Monthly Archives: April 2017

RCGP Chair’s address….

It takes 10 years to train a GP. There is no prospect of the 200 extra GP trainees needed per annum, when the total capacity is about 140 per annum now. There are schemes to attract doctors to Wales, such as £20,000 inducement for trainees, funding for moving and/or first exams taken, and other perks. However I am told that trainees will need to promise not to leave Wales for a year after completing training. (Contravening European Convention of Human Rights?) NHSreality takes issue with the college on only one issue: there is no longer an NHS. The evidence is all around the citizens of Wales, with limited access, much reduced choices, and covert post-code rationing. When the WHO reports on the 4 UK Health systems Wales will almost certainly have the worse figures for perinatal mortality, maternal mortality, life expectancy, obesity and smoking…

The solutions are all long term. They have been addressed many times, and ignored for 4 years on NHSreality. There is no reason to think this will change. Welcome to the reality of a two tier health service.

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In the latest Welsh newsletter, Rebecca Payne, the chair states:

This edition focuses on workforce, RCGP has been consistently calling for a rise in the workforce in Wales. Latest calculations show that 500 more full time equivalent GPs will be needed by the end of this assembly term in 2021 (5 years time)

Over 2000 more Full Time GPs would be needed to enter the workforce each year to make this a reality, and so we are acalling for more GP training places in Wales, as well as increases in the share of NHS funding going to General Practice, so that Wales becomes an attractive place to train and work. …..

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She has also welcomed increased funding…. but will it make any difference to you and me? Not for some years yet.

IT – the solution and a problem… Every patient deserves an examination. GPs must not be robots..

On the wall above the patient in my trainers office, in large capital letters was written “Every Patient Deserves and Examination”.

IT or Information Technology has been a great failure in the Health Services so far. There are potential benefits, and high risks.

If there are going to be too few doctors, and especially GPs they need to work smarter. New symptom checker systems could improve speed and access if used properly. What the doctor offers is a differential diagnosis, judgement in use of tests to determine the exact diagnosis, and treatment options. To achieve this he needs to Examine the Patient. If your GP never examines you he is reducing his specialist skills to those of a computer and/or robot. GPs need to retain the skills to do all appropriate examinations, including rectal and internal examinations. It could save a lot of resources if a member of each practice learned to do endoscopy and sigmoidoscopies, and another to do Ultrasound Scans. These examinations/tests would increase speed in diagnosis. Unfortunately the trend is going the other way. Male doctors in particular are not doing internals when they could help assess the possibility of ovarian/uterine causes for symptoms. They refer on, either to a colleague or a specialist and this wastes time. USS and other (CAT and MRI) investigations and out patient appointments all have waiting times…  Ray Charles has his opinion, but its not mine (Ray Charles I Don’t Need No Doctor – YouTube).

If the risks are to be addressed then the Health Services will need a team of experts, constantly trying to break in, just as the big public companies have, and insurance is another matter!

Richard and Daniel Susskind opine in the Harvard Business Review October 2016: Technology Will Replace Many Doctors, Lawyers, and Other Professionals

Mark Bridge in the Times 28th April reports: Hospitals held to ransom as state hackers step up attacks

Do you really have confidence in your records being confidential? Do Hospital Trusts have cyber insurance?

NHS data-sharing project scrapped – another opportunity missed..

Incompetents lead IT change into vast cash losses, and need to be disbanded. This is one area which should be privatised..

Increasing incompetence: Another NHS crisis looms – an inability to analyse data

Electronic Medical Records A Disappointment In The USA

Jeremy Hunt has enlisted a US professor to review the digital future of the NHS to keep it from falling into “elephant traps”

Doctors should have electronic records everywhere possible. It will reduce mistakes and litigation. GPs have been paperless for 20 years..

The Future for our Health Services

Health & Social Care Information Centre

The worried well demand more in a free service.. More information is good, it’s the perverse nature and philosophy of the health services that needs to change.

Too much technology? Its no good protesting – but it would be good to discuss exactly where spending is best directed.

Evidence basis is needed for all treatments – and confirmation by independent third party. Hospitals and pysicians collude to waste money.

How the NHS Wales wastes money on bureaucrats in non-jobs yet has lethally long waiting lists that would shame a Third World country

Ditching ineffective ways of working (Work Smarter in GP)

Symptom Checker | The one the doctors use

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Tissue committees and audit reports on histology would have exposed Mr Butcher. The iceberg of mismanagement is the real issue..

In several other health systems there is a committee in each Hospital: the Tissue Committee. It can be argued that this is the job of the “ethics” committee, but these are being centralised without sufficient IT linkage. The UK Health Services have not been able to initiate decent IT yet. Tissue committees and audit reports on histology would have exposed Mr Butcher. We do not have good enough IT systems, and the work involved in such audits does not happen.. If we had no fault compensation the bill would have been much less, and what is to come? The Shipman and Butcher incidents are notorious now, but the iceberg of mismanagement is the real issue.

When a family member went to collect a result they were given the wrong image on a CD. There was no “critical incident” reported, no letter of apology and no recognition of the systematic failure. We debated about asking for a “report” but decided not to as we did not want a junior scapegoated. It is if you let the smaller issues slip that the larger issues rise up, tand he iceberg overturns ….

Alexandra Topping repots in the Guardian 29th April 2017: NHS pays out millions to patients of surgeon convicted of needless breast operations – Consultant Ian Stuart Paterson carried out unnecessary procedures on 10 patients but could have more than 1,000 victims

The Times:

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Breast surgeon who played God may have 1,000 victims

Katie Gibbons reports in the Times: Liar betrayed patients who adored him

With nearly 20 years experience of treating breast cancer, Ian Paterson was, at the height of his career, the consultant of choice for women in the West Midlands. Adored by his patients for his charming bedside manner, he instilled confidence when they were at their most vulnerable.

A family man, with a son and twin daughters, Paterson, 59, treated thousands of women — including three generations of one family. Beneath the charisma he was an accomplished liar. Exploiting women with a family history of cancer, he used favoured phrases to convince his “ladies” to have surgery. A lump was “nasty” and “sinister” and patients who underwent breast removals were “very, very lucky”.

An independent review of the Heart of England Trust in 2014 found Paterson was “charming and was much-liked by his patients” but not a team player. Former colleagues described him as “bullying and overbearing”.

He grew up in Glasgow, graduated in medicine from the University of Bristol in 1981 and moved to the West Midlands. He was a regular speaker at events led by Breast Friends, a local support group for women with cancer.

After his surgical malpractice he split from his wife Louise, 54, a physiotherapist, and sold their £1.25 million home in Edgbaston.

Throughout the trial he spoke directly to the jury. With his glasses on the end of his nose, he gesticulated enthusiastically, flipping through files and using a pen like a lecturer’s pointer. His contempt for the prosecution’s medical expertise was obvious.

The celebrated surgeon persona was back — but only briefly. Yesterday he sobbed as each count of guilty was read out, realising that he faced a life sentence.

The Times leader: Grievous Bodily Harm – Behind an appalling story of medical malpractice lies another of failed management

First, do no harm. This fundamental principle of medicine was turned on its head by Ian Paterson, a surgeon convicted yesterday of 20 counts of “wounding with intent” and “unlawful wounding”. These crimes were the tip of an iceberg of unnecessary surgery carried out over many years, mainly on women wrongly told that they were at risk of breast cancer.

Paterson’s modus operandi was to intervene first and deal with the consequences later. When these consequences required further surgery, he was only too willing to perform it. He told patients that they were in mortal danger when they were not. One underwent seven operations, including a full mastectomy and breast reconstruction, for no good medical reason. Another agreed to several excruciating procedures on her nipple when all she needed was a course of antibiotics. This patient tells The Times today that by the time she was told that the operations were unnecessary she had made plans for her own funeral.

Lawyers for the ten women who testified against Paterson believe that he operated pointlessly on up to 1,500 people in all. Few families in the area of the West Midlands where he worked do not know one of his victims.

It is impossible to take in the findings of his trial without bewilderment as well as anger. He worked partly at a private hospital but, given that police believe that money was by no means his only motive, what were the others? The eight-year gap between the time when concerns about his conduct were first raised and his suspension demand the question of why was he not stopped sooner?

The answers appear to involve a culture of deference to doctors, and especially surgeons, that should long since have been consigned to history. It appears to have survived in the Heart of England Foundation Trust (Heft) that paid Paterson’s £100,000 NHS salary, and to have enabled him to violate guidelines, laws and patients with impunity.

This was an extreme but not an isolated case of a medical professional with a God complex. Good surgeons are team players who are not threatened by the idea of second opinions and actively encourage patients to seek them out. This one was instead found by an inquiry before his trial to be a “road block” who forced others to work round him. Even so, none of those who should have intervened to stop him emerges with any credit.

Paterson first prompted colleagues to raise concerns about his methods in 2003 when two senior NHS oncologists questioned his use of a controversial breast surgery technique known as a cleavage-sparing mastectomy that can increase the risk of cancer returning. He was allowed to continue using it. By the time of his suspension in 2011 by Heft and the private Spire hospital, where he earned extra money, he had been the subject of more than 20 staff complaints, four internal investigations and several external reviews.

A 2013 report by Sir Ian Kennedy accused Heft of concealing Paterson’s malpractice with a “blanket of confidentiality”. Those who threw it around the case delayed justice for patients whose lives had been upended, and must be held accountable. The patients themselves deserve compensation. A civil trial looms at which damages will be assessed. Money alone will not make whole those who Paterson wounded, but it will help. Spire and Heft should brace themselves.

 

The NHS will be ignored by most voters in this election…

NHSreality agrees that the NHS will be ignored by most voters in this election… The issues are Brexit and the unity of the United Kingdom – with such large stakes health is irrelevant. Its going to get worse and the landing will not be soft.

The irony of this election is the potential for the Liberal Democrats to profit from the “first past the post” system. Where a Brexit supporting Conservative competes with any Labour candidate, but especially a Brexit Labour supporter, there is a choice for Remainers to vote Liberal. Throughout the shires and cities, a mere 34% of the vote could win any seat. Young people should take note. No young person with a vote should abstain if our nation is to remain united. Brexiteers will die off quicker than Remainers and the problems of today could disappear as the demographics change….

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What role will the NHS play in the 2017 election?  (BMJ 29th April 2017;357:j2024)

Ben Page looks at how public attitudes to the NHS might affect the general election campaign

The public sees the NHS as one of the top issues in this election campaign, as it did in the 2015 election. But will it be a decisive issue?

Pessimism about the future of the NHS is now the highest we have ever recorded, with 62% expecting deterioration. This puts the UK among the most negative countries globally on the future of healthcare in our 2017 Global Trends Survey.

As the NHS struggles with continuing austerity, the public has also become more sceptical about the central government’s plans for public services generally. But most people still feel personally unaffected. This and the perceived incompetence of the Labour party may explain the Conservatives’ strong lead in the national polls.

The Conservatives’ lead continues even though 62% of the public do not think that the government’s plans will improve public services. The proportion holding this view has increased since the start of the coalition government in May 2010 when 44% said that they did not think that the government’s plans would improve public services.

It has also continued despite the fact that most of the public (63%) say public services have deteriorated in the past five years, and the fact that the proportion holding this view has increased markedly since 2015 when 43% did so.

As we go into this snap election, the government still seems to have some breathing room. Despite pessimism about the future, only 26% say they and their families have personally been affected by cuts. This figure has been stable for a few years, and is lower than in 2012 when 33% said they had been personally affected. Just under half are worried about the impact of cuts in the next year. But this figure has been static for five years, and has been unchanged since before the Conservative victory in 2015.

With the Conservatives winning on economic competence and on having the best candidate for PM and—in some polling—the best team to run the NHS, this election looks pretty much cut and dried.

Overall satisfaction with the NHS remains much higher than at the turn of the century, despite newspaper headlines. And so, with Labour not mounting an effective national challenge, it is very unlikely that the NHS will be the decisive factor in the 2017 election.

GB needs a general election and a clear choice between a “remain” and a “brexit” party – Liberals v the Rest?

Health care and the Welsh elections – comparative analysis and graphics with England

Reality is a word rarely used in Health debate and discussion. The Economist comments on post election realities..  (May 2015)

And a GP does tell the Times “as it is”….

The contestants – who will promise the most irrelevant package? Listen and (later) read their prospectus.

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The Irrational rationing of healthcare.. Carl Heneghan in the BMJ 29th April 2017

The Irrational rationing of healthcare.. Carl Heneghan in the BMJ 29th April 2017

The rationing process in the NHS is messy,” said the King’s Fund. On this I think we can agree. Just look at what is happening with IVF services to understand the messiness with commissioning and the rationing of health services.

Croydon’s clinical commissioning group (CCG) has decided to save over £800 000 a year by no longer funding IVF. This is despite 77% of people consulted opposing the decision. Meanwhile, across Scotland three cycles of IVF are provided on the NHS, ending local variation. Over the border in England, 80% of CCGs fail to commission three cycles, despite this being the official guidance from the National Institute for Health and Care Excellence (NICE), while in Northern Ireland and Wales one and two cycles are offered, respectively.

The King’s Fund argues that some rationing is inevitable, but we must avoid the “fudges” seen with commissioning IVF. Whose job is it then to sort messes like these out?

It is not NICE doing the rationing; they recommend that women under the age of 40 years, who have not conceived after two years of regular unprotected intercourse, should be offered three full cycles of IVF. Individual CCGs decide to ration services through stricter criteria, thus introducing local variation and postcode lotteries. CCGs therefore decide what to fund based on local needs—hopefully following proper consideration of the evidence, national priorities, and NICE guidance.

How and what CCGs ration is also informed, to some extent, by how their predecessors (the primary care trusts (PCTs)) reduced spending on low value clinical treatments. A 2011 Audit Commission briefing identified Croydon PCT as a forerunner in identifying low value treatments. The “Croydon List,” as it became known, included procedures where cost effective alternatives should be tried first, interventions with a small benefit or risk balance done in mild cases, and cosmetic or ineffective procedures. PCTs identified some 250 different procedures with limited clinical value, but no single, nationwide list was collated.

Identifying low value interventions became part of the remit of the NHS Right Care Programme, yet they advocate using NICE guidance. Consequently, CCGs develop their own approaches, often incorporating the Croydon List of low priority treatments.

Stopping low value interventions in the NHS must be a good thing; but IVF doesn’t meet the Croydon criteria and wasn’t on their list. IVF remains an easy target and it is likely that many CCGs will follow Croydon’s lead as they try to save money.

Once CCGs refuse to pay then market forces become the dominant factor in accessing healthcare. Leaving rationing to the market, however, is deeply troubling on many levels: in America, many individuals go without health insurance, without prescriptions, forego preventive care, and often wait when sick because they cannot afford the market cost of healthcare.

If we want to bring an end to postcode variation, remove market forces, and reduce irrational rationing, we need to boost funding. We also need to be more open and explicit, as a national health service, as to what we will fund, what we won’t fund, and what evidence we will use to stop low value interventions.

Carl Heneghan is professor of EBM at the University of Oxford, director of CEBM, and a GP.

Where next for evidence based healthcare?  Carl Heneghan, Fiona Godlee

And a GP does tell the Times “as it is”….

In direct contrast to the RCGP Chair, a retired GP, Dr Paul Menin tells it as it really is in The Times 27th April 2017, and the implication for the politicians is that it may be too late to be honest. A two tier health service is developing by neglect, in all 4 Health Systems.

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BURNT-OUT GPs

Sir, As a recently retired GP I have been dismayed to be offered an incentive payment of up to £4,000 by the government to go back to work. I had reached a point of stress where I was likely to be no longer as effective and safe in the consulting room, so I retired. This is a situation in which a huge number of GPs find themselves — hence the manpower crisis in general practice and this offer.

Luring burnt-out GPs back into practice might help for a short while but it does nothing to address the underlying problems. To now effectively pay me more than an existing partner, with all the huge responsibilities that they carry, is insulting to all the GPs who are continuing to work. To add insult to injury, working as a locum with no managerial burden at all you can earn far more. The solutions are many and varied and are all possible without any significant extra expense — but none of them I fear will win elections.

Dr Paul Menin

Hythe, Southampton

RCGP Chairman misses the opportunity to tell it as it is.

Burn Out GPs

RCGP Chairman misses the opportunity to tell it as it is.

Helen Stokes-Lampard, the RCGP Chair missed the opportunity to tell it as it is on BBC1 this morning. She skied graciously away from party politics, but failed to say that:

There is no NHS – and talking only about England is belittling, especially when Wales is so bad.

The WHO agrees with the above.

That standards of access to care are appropriate for different individuals. The “cry Wolf” person/family is treated differently appropriately: But also people in work have a right to attend a doctors appointment.

Evening and weekend surgeries are all very well for large practices, but not for smaller and rural ones, and especially in areas of high unemployment. Having “access” does not mean these appointments are used properly… are GPs going to be allowed to exclude the unemployed and retired from these surgeries?

Patients receiving a “free” service where nothing is “excluded” will doubtless indicate they want more of everything.

The Health services have to be honest about what is not going top be available, and that includes, for the next 10 years, enough diagnosing doctors.

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Chris Smyth in the Times 27th April reports: Workers miss out because they can’t get to see doctor

Working people get a worse GP service because they cannot get convenient appointments, NHS England claims.

MPs also claim that patients in some areas find it hard to see a doctor because some surgeries close during working hours for no good reason.

The public accounts committee (PAC) criticises family doctors for erratic opening hours at the same time as warning that ministers are pressing ahead with out-of-hours appointments while failing to understand the problem. Taxpayers risk paying too much for evening and weekend appointments because they are 50 per cent more expensive than the out-of-hours services they are duplicating, a report published today claims.

A political row erupted earlier this year when Theresa May ordered GPs to open at evening and weekends, blaming those who did not for fuelling a winter crisis in A&E. She pointed to figures from the National Audit Office showing that almost half of surgeries close between 8.30am and 6pm. One in five close for at least one afternoon a week, rising to three quarters in some areas.

Higher A&E attendances were linked to surgeries with shorter opening hours.

Meg Hillier, chairwoman of the PAC, said that afternoon closing was a “ historical remnant” that had become normalised in some regions. She said: “If you can’t see your GP you are more likely to attend A&E and suffer poorer health outcomes. So we need to have GPs open at the right times.”

Three quarters of surgeries that are paid to offer evening and weekend appointments close during the working day. Ms Hillier said: “Staying open during core hours would be a cheaper way of providing more contact time with GPs than providing extended hours.”

Rosamond Roughton, of NHS England, told the committee, however, that they were prioritising out-of-hours appointments because people with jobs found it so hard to see a doctor.

“If you are in work and aged between 18 and 50, you will have a worse experience of general practice,” she said. “The older you are, the better your experience of general practice is. In terms of convenience of appointments, working-age people find it much harder to get an appointment.”

Chaand Nagpaul, chairman of the GP committee of the British Medical Association, said that there was an acute shortage of family doctors.

He said: “In this climate, it is inevitable that despite the continued hard work of NHS staff, there are not enough appointments being delivered to patients.”

An NHS England spokesman said: “Seventeen million people now have access to GP appointments at evenings and weekends and the public are clear that they want this across England. Directions have been issued which mean that practices that shut for half-days each week will lose their share of the £88 million enhanced-access scheme.”