead.’

 

‘Dear Jezza

I’m never coming back from AUSTRALIA!! I made £200k last year, when I worked for your predecessor I was a miserable GP partner aged 33 burning out for around £100k. My wife never saw me, my kids were in bed when I got home and all I had the energy to do after work was sleep. You can keep your crappy contract, you can keep your crappy ideas….

I just don’t give a sh&t anymore. IM FREE. Free from your dictates, free from the guilt and shame at working hard and trying to make a better life for my wife kids, I’m free from the garbage mentality that it pervading Britain, the culture of entitlement………….. I’m free of the bloody hassle it is is getting anything done in the uk because everyone is so bloody miserable and abused they try to shaft the next man because they themselves are being shafted by someone else and so the vicious cycle of the shaft continues unabated. I’m free of the class system that protects the landed gentry, I’m free of the fear of a vexatious complaint and a GMC referral and a public dragging of my name through the dirt before I’m hung drawn and quartered. I’m free of all these tosspots who claim to represent me but who actually lie whilst they feather their own nests while I pay for the self inflicted caning. I’m free from all the do good GPs also that would rather self suicide than actually try to stand and fight for the profession with some good old fashioned proper action.

Link to the original post here

The BMA also provides some information of moving to work in Australia

Working in Australia( click to view original article)

Healthcare system

Australia has a healthcare system that is managed by both the Australian Government and the State or Territory Governments. Australia’s public healthcare system, Medicare, is funded largely from general taxation, which includes a Medicare Levy based on a person’s taxable income. Australia’s public hospital system is jointly funded by the Australian government and State or Territory governments and is administered by State or Territory Health Departments.

1 in 5 mentally ill children turned away by the NHS. The “random walk” of health care decision making…

Rosemary Bennet reports in The Times 12th May 2015: 1 in 5 mentally ill children turned away by the NHS – A clear case of covert rationing. Why have a cancer drugs fund with poor outcomes when we turn away mentally ill children? Because the media like cancer stories, and they dislike mental health stories, and the politicians are afraid to challenge them with an ideological argument. After all, if there is no rationing, but simply “random walk” of post-coded restrictions and priorities there can be no debate…

More than a fifth of children with serious mental illnesses who are referred for specialist treatment get turned down, according to new figures.

The most common reason given was that their condition was not serious enough to reach the threshold for treatment. Lack of investment in children’s mental health services, despite soaring demand, has forced many NHS services to raise their thresholds for care.

Experts say that this means children must wait until their conditions worsen, and even become suicidal, before they are referred again for treatment. By then their illness is invariably more complicated to treat.

Inquiries made under the freedom of information act to NHS mental health trusts in England found that 39,652 children who were referred by GPs to Children and Adolescent Mental Health Services last year were turned away. Experts say it is often difficult to get a referral, with many doctors adopting a “wait and see” approach, hoping the situation will resolve itself.

Even those who do get accepted for treatment can be in for a long wait. In Croydon, South London, children were waiting more than 16 months after being accepted for treatment, a study found. The longest waiting time was 92 weeks.

The data was compiled by the NSPCC which said it was particularly concerned that children who have been abused and neglected are not getting the help they need, even though it is well established that these experiences are a trigger for many mental health problems.

“If children don’t receive the right kind of help and support, the damage can last a lifetime and include post-traumatic stress disorder, depression or suicidal thoughts in adulthood,” said Peter Wanless, chief executive of the NSPCC.

“Not addressing their needs early on is just creating a time bomb of mental health problems. There is a vacuum that needs to be filled and it needs to be a national and local priority.”

The government has pledged to spend £1.25 billion extra on children’s mental health services over the next five years. However it has decided to spend only a small part of this over the next 12 months; £143 million is pledged for eating disorders and post-natal depression.

It has agreed to a study to calculate how much worse children’s mental health has become. The last one was conducted in 2004. It is unlikely the results will be seen before 2018.

Last year four of the top ten issues for ChildLine, the helpline run by the NSPCC, concerned mental health, including self-harm and suicidal thoughts. Counselling sessions run by the helpline for self-harm have tripled in the past three years to 24,308. Sessions involving suicidal thoughts have doubled to 17,930.

Sir Hughes-Hallet proposes “Healthforce” – an army of volunteers to “stop NHS sinking”. It might work in Wales, but rationing overtly still has to be part of the package.

Sir Hughes-Hallet proposes “Healthforce” – an army of volunteers. It just might work in social Wales, but rationing overtly still has to be part of the package. This is the distasteful tablet that the politicians are unwilling to swallow.. As soon as it is clear that the service is well founded and sustainable for the future the professionals will come on board again. An army of ageing volunteers does not appear sustainable to NHSreality. He remarks on the need for clear leadership, poor morale, doctor exodus, and attempts to start the debate without mentioning rationing.

On Radio 4 on 12th October 2015 reported in Today: NHS trust chair, Sir Hughes-Hallet (Chairman of Chelsea and Westminster Trust) proposes alternative solution to NHS funding crisis – Listen!

Sir Hughes-Hallet proposes 3 options and says that “the route of the problem is we need to be honest with the public” and “…by explaining to the public that we might have to reduce the offering of free health care, unless we take one of three measures that would solve the problem”:

1. Significantly more new money

2. “Reduce the menu”. Clearly fund emergencies for free – but charge for other services.

3. Radical thinking. “Healthforce”. Use an army of volunteers backed up by data and technology, to empty hospitals.. We must not be afraid to “care”…

He points out that in 1942 Lord Beveridge said specifically “that we should not take away from the citizen the entrapaneurship of caring for their own healthcare”… NHSreality found this podcast inspiring. Will he be listened to? Will politicians suddenly become honest on health?

Recent BBC news bulletins have been more vocal on the crisis.

Nick Triggle 9th October: NHS deficits hit ‘massive’ £930m

Hugh Pym on 9th October: Latest NHS accounts show growing deficits and What’s gone wrong with NHS finances?

Panorama – NHS – The perfect storm 3rd June 2015

and Mark Smith and Clair Miller in Walesonline (Western Mail) 12th October report on a symptom of the parlous state of the Welsh Health Service: Welsh NHS spends £19m on private healthcare in just 12 months  – perhaps it will get worse with the only new proton beam therapy in Harley St!

NHSreality posts:

Rationing in the recent news. Obscene denial of the truth by politicians…There’s a painful list of conditions we are no longer treating on the NHS

Listen to the eminent, the great and the good on Radio 4. Nobody suggests rationing overtly – yet..

Update: The parlous State of NHS Wales and its aspirations does not help doctor recruitment.

Devolution of health to Wales was a mistake?

Nuffield Trust reports on “Future Model Options” in Primary Care – an acceptance that the status quo is mad…?

Patient co-payment for general practice services: slippery slope or a survival imperative for the NHS?

Labour philosophy on health – in Wales anyway – explains some of the thinking which has led to the current crisis.

Rationing in the recent news. Obscene denial of the truth by politicians…There’s a painful list of conditions we are no longer treating on the NHS

A search for “News Items” related to Health Services rationing in the last 6 months reveals a number of clear cases of covert rationing which are not accepted as such by politicians and managers and administrators. They call them restrictions or prioritisations – but its the same as food during the war. The denial to see and describe from their voters perspective is obscene. If veracity is a virtue, then politicians have none:

The Guardian 7th April There’s a painful list of conditions we are no longer treating on the NHS  and 24th April 2015: Rationing care is a fact of life for the NHS

The Independent 13th May 2015: Vasectomies being given the snip as GPs in Essex told they must ration number of procedures

GPonline 10th June 2015: Exclusive: Obese patients denied surgery by NHS rationing

The Edinburgh Evening news 11th June 2015: Horrified carers slam ‘rationing‘ amid funding crisis  and the Daily Mail on the same day: Prostate cancer patients to be denied drug enzalutamide which stops disease spread

The Local Government Chronicle 18th June 2015: Hearing aid rationing plan gets council green light

The Guardian 20th July 2015: Rationing of weight management services undermines health efforts

The World Socialist Website 27th August 2015: NHS hospitals face massive deficits and demands for further cuts

The Telegraph 4th September 2015: Thousands of cancer patients to be denied treatment

The Local Government Chronicle on 7th September 2015: Nearly a third of CCGs consider rationing services

The Grimsby Telegraph 8th September 2015: 17 cancer drugs to be withdrawn for patients by NHS

From the USA – The Hartland Institute 4th June 2015: Obamacare’s Muse: The UK’s NHS and The Tyler morning Telegraph (US Republican) 9th September 2015 British NHS shows the future of ACA ( Affordable Care Act) – When supply is limited but prices are fixed, there’s only one way to deal with high demand – rationing……

The Mail 17th September 2015: Cancer drugs fund ‘is not sustainable’ after exceeding its budget by 50% – a short-term basis which are awaiting approval by the NHS rationing body … ‘However, at a time of increased pressures on NHS funding, the Cancer 

The Express on 22nd September:Non-invasive liver damage test gets NHS approval – THE NHS has begun rationing hearing aids in the push to find £22billion in so-called ‘efficiency savings’ even though experts and charities warn the …

WebMDBoots report 29th September 2015: Rationing body ‘yes’ to leukaemia drug and 23rd September Non-invasive liver damage test gets NHS approval

Pulse 1st October: More NHS services will be ‘rationed‘ under ministers’ plans

Government plans for NHS ‘efficiency savings’ cannot be delivered without rationing of services, Labour’s new shadow health secretary has warned.

The Daily Update 2nd October 2015: The NHS Is Set to ‘Ration’ Hearing Aids – Yet 4 Million Could Benefit from Them: Hidden Hearing …

 

Listen to the eminent, the great and the good on Radio 4. Nobody suggests rationing overtly – yet..

The denial continues despite the Kings Fund and the United Nations warning us … Listen to the eminent, the great and the good on Radio 4 since the announcement of the deficit. Nobody suggests rationing  overtly – yet.. it is the GPs who have made the Health services efficient for many years, but lack of numbers, over-management, demographic changes, stupid innovations and obscene perverse incentives have all but destroyed them. IT overspend as a result of strategic failure compounds the problems.

 Thinking of this as a financial problem is incorrect. It is an ideological and philosophical problem manifest in the finance. THE  different Regional Health Services (there is no NHS now) are insurance based. Should there be a co-payment? Is there benefit in hypothecated taxation? Should there be regional differences in delivery? Should there be overt rationing of health services so that patients know what is not available to them in their own post code? Should the value of all goods and services be made overt to patients? Should the system encourage autonomy as much as possible? Do we believe in “deserts based rationing” for some people/goods/services? Do we believe in Everything for everyone for ever? And that’s without mentioning choice…

Chris Smyth for The Times reports 10th October 2015: Hospitals heading for £2bn overspend

NHS hospitals have run up a record overspend of £1 billion in three months, prompting regulators to warn that the health service cannot carry on as it is.

Experts say the deficit means that patients will wait longer and receive poorer care as bosses struggle to balance the books.

A ballooning agency staff bill and relentless demand from an ageing population have pushed more than three quarters of hospitals into the red as they struggle to achieve efficiencies at the rate demanded by ministers.

A string of targets on A&E waiting times, ambulance response times and cancer treatment were missed in the first quarter of 2015-16, according to delayed figures from regulators.

Ian Wilson, of the British Medical Association, said: “These figures are staggering. The NHS is facing a funding crisis the likes of which we have never seen.”

Overall, NHS trusts overspent by £930 million between April and June, more than the £822 million deficit in the whole of 2014-15, and are on course to reach £2 billion this year.

Analysts urged the government to produce a plan to help the NHS to make the £22 billion of efficiencies demanded by 2020, but officials insisted that savings would kick in soon.

David Bennett, chief executive of the regulator Monitor, told hospitals that “radical and long-lasting change” was needed immediately. “The sector is under massive pressure and must change. The NHS simply can no longer afford operationally and financially to operate in the way it has been and must act now to deliver the substantial efficiency gains required to ensure patients get the services they need,” he said.

NHS bosses protested that they had been hit by a “triple whammy” of rising demand, a funding squeeze and the need for extra staff after the Stafford Hospital scandal. Hospitals spent £648 million on agency staff in the three months as they struggled to find permanent doctors and nurses.

Richard Murray, director of policy at the King’s Fund think tank, said: “The government must now acknowledge it cannot continue to maintain standards of care and balance the books. Unless emergency funding is announced in the forthcoming spending review, a rapid and serious decline in patient care is inevitable.”

Heidi Alexander, the shadow health secretary, said ministers were in denial. “With a difficult winter approaching, hospitals are facing a stark choice between balancing the books and delivering safe care,” she said.

Publication of the figures was delayed for more than a week and Nigel Edwards, chief executive of the Nuffield Trust, accused ministers of an “overly leisurely” attitude. “Financial problems on this scale cannot be explained by individual pockets of mismanagement. We are looking at a systemic problem across the health service,” he said.

A spokesman for the Department of Health said: “The NHS must play its part in delivering efficiencies, so we’re taking action to help hospitals clamp down on rip-off staffing agencies and cut spending on management consultants. We expect the impact of these measures to be reflected in figures released later in the year.”

Nick Triggle reported 9th October for BBC News: NHS deficits hit ‘massive’ £930m (as usual the BBC reports first)

 

 

The Unintended consequences of CQC inspections

An Editorial in the Journal of the Royal College of General Practitioners (DOI: 10.3399/bjgp15X686809 Published 1 October 2015 ) points out The Unintended consequences of CQC inspections. GP partnership is like a marriage – and they sometimes fail, just like hospitals. The epidemic of practices under special measures is sometimes about recruitment, but at other times a result of partnership breakdown..

The Royal College of General Practitioners (RCGP) is working in partnership with the Department of Health and NHS England in a pilot programme to support practices which have been placed in special measures following a Care Quality Commission (CQC) inspection.¹

Although it is too early to evaluate the pilot, our early experience of working with practices in special measures has uncovered some unintended consequences of being placed in special measures, which could impact negatively on the quality of care received by patients.

Blake, Sparrow, and Field outlined the new methodology for CQC inspections focusing on quality and highlighted the five key questions introduced in April 2104.² Since 1 October 2014, CQC reports have rated practices on a 4-point scale: ‘outstanding’, ‘good’, ‘requires improvement’, and ‘inadequate’. This January the CQC announced that all practices rated as inadequate would enter special measures, acknowledging that previously there had been a lack of clarity over which inadequate practices would enter special measures.³

By the end of May 2015, of the 1164 general practices inspected, 33 (2.8%) have been rated inadequate and placed in special measures. To set this in context, 29 (2.4%) have been rated outstanding, 656 (56%) rated as good, and 106 (9.1%) rated as requires improvement, the remainder not being rated for a variety of reasons. Currently there are 9325 providers of general medical services registered with the CQC. The experiences detailed below are derived from a mix of practices in disparate parts of England, all sharing the common characteristic of being rated as inadequate following a CQC inspection.

EMERGING THEMES

Difficulty with recruitment and consequent staffing costs

Common themes within practices in difficulty include inadequate clinical staffing and lack of effective leadership or practice management. Attempts to rectify these issues may be hampered by placing the practice in special measures. We have experienced staff recruited prior to the announcement of special measures either withdrawing their application or deciding not to sign a contract once the situation is public. There appears to be a fear among healthcare professionals, especially GPs, that they could be placing themselves or their career at risk by working in such an environment. There is also a risk that struggling GPs unable to get jobs elsewhere can end up in struggling practices, which may contribute to complaints and poor practice.

Not surprisingly, we have found that suitable applicants willing to work in a challenging environment are tending to seek a financial premium. For GPs this can be significantly above the usual rate. Because of the current difficulties in GP recruitment and retention, which is a national and well-documented issue, these requests have been acceded to, as the alternative would be a shortfall in clinical cover further compromising the effectiveness and safety of the practice.

This issue can be mitigated by advertising specifically for GPs and practice managers who are interested in helping turn a practice around, seeing this as a challenge and a way of furthering their career aspirations by taking on an unusual situation and being tested in the leadership competences.

The secondary consequences of this for the local health economy on driving up GP salaries and locum cover rates is apparent and it would seem that this is a significant worry for neighbouring practices and the local medical committees (LMCs). In addition, higher salary levels have the potential to cause difficulties to any provider seeking to merge with or take over the practice in special measures.

Undue strain on management systems

All practices placed in special measures to date have been judged as inadequate in the ‘well led’ domain and one could therefore assume that there are already significant leadership issues, both clinical and managerial, in this group of practices.

Being placed in special measures generates a significant workload to respond to CQC warning and compliance notices. Writing improvement plans, responding to similar requests from NHS England, and attending quality meetings takes resources and personnel away from their usual roles. This puts the ongoing safe running of the practice at risk with staff torn between producing CQC and NHS England paperwork to tight deadlines or trying to run the practice. One or other suffers as a consequence. The workload would be immense for a well-functioning practice and for those in special measures that are likely to have underlying management issues the risk is that the tipping point is reached.

This could and should be mitigated by coordination between the CQC and local stakeholders to reduce the number of written reports, and balance the requirements for written reports, with the need to undertake urgent actions necessary to ensure patient safety. The RCGP teams, where involved, have played a significant role in supporting and facilitating the generation of the required documentation.

Staff morale

Inevitably, working in a practice that is struggling puts a strain on staff, but when your workplace is publicly reported as being inadequate this can take a huge toll on staff, many of whom work in their own local communities. We have heard anecdotal reports of receptionists being harangued in the supermarket, but also of cakes being brought for staff by sympathetic and grateful patients. Staff meetings (in known struggling practices) need to be more frequent and communication more robust, thus increasing the strain further on an already overstretched leadership team and risking taking time away from patient care.

We have observed that practices are less likely to be stressed by the experience of special measures if there is effective and timely communication between the CQC, the practice, and key stakeholders such as NHS England area teams, clinical commissioning groups (CCGs), and LMCs. When feedback to the area team and practice at the end of a CQC inspection has not reflected the final written report, valuable opportunities have been lost. Where such communication has been good (approximately 30% of practices we work with), and practices have acknowledged the improvements needed, they have been able to prepare staff for the CQC outcome, start working on identified weaknesses, and think about how patients will be involved in the process.

Patient morale

No patient wants to hear that the practice with which they are registered is offering an inadequate service, despite the fact that some may have been dissatisfied for some time and indeed expressed their concerns. Some patients want to express their sympathy and support to the practice staff and we have seen examples of very constructive help being offered by well-functioning patient participation groups (PPGs). A good example of this would be the chair of a PPG working closely with a newly-appointed practice manager to improve access. However there is also an inevitable loss of confidence in the service which, in itself, can lead to increased demand and risks to health outcomes.

We have also witnessed concerns from neighbouring practices that they could become inundated with requests to transfer from practices in special measures. Some local practices have discussed the possibility of closing their lists with NHS England. By and large, these fears have not been born out and patients have not deregistered in significant numbers. NHS England data on patient registrations and deregistrations could help to confirm or disprove major shifts in patient flow.

Increased financial costs

As discussed above, practices in special measures may have to pay premium rates to attract staff and extra costs to obtain standard assessments, such as for Legionella risk and health and safety. In addition, there are significant costs associated with the rapid drive to meet the multiple deadlines required in writing and implementing an action plan and producing timely reports to key stakeholders. In a well-functioning practice these costs are usually budgeted for across the financial year. There is a correlation between practices in special measures and low income per patient. When premium rate personnel are needed to manage multiple management issues, this can serve to further exacerbate strains on cash flow, which add considerably to the challenges of turning around the practice.

HOW CAN THESE ISSUES BE MITIGATED?

In highlighting some of the corollaries of special measures we hope to open the door to dialogue and discussion rather than say that practices that are failing to deliver good services should not be identified.

Indeed, implicit in all of this is the need for patient safety and improvement in those practices which are not providing good care. We have seen that many of the issues identified in this editorial can, unfortunately, work against rapid improvements in patient safety, rather than having the desired effect of improving the service to patients. Significant resources are made available for acute trusts placed in special measures with ‘buddying’ from another trust being common. The responsibility for the improvement in quality is currently deemed to be the responsibility of the practice with the independent contractor status being sighted as justification for this.

The RCGP pilot programme partners a small team of two or three advisors, usually including a GP and a practice manager, with a practice. It offers the practice support for the turnaround process. How that support is utilised is dependent on the needs of each practice. Discussions can begin as soon as a practice knows it may be entering special measures. There is a maximum contribution of £5000 from NHS England to fund the intervention dependent on this being matched by the practice itself. This is regardless of practice population size.

Our teams have helped with writing and implementing improvement plans, staff recruitment, and general support to GPs and practice managers as well as engagement with, and support to, the wider practice team. However, what it cannot and should not do is make changes that are not embedded in ongoing practice processes, which is why long-term ongoing support and staffing need to be identified at an early stage.

The support from local networks including neighbouring practices, the NHS area team, CCG, and LMC has varied. Often there have been rapid offers of initial support, although finding the personnel to undertake the work needed has sometimes been a struggle. Providing resources to effect sustained change is even more problematic.

The use of non-contextualised data in the form of ‘intelligent monitoring’ has been criticised and the banding of practices has now been abandoned by CQC. Local health economies including the LMCs, local area teams, and CCGs, which have a historic relationship with practices are often aware of problems before formal CQC inspection.

Many of the practices placed into special measures are already known to be outliers, either from data such as the Quality and Outcomes Framework and referral and prescribing patterns, or from whistle-blowing of staff members concerned about the leadership within the practice. We would urge the CQC and local health economies to work closely together to support these practices, and importantly the patients they care for, by acting quickly on soft intelligence about struggling practices and developing an infrastructure that allows for the rapid deployment of help when a need is identified.

After all, it is much better to make improvements when practices are first struggling than deal with the many negative outcomes of being placed into special measures.

REFERENCES

1. 1. NHS England

   Framework for responding to CQC inspections of GP practices, http://www.england.nhs.uk/wp-content/uploads/2014/10/frmwk-respond-cqc-insp.pdf (accessed 26 Aug 2015).
2. 1. Blake A,
   2. Sparrow N,
   3. Field S

   (2015) The CQC inspections: what they mean for general practice. Br J Gen Pract doi:10.3399/bjgp15X683845.

   OpenUrlFREE Full Text
3. 1. Care Quality Commission

   An update: CQC’s proposals for special measures for GP practices, http://www.cqc.org.uk/content/update-cqcs-proposals-special-measures-gp-practices (accessed 26 Aug 2015).

Keep the moral high ground…. Do something but don’t go on strike. It’s the public support which matters..

NHSreality offers advice to the threatening junior doctors: “Keep the moral high ground…. Do something but don’t go on strike. It’s the public support which matters..” Juniors make the first diagnosis usually on admission, but this is updated after review by consultants and if necessary corrected. However, many incorrect diagnoses are made, and even in 2008 USA ICUs (Intensive care units) the post mortem showed 40% errors. (Overconfidence as a cause of diagnostic error. Berner & Graber The American Journal of Medicine (2008) Vol 121 (5A), S2–S23) 

Litigation often results. If paramedics and Nurse practitioners are asked to make the initial diagnosis it may make no difference, but it may make a whole lot of litigation for the regional health services. It might be cheaper to pay the juniors! We have yet to do the study… Meanwhile Mr Hunt has managed to unite a profession and increase dramatically the membership of the BMA. (Anthony Bond in The Mirror 6th October)

Kat Lay in The Times 8th October reports: Junior doctors back strike over reforms

Junior doctors want to go out on strike, according to their leader, who has accused the health secretary of wilfully misleading NHS staff.

The blame for the current stand-off over contract changes lies squarely with Jeremy Hunt, who has cornered doctors and left them with no option but industrial action, Dr Johann Malawana told The Times.

The chairman of the union’s junior doctors committee said: “We have tried our absolute best to work with the Department of Health and go through a consultation process. They have not been serious about that. They have been disingenuous, and when they thought that they could they pushed us into a corner. I’m assuming they thought we would just back down and go with what they wanted to do, but our members aren’t going to do that.”

His comments came as a poll shared exclusively with The Times found that 95 per cent of junior doctors were prepared to vote in favour of strike action. Sarah Eglington, healthcare intelligence director at Binley’s, which conducted the poll via the online community OnMedica, said that the result illustrated a “huge amount of dissatisfaction among junior doctors”.

Dr Malawana said that a speech by Mr Hunt in July in which he threatened to impose the contract if an agreement could not be reached in six weeks had been the starting point for grassroots protest. “To try to shift the blame on to us is disingenuous,” he said. “You can’t just keep attacking frontline NHS staff and not expect them to react.”

The British Medical Association is unhappy with government proposals to extend standard working hours so that overtime rates only apply after 10pm Monday to Saturday, calculating that this could mean pay cuts of up to 40 per cent for some junior doctors.

It says that the proposals remove safeguards that prevent doctors working excessive hours, and that plans to abolish automatic pay increments will put doctors taking time out for reasons such as parental leave or to undertake academic research at a disadvantage.

The Department of Health says that the changes will make it easier for hospitals to staff seven-day services. It insists that the changes are not a cost-cutting measure and that doctors would not work longer hours. Dr Malawana said that the BMA was still deciding what form industrial action could take. Many doctors say that a strike is the only reasonable option open to them, with past forms of industrial action such as work-to-rule having no real impact.

Dr Malawana, an obstetrician at a London hospital, warned that even if the BMA agreed to an “unfair” contract, the NHS could still see an exodus of staff unhappy with the new terms.

“We are talking about talented individuals who have options, in medicine and outside of medicine,” he said. “If we lose even a proportion of the doctors . . . it makes the NHS not safe to deliver.”

A Department of Health spokesman said: “This is deliberate misrepresentation from the BMA. The government has yet to table a formal contract proposal, and we continue to urge the junior doctors’ committee to come back to the table so we can determine the best deal for the profession.

“In the meantime, we have been absolutely clear that we want to see higher basic pay, average earnings maintained, and that we won’t cut the junior doctors’ pay bill by a penny.”

Update 12th September: Times letters – Why junior doctors will support strike action

‘Junior doctors believe the proposed contract is unsafe for patients and unfair for doctors’

Sir, Conflating the government’s rhetoric on a seven-day NHS with the BMA’s decision to ballot junior doctors on industrial action is wrong (“Weekend Working,” leading article, Oct 10).

The “weekend effect” on mortality rates is an internationally observed phenomenon, not the fault of already overstretched UK doctors, who have been explicit in their support of high standards of care across the week. Nine out of ten consultants already work weekends; junior doctors work nights and weekends as well as daytime hours; and GPs provide ongoing care. It is under-resourcing that limits quality, not contracts. While consultants have re-entered negotiations, the decision to ballot junior doctors over industrial action reflects their anger at the government’s plan to impose a new contract in the face of the concerns they have been raising.

Junior doctors believe the proposed contract is unsafe for patients and unfair for doctors. It will remove vital protections on safe working patterns, devalue evening and weekend work and could have a real impact on the quality of patient care if we return to the days of exhausted junior doctors working dangerously long hours.

No doctor takes industrial action lightly, but we can only deliver a fair contract if the government negotiates without the threat of imposition.

Dr Ian Wilson

Chairman, representative body of the British Medical Association

Sir, You have conflated the consultants’ contracts with those of junior doctors: junior doctors can neither work privately nor opt out of weekends. Although consultants do work privately, of the 23 hospital trusts who submitted freedom of information responses, only 35 out of 5,661 consultants opted out of NHS on-call work, less than 1 per cent.

Although junior doctors are supposed to work an average of 48 hours per week, notfairnotsafe.com has nationally logged 17,680 hours of unpaid time in seven days, demonstrating that current assurances, which would be removed by the new contract, are inadequate.

Kaushali Trivedi

Junior doctor, Epsom, Surrey

Sir, We all support better staffing levels at the weekend, but this cannot be achieved by the health secretary’s plans to reclassify Saturday as a weekday in order to make junior doctors provide the extra cover required for no extra remuneration.

There is already a recruitment crisis. Adding more antisocial hours to junior doctor rotas, rather than employing more medics to split the workload, is destined to drive even more of our number overseas.

Doctors in training are virtually never involved in private practice, and to suggest this shows a lack of understanding of the situation. And, for the record, junior doctors cannot opt out of weekend working. The “overtime hours” for which we receive extra pay are not shifts we choose to work. This is mandatory out-of-hours time over which we have no control, making planning life events reliant on the goodwill of our colleagues. This can result in dangerously long periods of work (my wife gave more than a year’s notice for our wedding, yet was rostered in to work that weekend, so on returning from honeymoon had to work 12 days straight).

The huge locum bill facing the health service is not because doctors refuse to work at the weekend (we can’t), it is because the current terms of employment are so unappealing that 50 per cent of GP training jobs are unfilled in many areas, and most hospital rotas are underfilled. Hospitals are therefore forced to employ locums to fill the gaps.

Update 13th Nov 2015  Letters from The Times:

Sir, Daniel Finkelstein misses the point when he describes the junior doctors’ dispute as a dispute about overtime pay. It’s about an exhausted, demoralised group of professionals who feel neither respected nor valued by their employer.

Kathryn Wood

Sevenoaks, Kent

The BMA’s strike ballot is a step too far for Daniel Finkelstein, and should doctors be allowed to buy as well as sell healthcare?

Sir, That groups of family doctors in clinical commissioning groups (CCG) who control local NHS budgets have handed at least £2.4 billion of taxpayers’ money to organisations that their members own or work for is of little surprise (reports, Nov 11).

This huge conflict of interest was eminently foreseeable when the Health and Social Care Act was going through parliament. Indeed, I moved an amendment which would have made these arrangements much more transparent and prevented CCG board members from directly benefiting from contracts to provide services.

Like much else, this was rejected by the government and we are seeing the results. It’s vital that action is taken at once to stop this potential abuse and ensure GPs do not benefit financially from decisions that are meant to be taken in the public interest.

Lord Hunt of Kings Heath

Shadow health minister,

House of Lords Sir, As one of the senior doctors that Daniel Finkelstein refers to, I also deprecate the thought of strike action (“Moderate doctors must defeat the militants”, Nov 11). And I am sure these young and middle-aged physicians and surgeons will not take such extreme action. But the Department of Health has landed its secretary of state in a real mess by its poor communication and even worse track record. Hence, almost no one believes the assurances that pay will be protected. And as for the independent pay review body: no sign of independent thinking there.

All of us agree that patients require care 24/7 but when the OECD reports that the NHS has one of the lowest ratios of medical staff to population in the developed world, clear thinking is required, not confrontation.

This dispute could be managed by creating a group of honest brokers to mediate — just as happened when Andrew Lansley’s reforms were going badly. David Cameron took a bold decision then and Jeremy Hunt needs to take a similar one now.

Professor Tony Narula, FRCS

President, ENT UK

Sir, If junior doctors have the courage to go on strike (the last time we did was in 1975) it is unlikely to harm a single patient as doctors will make sure that emergencies and unforeseen circumstances are covered. Daniel Finkelstein claims that there is “not a scrap of evidence” that the new contracts will be unsafe for patients because doctors will be exhausted. But if doctors are fatigued day after day there is surely no doubt that their decision-making is blunted, that mistakes are more likely and that people do not perform at their best. I know that fatigue harms patients and that a strike is the last resort to get the government not to impose a contract that will harm patients.

In the past I have worked 120 hours in a week: I know what happens when doctors are tired. Finkelstein doesn’t.

Dr Ron Singer

Junior doctor 1973-81 and GP 1981-2009, London E7

Sir, Daniel Finkelstein asserts that a strike could only ever be justified when “some incredibly extreme government measure . . . might harm medical care”.

The new contract is precisely that. Reducing pay for unsociable hours — which, incidentally, will disproportionately clobber doctors in acute (emergency) specialties who look after the sickest patients at night and weekends — will discourage the brightest and best from becoming tomorrow’s doctors, and risks driving the best of today’s junior doctors into other professions or to other countries.

Dr Oliver Boney

Anaesthetics registrar, London NW5

 

Too many Rugby World Cup injuries?

Are we surprised by the number of injuries at this years  Rugby world cup ? Evidence from a previous study in Australia suggests that this is not a deviation from the norm for rugby union. (A guest posting from Dr John Evans, Solva).

(Australian Rugby Union 2013 Research of Injury Risks in Rugby Union ).

Could even more injuries bring about a lower standard of rugby in the final stages  than would be expected ? A Study into rugby injuries (see link) suggested that

improvements in coaching could reduce the risks of injury.

Key findings and implications: •” Injury incidence increases with age and level of play. ”

What injuries are most common and which positions suffer the greatest number of injuries ? 

information from a research paper in 2005 (via link) . However a more recent audit from the English top tier clubs suggests things have changed since 2005 

• “Concussion was, for the third consecutive season, the most commonly reported Premiership match injury (10.5/1000 player-hours) constituting 12.5% of all match injuries. Improving concussion awareness amongst players, coaches, referees and medical staff and the standardisation of concussion management has been the major medical focus of the English professional game since 2012 and is likely to have contributed significantly to this continued rise in concussion reporting.” link to full audit report here.

Most professional sports people have one year renewable insurance policies, either as individuals or through their team/club. Unfortunately these policies are stopped after serious debilitating injury, and the ongoing cost is met by the state. Is this appropriate in a cash strapped health service ? The NZ Herald reports skyrocketing costs of sports injuries in NZ.

Estimated costs of sports injuries in the UK in 1994 were £0.75 Billion 

BBC News 1st October 2015: Why are there so many injuries at the Rugby World Cup?

The Mailonline reported 29th September: Rugby World Cup takes its toll as 24 players succumb to injury in under a fortnight

 

 

Previous NHSreality postings:

Professional Contact Sports – should the Health Services cover them fully?

Rugby and Dementia pugilistica…. an unfair cost on the health service

School rugby plan ‘too dangerous’

Professional Rugby: the price we all pay. Co-payments or insurance are needed..

Danger of boys’ rugby exposed. Should participants in sporting activities be insured or face co-payments?

Brain injuries from contact sports – should these be covered by the Health Service?

 

NICE – U.K. cost gatekeeper gives thumbs-up to Gilead’s Zydelig for CLL

Good news for leukaemia patients, but bad news for the health services as a whole. Treatments are post-coded and regionalised, and these new treatments are usually expensive. Given the current finances of the different UK Health Services, we are going to see more and more covert rationing (restrictions on Hearing Aids, perhaps one lens for glasses, and only one hip? (hop!). Read the NICE statement

Emily Waaserman for “FiercePharma” September 24th 2015 reports: U.K. cost gatekeeper gives thumbs-up to Gilead’s Zydelig for CLL (Chronic Lymphocytic Leukaemia)

Gilead Sciences ($GILD) has been working hard to build momentum for its cancer fighter Zydelig (idelalisib), racking up approvals for the drug in the U.S. and Europe. Fortunately for the company, a pricing setback in Germany didn’t signal disaster elsewhere; after some initial skepticism–and a discount offer from Gilead–the U.K.’s cost watchdog gave its thumbs-up to the drug for chronic lymphocytic leukemia (CLL).

The National Institute for Health and Care Excellence (NICE) in final draft guidance recommended Zydelig in combination with Roche’s ($RHHBY) Rituxan. The green light covers the combo for previously untreated adults with CLL who have a specific genetic mutation, and patients whose cancer came back less than two years after treatment.

NICE earlier this year asked the company for more information about Zydelig’s cost-effectiveness, and Gilead responded with new stats and a discount to the drug’s £37,922-per-year ($57,717) price tag. The cost watchdog is staying mum on the exact size of the discount, but says it is “delighted” that Gilead followed its recommendations, NICE director Carole Longson said in a statement.

“For people whose cancer has returned less than two years after their last treatment, their options are currently limited. With this new positive recommendation, the NHS will have another clinically effective option for treating adults with chronic lymphocytic leukemia,” Longson said.

Meanwhile, Gilead is doing everything it can to set Zydelig apart from its competition–and pricing plays heavily into that plan. The company priced the drug in the U.S. slightly slower than its head-to-head competitor, Johnson & Johnson’s ($JNJ) Imbruvica, at $7,200 for the former compared with $8,200 for the latter.

And a recent string of approvals could move Gilead closer to achieving blockbuster sales for the med, which some analysts expect to rake in $1.2 billion by 2020. Others predict even faster growth, with $1.5 billion in sales by 2017.

Zydelig was approved by the FDA in 2014 to treat relapsed CLL and two types of non-Hodgkin’s lymphoma. But regulators slapped the drug with a black box warning to highlight serious risks including potentially fatal liver problems. Imbruvica’s label does not carry the same warning. EU authorities last year also signed off on Zydelig to treat adults with CLL who have a specific genetic mutation and who’ve had at least one prior therapy, as well as patients with follicular lymphoma who have not responded to two previous treatments.

But in January Gilead faced a setback for Zydelig in Germany, as the country’s notoriously strict price watchdog, IQWiG, found that the drug has no added benefits for patients with CLL compared to other therapies on the market.

and Walesonline reported 4 days later: New drug set to be made available for adult leukaemia patients in Wales

Oliver Moody in The Times reported on new treatment for Chronic Myeloid Leukamia 2nd September 2015: New treatments boost chances of beating leukaemia

NHS cash crisis: Patients to pay for hospital shortcomings – HOSPITAL patients could suffer this winter – The difference in bail out per capita will be interesting. Emergencies will always trump other demands..

We do not know the true state of the finances of the different health services. We know they will all be different, and we know they will all need bailing out and subsequent rationing. The difference per capita by post-code or region in the bailout will be interesting. Emergencies will always trump other demands.. (The Mirror 2011 – Norman Tebbit: Don’t let David Cameron destroy our NHS)

Ben Borland in the Sunday Express reports 4th October 2015: NHS cash crisis: Patients to pay for hospital shortcomings – HOSPITAL patients could suffer this winter because of a looming cash crisis to pay for emergency beds and staff cover.

Health boards are already warning that Scottish Government targets on reducing bed blocking and emergency waiting times may not be achieved.

The annual surge in demand could be even more extreme this year as weather forecasters are predicting an unusually severe winter.

El Nino – the warming current in the Pacific Ocean – usually causes temperatures to plunge in Europe, such as in 2010 when Scotland suffered the worst winter in decades.

In July, Shona Robison wrote to all health boards to demand there be no repeat of the chaos caused by cancelled operations and overcrowded hospitals last winter.

The health secretary wants to see bed blocking reduced to the level of October 2013, when 1,062 healthy patients were stuck in hospital because they had nowhere to go.

In October 2014 the figure was “significantly” higher at 1,380, although by July this year it had been reduced to 1,124.

Ms Robison also said all health boards must do more to ensure that 95 per cent of casualty patients are seen within four hours.

Scotland’s 14 health boards are currently working on their winter plans, which have to be ready by the end of October.

However, NHS Grampian is already raising concerns about Scottish Government funding being axed this year.

A report by Director of Modernisation Graeme Smith warns: “Some aspects of surge response depend upon an increased spend on capacity such as emergency beds or agency staff.

“In winter 2014 these costs were met by non-recurring funding provided by SG however it is unlikely that a similar funding stream will be available for the coming winter.”

Mr Smith also warned that meeting the bed blocking and four-hour waiting time targets set by Ms Robison presented a “significant challenge”.

Ministers set aside £18.2 million to help ease the pressure on the NHS last winter, before Ms Robison was forced to give an extra £10million just days before Christmas.

However, after working throughout the year on measures to avoid another breakdown in hospital care the Scottish Government may not be inclined to bail out health boards so easily this year.NHS Lothian has set up a special “winter planning board” which is working on the “assumption” that there will be additional money for winter.

However, the health board is warning that the risk of missing both the bed blocking and four-hour waiting time targets remains “very high”.

More patients than ever are waiting for a care home place, especially in Edinburgh. There are proposals to increase bed numbers, although they will push the health board – which is already predicting a £26million overspend – even further over budget.

Professor Alex McMahon, Director of Strategic Planning, warned: “In the short term the inability to resolve the current position means that we have little additional capacity for ‘winter’ demand spikes.”

Theresa Fyffe, RCN Scotland Director, said: “Planning for increased demand on our NHS during the winter is essential. Patients, quite rightly, now expect it and it’s good that the Scottish Government and health boards are focused on this serious issue.

“But, with vacancy rates still increasing, as the most recent workforce statistics showed, health boards, which are already overstretched by increased demand on services all year round, face a huge task to be ready before the end of October.”

However, Ms Robison insisted a “record” £100million investment had been put in place to tackle bed blocking across Scotland, adding that winter funding levels would be “similar” to last year.

She said: “We know that the winter months are always more challenging for our health boards but we have robust plans in place and funding levels will be similar to last year. With more people now living with long term conditions and a growing number of older people with multiple conditions and complex needs and it is vital that we learn from the lessons of last winter.

“We’ve issued winter guidance to health boards almost two months earlier than last year, to ensure they build in optimum levels of resilience capacity in preparation for winter.”