Monthly Archives: October 2016

Immoral funding half-truths and creative accounting leave covert post-code rationing as the only option..

Dennis Campbell reports in the Guardian 30th October 2016: Theresa May’s claim on NHS funding not true, say MPs

Image result for creative accounting cartoon

Two Tories among signatories of letter pointing out that PM’s statement about £10bn extra cash for the health service is untrue

Theresa May’s claims that the government is putting £10bn extra into the NHS are untrue and the underfunding of the health service is so severe that it may soon trigger rationing of treatment and hospital unit closures, a group of influential MPs have warned Philip Hammond.

Five MPs led by the Conservative Dr Sarah Wollaston, the chair of the Commons health select committee, have written to the chancellor demanding the government abandon its “incorrect” claims of putting £10bn into the NHS annual budget by the end of this parliament and admit the severity of its financial shortage.

“The continued use of the figure of £10bn for the additional health spending up to 2020-21 is not only incorrect but risks giving a false impression that the NHS is awash with cash,” Wollaston and four fellow committee members tell the chancellor in a letter……

BBC News reports: NHS funds need urgent boost, say MPs

The Health Committee has written to the chancellor to say using the figure gives the “false impression that the NHS is awash with cash”.

It is calling for more NHS funding to be announced in November’s Autumn Statement.

The government insisted the £10bn figure was accurate.

The Health Select Committee, chaired by Dr Sarah Wollaston, has been hearing evidence over recent months on the state of NHS finances.

Its letter says what it was told by senior NHS figures “clearly demonstrated the financial pressure facing the NHS”.

But it warned that “the extent of this pressure is not sufficiently recognised” by government.

Ministers regularly state that there will be £10bn extra in funding for the NHS by 2020-21.

The £10bn figure is calculated in real terms once inflation has been taken into account and includes £2bn which was announced in the last Parliament.

The health committee said in July that it calculated the true figure to be about £4.5bn.

‘Pressure is building’

The committee called on Chancellor Philip Hammond to “seriously consider” finding more money for the NHS – and social care – in next month’s Autumn Statement.

Richard Murray, from think tank the King’s Fund, said: “The most urgent priority for the Autumn Statement is to increase funding for social care.

Image result for creative accounting cartoon

Immoral funding half-truths and creative accounting leave covert post-code rationing as the only option..

PMI or private cover? Should GPs ask patients if they have private health insurance? Putting the patient in front of you at the centre of your concern – includes asking about attitudes to non state options..

“Would you like to discuss non state provided options?” This, or a similar question SHOULD occur more frequently in many doctor consultations.. in Hospital or the Community. It is only in emergency care that the private provision is lacking, and in cities this is changing..

It is concerning if a colleague rejects to offer or to even discuss or offer options outside of the Health Service locally. The first duty of a doctor (GMC) is to “put the patient at the centre of your concern”, and this makes no reference to the state provided health services. Your duty is not primarily to the state, and where the interests of the state and the patient differ, a doctors duty is to their patient. It may be a GP aware of long waiting lists, or an oncologist aware of treatment exclusions – and covert rationing.

And the patient has also got the choice to pay directly. Monthly payments of £300 amounts to nearly £12,000 over 3 years, which covers most joint replacements and a lot of physiotherapy. Just because somebody looks poor, or lives in an impoverished area, does not mean their doctor should assume that they have no savings or insurance. Increasing their options with an honest discussion could be good for their health. Telling the truth is a virtue – even if it includes saying a patient is obese.

Putting the patient in front of you at the centre of your concern includes asking about PMI  (Private Medical Insurance) or direct payment if the local service puts them at risk. It does not imply that the doctor makes the choice as to whether to use said insurance (what is the excess? )or to pay directly.

What is shameful is that for 60 years only 10% of the population chose to have PMI, but in the years ahead it may rise well above this, and a two tier system will become de facto.

If patients ask you for recommendations that is another matter. You might refer them to a broker, or to Benenden which promises to cover everyone (but with important exclusions including heart disease and cancer). Benenden advertises at £8.71 per month per person!

There is no harm in asking. The decision to pay is different to asking the question, and being honest about ALL the options is part of the duty of a doctor. You might also wish to point out the difference in the Perverse Incentives: to undertreat in the one system, and over treat in the other.

Fortunately, as yet, different Post Codes are not being charged different premiums, but they may be. Where there is less choice there should be more demand for private services (Wales) and premiums here may rise.

As communities realise the deficit in their potential care, they could group together. PMI is much cheaper for groups and communities. Perhaps a whole town may decide to have a policy. Once again this will favour the richer suburbs., and increase the health divide. But at least they would all know what was excluded, unlike todays covertly rationed health services.

Image result for private medical insurance cartoon

Charlotte Alexander asks in Pulse 27th October : Should GPs ask patients if they have private health insurance?

YES

I do not see anything wrong with asking patients whether they have private insurance if it helps to create some much-needed slack in the NHS. A recent scheme in Mid-Essex has seen private referrals increase by 6% since the start of the year, which suggests that health insurance is being underused. It may be that people forget to use it or have a ‘no-claims bonus’ attitude towards it, resulting in a pick-and-mix approach to the NHS. Whatever the reason, I do not think most would object if they were gently reminded that they could see the most senior person available more quickly if they did use their cover.

I know some people think this is an inappropriate way to try to save money, but with a dwindling pot can we afford to be so high-minded? Which is worse, trying to increase uptake of health insurance with those fortunate enough to have it, or having to save money by banning non-urgent procedures such as vasectomies, sterilisations and ear syringing?

Some people have said it puts unfair pressure on patients to refrain from using NHS services that are within their rights, but GPs could exercise judgment about who to ask. For example, for those who have used private healthcare before, it is not a huge leap to ask them whether they would like to again. Premiums may go up as a result, but the person will choose to pay it or not. It is not denying them care they are entitled to, it is offering them a choice to use NHS or other services, like the choice between a state or a private school for their children.

Some say that asking patients about their private healthcare insurance compromises the impartiality of the consultation. Actually, we already do that with the QOF, prescribing certain medications because they are cheap and having personal stakes in private companies providing NHS services.

People will also say that this approach lets the Government off the hook as it will continue underfunding the national system. This may be true, but what is the alternative when there is no extra money? While we are living in this time of unfettered corporatism and very high societal inequality I see nothing wrong with redressing this slightly by asking people to use their insurance if they can. The NHS is staggering under the weight of demand and cost cutting. Unless we do everything we can to preserve the cash flow, it won’t get up again, even after multiple infusions.

Dr Charlotte Alexander is a GP in Addlestone, Surrey

NO

On the surface, asking patients about private healthcare insurance may appear to be a positive move; I am sure I’m not the only GP who finds themselves apologising for ever-increasing waiting times for outpatient clinics and elective operations. However, not only are GPs constantly apologising for problems that are beyond our control, we are now being put in the difficult position of asking patients to forfeit the NHS care they deserve as much as the next person. This could potentially put the patient-doctor relationship at risk, and could even jeopardise a doctor’s ethical or moral standing if the patient disagrees with the principle.

It could be suggested that encouraging patients to use their private insurance will take pressure off NHS waiting lists by filtering some patients out. But in reality, it creates a two-tier system, further broadening the gap between the rich and poor and exaggerating health inequalities. While those who can afford either private care or health insurance will find themselves being seen and treated quickly, others who rely on the NHS may be at risk of their health conditions deteriorating while they wait ever-increasing amounts of time.

Asking about private health insurance would also produce geographical health inequalities. Affluent areas will benefit more, not only from a larger number of the population accessing private care, but from the higher number of patients filtered out of NHS waiting lists, freeing up more appointments and improving services in the area. But conversely, in deprived areas, where fewer people have access to private healthcare, NHS waiting times will continue to remain above what is acceptable, further widening regional differences in care.

A final issue is that schemes such as this free the Government from the responsibility for their funding cuts. The NHS is currently in dire straits, and the solutions lie with our Government and the way it funds the NHS, not with alternative solutions such as pushing patients towards the private system. This merely patches up the system while the Government continues to slash funding to public services. It would be more prudent for local health boards or CCGs to fight for more enduring, appropriate solutions, rather than taking us one step closer to an unfair insurance-based healthcare system.

Dr Rebecca Jones is a GP in Hastings, East Sussex

Putting the patient in front of you at the centre of your concern – includes asking about PMI

Image result for private medical insurance cartoon

How to cause disenchantment with those who are badly needed – Brexit will make things even worse for staffing levels..

BBC News reports 28th October 2016: NHS set to miss target on foreign patient costs whilst the Oxford Mail is more dramatic: NHS ‘hundreds of millions of pounds short’ regaining cash from overseas patients. As NHSreality has opined in the previous posts on this subject, there is no incentive for staff to ensure patients are charged correctly. Indeed, there is a bureaucratic disincentive with form filling and handling of money safely…..

Image result for staffing cartoon

‘Health tourists’ run up unpaid NHS bill of £62m – less than £1 per capita…

NHS paying for other nations’ healthcare

All hospitals must sell skills abroad – (When they can’t even look after us!)

NHS ‘can save £500m’ on foreign care

Polly Toynbee has got a lot to say in The Guardian 6th October: Telling NHS doctors to go home is self-harming madness

.A wise government facing the multiple threats of Brexit would strive in every way to mitigate its worst effects. The chancellor dashes to Wall Street today to try to calm markets as the pound falls again and future investment to Britain is in jeopardy: the idea of Philip Hammond on a “charm offensive” may be a tad improbable – but at least he’s trying.

Not so the prime minister, home secretary and health secretary: in a hole, they keep digging…

….Hunt’s claim that we will be “self-sufficient” in medical staff is nonsense – and he knows it. These new doctors won’t qualify as consultants until 2030, while everywhere has ageing populations and the World Health Organisation estimates a global shortage of 2 million doctors. The number of people in Britain over the age of 85 will double by 2037 – and who is to care for them if we chase away all foreigners?

Hunt is right to oblige British-born doctors to pay back with four years’ service to the NHS – but that’s not enough. And it’s only necessary because of all he has done to alienate junior doctors instead of wooing them to stay for life. Treasuring them, begging them not to depart for easier work in Australia would be economic prudence. Scaring away the foreign-born doctors will do untold damage.

The NHS has lost a decade in progress, returning to where it was 10 years ago in A&E-waiting and ambulance-response times. Waiting lists for operations are at their highest since 2007.

The social care calamity in local government has helped tip the NHS into crisis – a crisis happening right across the UK, where doctors are needed everywhere. Over 60% of care workers in London are foreign-born, mainly from outside the EU, people May could have banished long before Brexit. But the government knows that if it drives out cheap foreign care-labour it will need to pay higher rates with better conditions to attract British-born staff. Good idea, but will they raise the tax to do it?

Paeans of praise poured from the prime minister in her speech on Wednesday, bidding to be the party of the NHS. But she showed no sign of confronting the NHS crisis. Instead, it was a go-home message to invaluable NHS and social care staff. She looks and sounds like a safe pair of hands – but we may find her neither as practical nor as competent as she pretends.

Ironically, many of these imported medics and nurses may not be eligible for free health care after Brexit, until they have worked here for some time!

 

There is no plan – only inactivity and statemate. Gradual decline in state standards seems inevitable, in contrast to private…

The general public will not be aware of how difficult it will have been for the reporter to persuade doctors to talk, and e named, but over the last few years their natural reluctance to “let their Health Service” down has been eroded. The “truth” needs to be heard and they appreciate this, but there are still far too few of them willing to speak out. If only the directors, CEOs and Chairmen would have the same courage and honesty.. It is most unfortunate that there is no plan… and for the new consultants contract: inactivity and stalemate. A gradual decline in state standards seems inevitable, in contrast to private .. And of course we are going to Reduce NHS reliance on migrants.

Image result for a cunning plan cartoon

Emma Thelwell reports for BBC news on the views of 5 doctors questioning their professional direction and altruism.

‘I can’t imagine being a doctor for five more years’

Should patients be worried that poor morale among doctors is putting them at risk?

The General Medical Council has taken unprecedented steps to warn there was “a state of unease within the medical profession across the UK that risks affecting patients as well as doctors”.

Five doctors speak about their experiences.

Worried I’ll miss something: London GP Dr Eloise Elphinstone, 31, says she feels “very demoralised and pressured in the current climate”.

“I work incredibly long hours to ensure patients get the treatment they deserve, but sometimes to the detriment of my own health.

“I worry that I may miss something, being so tired by the end of a 12 hour day. I feel it’s such a shame as it is an incredibly rewarding job on a good day.

“However, even over the last year the pressures are getting greater and greater and I feel we can provide a less good service.

“It has even got to the point that I have private health insurance for myself and my family as I worry that the NHS can not provide a timely service anymore with the pressures.

“I’ve also started looking to work in other environments – with the military or privately – where you get longer appointments with patients and the pressure is less…

“I also feel ashamed to say that a relative is thinking of training as a doctor, and I have been very reluctant to encourage this.”

Extremely Disheartening: Dr Kalpa de Silva, 35, a final year cardiology registrar from London, says the “unstinting” belief in the NHS he had when he left medical school “has been whittled away”.

A slew of government interventions have seen the training system “eroded”, and most proposals under Health Secretary Jeremy Hunt – leading to recent strikes by junior doctors in England – have “degraded morale even further,” he said.

“The way the whole saga has been portrayed by the government and, more worryingly by the media, has been extremely disheartening,” he said.

“I work days, and nights, seven days a week, on a rota, as do all of my colleagues, and many hospital specialties do the same…

“Whilst I do not ask for a pay rise, I am frustrated that I will be financially less secure despite the number of years I have worked and trained for.”

He added: “As cliched as it sounds, I work for my patients… no matter what happens I will do my utmost to deliver the best care that is possible.”

“I do however, think that overtime, a workforce that is disenchanted and disillusioned will inevitably be less inclined to work the extra hours, and go the extra mile…which would be a sad thing to see.”

Taking Breaks from Work: Dr Andrew Bull, from Bristol who qualified nine years ago, says he has had to take breaks from work due to low morale.

A GP for just two years, he says: “Gradually I am enjoying my career less and less. I originally thought I would be a doctor for 40 years but now I struggle to imagine being a doctor beyond five more years.

“The low morale has complex causes but most doctors chose this job for the satisfaction it gives rather than for the money. Take away the satisfaction and we are not left with much from our career.

“I’ve had a couple of breaks from work to help get my enthusiasm back. It worked – it’s useful to have a break, some people have enough and retire early.

“I’ve worked in Australia – it’s another health system, you realise the NHS isn’t as bad as everyone makes out. Outside the UK, many countries are jealous of the NHS. There are so many things it can do that the rest of the world can’t.

“I’m thinking of working abroad again, maybe next year as things can get a bit stale. It’ll be short term to begin with – maybe a year, like I did in Australia. I’m not planning on leaving forever. My plan would be to come back.”

The Last Straw: Dr Stefan Cembrowicz, 69, former Senior Partner at Montpelier Health Centre in Bristol, said that the current generation of doctors face fresh challenges.

In the mid-1990s, he interviewed 20 of his registrars at Montpelier about a number of staff conditions, including morale.

He said: “They all had surprisingly high morale – they nearly all said their morale was eight out of 10. Why? Well they were a capable, high calibre bunch, but it was because they were looking forward to a good career.”

Twenty years later, there is “a state of unease within the medical profession”, the GMC has warned.

Dr Cembrowicz said: “As I understand it, the junior doctors’ problem isn’t money, it’s the rota. What you have is a very hard pressed workforce already filling in the cracks, and being asked to fill in even more gaps on the rota is the last straw.

He added: “We must cherish them because they are the brightest and motivated people in the country.”

Dr Cembrowicz pointed out that his generations of doctors were almost entirely male and did not have the shared childcare duties that they face today.

“If you change have to ask people to change their child care for rotas all the time, the sky will fall – it costs money and what’s worse is all the organising”.

An Exhausting Privilage: Dr Matt Piccaver, 38, a GP from Suffolk, maintains doctors will take the pressure first, before it hits the patients.

“Doctors just put more hours in – there aren’t really corners you can cut. You can tell them to keep their coat and shoes on to save time, that’s about it. To do the job properly you have to do all the right checks and you can’t cut corners with those.

“You keep on absorbing until you personally suffer. I’ve been a GP for 11 years and it’s an exhausting privilege – I’m knackered but I love the job”.

With morale remaining low in the aftermath of the junior doctors’ strikes, he said: “I think patients are still on our side, but in the media it’s like we are the bad guys. We seem to be vilified in the press – it’s reduced the perception of it being an attractive career.

“No one wants to be a GP anymore, no one wants to work – unbelievably – in paediatrics, or A&E.

He said the NHS was being “set up to fail” by the government, which is not giving it enough money in the face of rising patient numbers.

“The government needs to shape society around a world where one in three of us is elderly. They need to invest in social and community care – and give us adequate funding for the job, we need to attract people to it and get away from this toxic, awful feeling”.

Andy Cowper reports – A view to a plan?  ( BMJ 2016;355:i5583 )

The Care Quality Commission has warned that the NHS is on the verge of a “tipping point.” But one of the key rescue plans for providers may be undeliverable, finds Andy Cowper

For almost all the wrong reasons, NHS performance is scarcely out of national news headlines. The State of Care report just published by the Care Quality Commission (CQC) outlines a system having to deal with a record 23 million emergency department attendances and six million hospital admissions in 2015-16. 1

The CQC chief executive, David Behan, identifies falling and failing social care provision and pressures in primary care as key contributors to problems with NHS performance. “[They] are now beginning to impact both on the people who rely on these services and on the performance of secondary care. The evidence suggests we may be approaching a tipping point,” he said……

Hugh Pym reports for BBC 27th October 2016: Doctors, the BMA and ministers – the state of play

The Evening Standard: Harley Street gets a new proton beam cancer unit splitting investors

Reduce NHS reliance on migrants, HEE told – Abi Rimmer in  BMJ Careers 14th October 2016 but Wales has differing ideas. They began in 2002, and have continued to fail. In 2006 – Rhodri: There’s no GP crisis looming – Wales Online – and now “financial Incentives” are needed despite refusing 9 out of 11 applicants to medical school for decades…

The Guardian 28th October: We mustn’t stop doctors in the UK giving us a dose of the truth

Image result for a cunning plan cartoon

I told you I was ill. Playing a short and irresponsible game: Ignoring the long term, and best advice, comes naturally to Politicians on both Health and the Environment….

It is several years since the State of Nature report, led by the RSPB, and produced jointly with many UK charities. The fact that we export our degradation of the environment by demanding “maggot free mangoes” is an additional insult. The new report from the Zoological Society of London (ZSL) and the conservation group WWF focuses on Vertebrates, but is on the invertebrates that most damage occurs: beneath the surface in rivers, out of sight, and in the absence of flies/moths on your windscreen after a summers evening drive. The rapid decline in many species is shocking and depressing. Humans have caused it and humans can reverse it too..Image result for short termism cartoon

So it is with the Health Services in the UK. Beneath the surface there is discontent, disillusion and an undermining of all the altruism which all professionals begin with. Training standards and experience are falling, as there are too few bodies on the ground, and service takes precedence. We focus too much on “length of life” rather than “quality of life”, and measure what is measurable rather than what is valued – such as “personal continuing family and individual care” – old style General Practice. Private demand is rising.. Private hospital profits rise as NHS buys more services (The Times 27th October 2016) and facilities such as the new Harley Street: £26m cancer unit gets go-ahead despite residents’ radiation fears (Evening Standard 27th October.

No wonder …Clare Gerada, former chairwoman of the Royal College of General Practitioners, said: “I am afraid that we are sleepwalking into a US health system.”… Who amongst us will be able to afford the new Proton Therapy?

It is urgent action that is needed in both the environment and in health. The urgent action needs to focus on the long term, on keeping a level playing field for all citizens, and in ensuring that the most advanced treatments are available when needed and when they produce better results. This can only happen by overtly rationing the high volume and cheaper treatments.  Whatever system of rationing evolves, it should be by design and open debate, rather than serendipity and market forces. The power of big pharma and high tech, and the pace of advances is beyond the state’s ability to pay for everything, so something has to go. Otherwise we are bringing back fear, rather than replacing fear as envisaged by our forefathers and Aneurin Bevan in particular. (In Place of Fear A Free Health Service 1952 Chapter 5 )

The Times reports 27th October 2016: Urgent action needed to protect wildlife as global populations halve in 40 years

Viv Aitken reports for the Daily Record: Urgent action needed to rescue struggling health service from brink of disaster, warns top doctor 

Surely it is not beyond our media and some of our eloquent writers to draw the comparison and bring our politicians’ to task for their irresponsibility. We are pretending to nurture whilst the edifice falls.Image result for short termism cartoon

When its too late we can reflect on the commentary provided by Spike Milligan, whose memorial is in Avenue Gardens Finchley, spike-milligan

 

and whose gravestone reads:

Image result

 

 

 

 

 

A two tier primary care (General Practice) service is evolving, like in Dentistry, by neglect…

It may be a year or two away from the deprived areas of Wales and the North East, but In the cities there are enough citizens to make private GP services, attractive. Patients appreciate smaller practices and personal continuing care, and they do not like to wait for appointments when they are ill. Mr Hunt is encouraging a move in the opposite direction… A two tier service is evolving by neglect. It would be so much better to evolve by design and planning…

Caroline Price looks at “How private GP services are expanding” in Pulse 26th October. Caroline Price looks at the companies at the sharp end of the GP privatisation drive

The private sector is increasingly looking to expand its offering in primary care as the pressures on GPs increase.

Several new private GP services – mainly using smartphone apps or online consultations – have sprung up in the past year, offering rapid, convenient appointments for people who do not want the hassle of booking an appointment at their GP practice.

The companies, often headed up by GPs themselves, are even being employed by some practices to reduce waiting times and relieve pressure.26836_1nov2016_nhs-appointments_3x2

The private providers claim they are helping drive down waiting times – and that there wouldn’t be any demand for them if it weren’t for the lengthening waits for appointments in NHS general practice.

A Pulse survey earlier this year found that the average waiting time for an appointment had increased to almost two weeks.

Joe Davis reported 6th May 2014: Private hospital to charge patients £95 for GP appointment 

How private hospitals are expanding…while others contract (Pulse 27th October) Making the most of the plight of the health services..

Caroline Price 26th October also reports: Private company expands ‘GPs to your door’ service

A private GP service that delivers a ‘GP to your door’ for £120 has launched in Birmingham after proving popular in London.

GP Delivered Quick says it is the first of the new online app GP services to offer on-demand home GP visits.

North London GP Dr Anshumen Bhagat set up the service and is already employing around 40 GPs who cover most of central London, where he said it had proved ‘a great success’.

The company is starting with 20 GPs in Birmingham but plans to take on more doctors as it grows the business….. …A Pulse survey earlier this year found that the average waiting time for an appointment had increased to almost two weeks.

Among the new providers taking advantage of the access problems within general practice is Doctaly, which is preparing to expand its ‘Uber-style’ GP service nationwide, after a successful pilot in two north London boroughs.

Nigel Priaties opines on “What do GPs owe the NHS?” and compares the threat of tethering to the armed forces contracts…. There is a real risk that ties between the profession and the public sphere are being irrevocably eroded and that the health service has taken its GP workforce for granted for too long.

Caroline Price also reports: Private companies see profits double while NHS waiting lists increase

On 20th October the dissuance and unreality of Mr Hunt was revealed “Health secretary announces ‘one-stop’ plan to revolutionise role of GPs

…The news comes as NHS England is in the process of developing a new voluntary GP contract for large-scale multidisciplinary GP practices with 30,000 or more patients, which aims for practices to employ a wider range of healthcare staff….

Caroline also reports that “Trusts earn millions through private work while some face remedial action”

NHS trusts saw a 14% increase in income from private patients between 2012/13 to 2015/16, with many making millions more, a Pulse investigation has revealed.

A freedom of information request answered by 54 NHS trusts revealed that some trusts increased their income from private work by a third while being in remedial action over missed waiting time targets.

DH figures showed that trusts earned £558m in 2015/16 – an increase of 14% from 2012/13 figures……….

Five million children failed to see a dentist in past year..

Image result for class social

‘Jeremy Hunt’s behaviour is unforgiveable’ – and I feel guity too….

Make no mistake, I am feeling guilty too. That is part of the motivation for this website. I wanted to vote against the new 2004 contract but i realised the tide was against me and that the profession as a whole wanted it. In order to keep us united a number of us voted for the new contract against our better judgement. All praise to Iona Heath for her longer term judgement and rationality. As the devolved Health services collapse (N Ireland, Wales, Scotland ) hers would be a welcome voice in the reconstruction and zero based budgeting that will now be needed.. It is sad, but until we ration health overtly – it’s going to get worse.

Image result for its going to get worse cartoon

Iona Heath opines in Pulse October 2016: ‘Jeremy Hunt’s behaviour is unforgiveable’

The former RCGP president tackles the health secretary and tells Caroline Price a rational approach is needed to reverse the tide of overmedicalisation

Fresh from a trip to Australia, Dr Iona Heath radiates warmth and enthusiasm.

The former RCGP president and renowned writer, who is a champion of a ‘less is more’ approach to medicine, is in great demand to speak at international scientific conferences around the world about overmedicalisation of healthcare.

Although she is now retired from her north London practice, it is easy to hear why Dr Heath is still so respected in the profession. As she sits down with Pulse she talks compellingly of the challenges for general practice in resisting pressure to overtreat and her distaste for the increasing number of interventions GPs are being asked to make in healthy people.

And her movement is gaining traction, with NICE recently releasing its multimorbidity guideline advising a more rational approach to prescribing in those with multiple conditions. But she still has a mountain to climb if she is to persuade politicians, desperate for votes, that medicine and healthcare have their limits.

Overmedicalisation has been partly blamed on increased guidelines and the ‘codification’ of general practice. Has the profession lost its way?

Yes. I think the QOF was done with the best of intentions, but if you define quality in terms of a checklist and try to base all practice on guidelines, then effectively you stop the doctor thinking about the individual patient.

There are all sorts of things that make people ill other than biomedical disease. If doctors stop thinking and just follow guidelines, the chance of making the individual feel seen and heard is reduced dramatically, leading to overtreatment, overdiagnosis and overmedicalisation.

We also seem to have raised a generation of doctors who are afraid of deviating from guidelines and see them as the legal standard of good practice. Young doctors seem to overestimate the rate of complaints and written litigation (although I know it’s going up) because we’re not doing enough to highlight the extent of uncertainty within medical practice. It is impossible get it right all the time. It’s an issue of judgement, every single moment of every day.

Where have guidelines specifically gone wrong?

They’re based on evidence derived from the past. If you’re following guidelines, you are not actually at the cutting edge of research evidence. Take the HbA1c threshold; we now know it was set too low and probably caused significant harm by precipitating hypoglycaemia and falls, particularly in older people…….

…Jeremy Hunt has such bizarre ideas. I don’t think he’s a stupid man but he’s made no attempt to understand the nature of healthcare, and at the same time he’s alienated a whole generation of doctors. He has a fiduciary responsibility to NHS staff to support their morale, to look after them, but I think he behaves in exactly the opposite way. I don’t see how that’s forgivable.

Was the 2004 GP contract a mistake?

Yes, I’ve always thought so. I voted against it and I would do so again – [because of the introduction of pay for performance] but also I think it was a tragedy for the profession that we lost control of out of hours. Nobody can work 24 hours a day, seven days a week, but we lost responsibility for how that was organised, and a lot of people stopped participating because there was absolutely no continuity of care.

Sally Nash: 20 Welsh practices handed contract back in past 12 months

Emma Wilkinson reports: More than one-third of practices close lists in one area 

Emma Wilkinson also reports on N Ireland: Out-of-hours services ‘broken’ as single GP regularly covers 370,000 patients

Sofia Lind reported in August: GP surgery numbers to be cut as part of major plans around sustainability

Despite the evidence, the health services culture crisis will be ignored by those with the power to act… It’s going to get worse..

Sarah Bloch-Budzier reports for the BBC News 27th October 2016: Doctors’ low morale ‘puts patients at risk’.

Image result for NHS bully culture cartoon

The doctors’ regulator said there was “a state of unease within the medical profession across the UK that risks affecting patients as well as doctors”….. The warning is included in the GMC’s annual report into the state of medical education and practice in the UK.

Image result for NHS bully culture cartoon

Sarah Johnson in the Guardian 26th October “lays bare the bullying culture” as she reports on a large survey.

The morale low and bullying extends to all groups, including GPs, and if Mr Hunt and the politicians remain in denial it is only the profession and the chairmen and CEOs who can speak out. Most are too cowed, so the truth is only available from those close to retirement, and those with no desire for public acclaim (gongs). Despite the evidence, the crisis will be ignored by those with the power to act, until failure is more obvious. They don’t even want “exit interview” feedback. It’s going to get worse until a group of influential people outside the profession speak up. together ..

Bullying is a pernicious problem in the NHS. That’s the stark finding from exclusive research by the Guardian. The online survey of more than 1,500 doctors, nurses and other health workers in hospitals, primary care and community settings, found that 81% had experienced bullying and for almost half of them (44%), it is still ongoing. Close to nine out of 10 bullying victims who responded have been left with their cases unresolved.

Although the survey on bullying was self-selecting, the findings underline the results of the official annual NHS staff survey. The 2015 survey of nearly 300,000 healthcare professionals across England found that a quarter of staff in NHS trusts had experienced bullying, harassment or abuse in the previous 12 months.

Some 87% of respondents to the Guardian survey, carried out between August and September, think bullying is a big problem within the NHS, while almost three-quarters said they felt the health service did not take bullying seriously. “The culture is driven by exerting undue pressure on others to get things done. If you don’t, you are targeted and eventually you end up with stress and depression,” one NHS manager said……

NHSreality wants scapegoats – and suggests the successive ministers of health (for England). Allyson Pollock might agree..

The NHS needs to be cherished and celebrated to survive

Image result for bully culture cartoon

Our nurses are being cast into a perfect Brexit storm

Sarah Jonson also reports on individual cases: ‘It’s ruined my career’: accounts of bullying in the NHS

Cleaning up the UK Health Services, changing the culture and importing honesty..

Stephen Bolsin – Bristol Scandal Whilstleblower mock interview in BMJ confidential. The duty of candour shows no sign of overriding the culture of fear and bullying.

Wales is the first Region to crack on questioning current philosophy

N Ireland the first Health Region to crack – and admit that the system is broken..

There are thousands of “ranting doctors”, but they keep their rants to themselves. Times for honest and open “exit interviews”.

Whistleblowing in the US – helping to change the organisational culture? No comparison with state owned organisations.. Exit interviews better and less destructive..

Muzzling NHS staff (2000 – 2014 and continuing)

The New Year’s Honours (RHS) List 2014

N Ireland the first Health Region to crack – and admit that the system is broken..

N Ireland Physiotherapists in the MCSP journal are reported: Northern Ireland politicians accept that NHS must find new ways of working, Just as the politicians are attempting to combine Heath and Social Care, Councils ‘don’t pay fair price for care, and many care home operators are dropping their Health Service agreements. (contracts) , Everything has been short term, including the staff training and manpower planning capability. Just as we are short of physiotherapists, we are short of all staff, and it’s going to get worse. The temptation to go “private” will steadily increase.

N Ireland the first Health Region to crack – and admit that the system is broken.. and try to turn a negative into a positive.. The Health service foundations are being washed away.

Image result for founded on sand cartoon

Northern Ireland’s health committee has responded positively to evidence of how GP surgeries elsewhere in the UK have benefited from self-referral to physiotherapy and having physios as a first point of contact…..

CSP senior negotiating officer Claire Ronald told the committee that these changes had saved time for GPs and resulted in fewer referrals for interventions, such as MRI or CT scans.

She attended the hearing on 6 October, as part of a delegation from the Irish Congress of Trade Unions.

Northern Ireland has been ‘very poor at transforming how we deliver healthcare’, Ms Ronald warned the meeting.

‘We are only just piloting self-referral to physiotherapy at South Eastern Trust, and it was a battle to get that pilot running.’

Extended scope practitioners and physiotherapists who have qualified as independent prescribers are under-utilised, she said.

Workforce planning

‘It comes back to workforce planning,’ she said. ‘But if you don’t engage with trade unions and professional bodies until you are implementing, then we are at the door saying “that is not going to work”, or “if you had done it this way it would be better”.’

Following Ms Ronald’s evidence, committee chair Paula Bradley said the MLAs recognised that the health system did not fully utilise a range of health professionals.

‘We will have to look at different ways of working, especially when we look at what’s happening within GP services at the moment,’ she said.

Speaking to Frontline after the hearing, Ms Ronald said the committee would launch an inquiry into the roles that allied health professionals and pharmacists could have in primary care, adding that her evidence met with a positive reception from the MLAs.

Marie-Louise Connolly reports 25th October for BBC: Bengoa review: Ambitious health care shake-up unveiled – Its 3rd sentence reveals that it is biased… and this because it is recommended by a government appointed panel unable to speak the truth: we have to ration health care somehow…

An ambitious plan to make Northern Ireland’s health and social care system fit for the 21st Century has been unveiled.

Health Minister Michelle O’Neill said the 10-year plan would improve a system at “breaking point”.

Its 18 time-specific action points are based on recommendations from a government-appointed panel.

Hospital closures are not mentioned, but services will have to meet criteria to prove they are viable, she said.

Opposition politicians have questioned the lack of details in the plan, which is not costed.

Belfast Telegraph: Fewer GPs in Northern Ireland now than in 1950s and (GPs) Bedrock of NHS is on life support and fading fast

Image result for founded on sand cartoon

World class cancer care (and Mental Health care) is possible, if we ration the high volume low cost treatments…

Nick Triggle for the BBC asks “Cancer care: Is world class status a distant dream?” on 25th October 2016.  Not only is current care well below world class, but it is getting embarrassing to discuss waiting times and cancer access comparisons with friends in other countries. World class cancer care (and Mental Health care) is possible, if we ration the high volume low cost treatments… It is good news that we are investing and trying to correct the deficit.. it is bad news if some citizens are denied access that others can avail… Linear Accelerators are one form of External Beam Therapy. Machines over 10 years old are unreliable and start to leak. The demographics of old age mean that more treatment centres will be needed around the country..

Image result for radiation cartoon

Linear accelerators are wonderful machines. They deliver high-energy radiation to a tumour, helping to destroy cancer cells while sparing the normal tissue which surrounds them.

About four in 10 cancer patients get treated with one. So news that NHS bosses are launching a £130m investment to upgrade or replace half of England’s stock in the next two years is understandably being welcomed.

NHS England chief executive Simon Stevens hailed as the “biggest single upgrade” in cancer treatment for the past 15 years that will benefit “hundreds of thousands” of patients.

It is just one of a number of steps NHS England is flagging in the update of the five-year cancer plan on Tuesday.

The strategy was launched in the summer of 2015, promising to create “world class” cancer care by 2020.

Alongside the linear accelerator investment, work has begun on how to ensure cancer patients get earlier diagnosis, which is seen as key to improving survival rates.

This includes piloting multi-disciplinary diagnosis clinics that house a range of specialists and tests under one roof, to try to avoid the delays and inconvenience caused by the practice of passing patients between specialists before they get a diagnosis.

New genetic diagnostic tests have also been made available on the NHS, while experts are developing a new “quality of life indicator” to track care post-treatment.

But big questions remain about how achievable the goal set out last year really is.

Cancer survival rates have improved dramatically in recent decades. One in two people diagnosed with cancer today can now expect to survive for 10 years – but that still means 30,000 people are dying early every year because we are not as good as the best.

The challenge the NHS faces – like it does in so many other areas – is how it copes with rising demand.

Over the past 40 years, the number of people being diagnosed with the disease has more than doubled, mainly because people are living longer.

But as money has got tighter, the NHS has struggled to keep up. The major waiting time target for cancer is the 62-day goal for treatment to start following an urgent referral.

The numbers being seen within that timeframe are going up, but so are the numbers that have to wait longer. There are simply too many patients.

Graph
Cancer graph

Few in the field are confident this is going to change in the foreseeable future – even with the investment being made.

Hence Dr Jeanette Dickson, of the Royal College of Radiologists, said while the funding of the linear accelerators was welcome, “significantly” more money would be needed if services were going to be able to cope with what was being asked of them.

There are other concerns too. Sir Harpal Kumar, the widely-respected chief executive of Cancer Research UK, led the taskforce that drew up the cancer plan.

But this year he was left gobsmacked by the government’s child obesity strategy. He said the report, which was criticised for not being tough enough on the food industry, was “inexcusable” given the number of cancers which are linked to lifestyle.

There may be plenty of things for NHS bosses to shout about today, but there is also a lot they should be worrying over too. World class cancer care is still quite some way off.

Surge in twins linked to obese young mothers: UK is one of the worst places in western Europe to be pregnant and have a baby: a ‘no go’ area for a politician but we should break out of the consensus on the NHS and learn from other countries..

Tim Shipman in The Sunday Times 23rd October 2016 reports the “excess” deaths in the English NHS. You can add 10% if you include the other Health Services: Up to 46,000 die each year as NHS lags behind world’s best (Up to 46,000 die each year as NHS lags behind world’s best)

A perverse incentive epidemic, especially in mental health – both for GP’s pay/workload in UK and increased organ donors in the US, or dying, means that the systems are likely to get worse ..

The cost of poor mental health

National Cancer Therapy

Chris Smyth in The Times 25th October 2016: Deaths blamed on outdated radiotherapy machines

Image result for radiation cartoon