Monthly Archives: April 2017

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

Listen to the various grades and shades of denial. In the end there is no real difference at present, so it might be best to cast your vote considering other issues than health – which is going to get worse whoever runs the 4 UK Health Services. Who or which party will offer the most irrelevant package?

Jeremy Hunt for the Conservatives

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Interview with JH 23rd May 2016 for the BMA/BMJ

Jon Ashworth for Labour

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Matt Forde interviews Jon 24th feb 2017

Norman Lamb for the LibDems

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22nd September 2015: Lib Dem Norman Lamb proposes tax changes to fund NHS – BBC News

I must make an apology for my own party, the Liberals as their policy on Health, especially in Wales, is unreal and unsustainable. But then so is the current policy under the Conservatives, which is by default leading to a two tier system, and the Labour policy seems to be to increase pay (a good idea) but without addressing the need for more staff, and less litigation. NHSreality will still support the Liberals as I believe their policies on Europe and on Proportional Representation trump all others.

the Today program 26th April had Health as an issue, with Jon Ashworth and Norman Lamb proposing their “solutions” without any honesty about the need to ration.

The Liberal Policy on Health in Wales is so idealistic and detailed that it can never win the hearts and minds of the professionals who know that “hard truths” need to be discussed openly, and that covert post-code rationing is unfair, and could lead to protests and civil unrest. The party say their policies are partly based on the GP questionnaire,,, when so few answered. (21%). Since there is a local government election in Wales 4th May I include the Local Government manifesto as it was 12 months ago.

Health for the Future 2015 conference

GP Health Survey 21%

101216_Local Government Manifesto_Paper May 2016

Mark Hookham in the Sunday Times 23rd April reports: Corbyn lags behind May over the NHS – A new poll shows voters have lost faith in Labour on a traditional battleground issue

Voters believe Theresa May would do a better job than Jeremy Corbyn of managing the NHS, according to an opinion poll for The Sunday Times.

The result, based on a YouGov poll carried out last week, is a blow to Corbyn, who plans to make “saving the NHS” a key plank of his election campaign. Fewer than a third of voters trust either leader but it indicates the Conservatives have edged ahead of Labour on what is traditionally one of its strongest issues.

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It will dent the hopes of senior Labour Party figures of capitalising on last year’s winter crisis, which saw a record number of patients enduring long waits in accident and emergency departments.

When asked who they would most trust to manage the NHS, just 29% of voters backed May but even fewer — 26 % — picked Corbyn and only 7% opted for Tim Farron, the Liberal Democrat leader.

The poll reveals dire ratings across the board for Corbyn’s leadership skills: 56% of voters think he is a weak leader, 57% think he will be unable to run a coalition and 58% do not think he is up to the job of being prime minister.

In contrast, almost 50% of voters said they would trust May to deal with an international crisis, with Corbyn on 12%. May and Philip Hammond, the chancellor, were picked as the team most trusted to manage the economy by 48% of voters, compared with only 19% for Corbyn and John McDonnell.

Asked who would make the best prime minister, 46% of voters picked May and 12% opted for Corbyn.

The Tories used the first five days of the campaign to seize on the perception that May is more competent than her Labour opponent, characterising voters’ choice as one between a “strong and stable leadership under a Conservative government” and a “weak and unstable coalition of chaos led by Jeremy Corbyn”.

Despite the complaint of Brenda from Bristol — the voter who last week exclaimed “Why does she need to do it?” when told the prime minister had called a snap election — May’s gamble to go to the polls three years early appears to have won widespread support.

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YouGov, which polled 1,590 people, found voters supported the early election by 48% to 26%. Just under a third said they believed May’s decision was about crushing her opponents, while 42% said they believed it was about increasing her majority and getting things done.

The poll also shows May riding high despite strong public opposition to some of her policies. A total of 48% said they believed May should drop the government pledge to spend 0.7% of gross national income on overseas aid. Despite pressure from right-wing MPs, May announced on Friday that the commitment, first made by David Cameron, “will remain”.

 

 

 

Cancer can present quickly, or slowly, as an acute same day appointment and a booked one, and in Casualty. We don’t know the historic ratios, but the press will vilify GPs anyway.

GPs are not getting a good press. As access to care, appointments and tests all collapse, NHSreality is expecting some form of public protest at the invidiousness of a two tier system by default. The Times reporting is factual, but the Mail and others is disgraceful. Sorting the wheat from the chaff when there are so many appointments is a skill. We can always get better; but we can never be perfect. Cancer can present quickly, or slowly, as an acute same day appointment and a booked one, and in Casualty We don’t know the historic ratios, but the press will vilify GPs anyway. What ratios would the tabloids accept, given that the recent government demands have been for QOF and chronic disease management? A cancer diagnosis is usually retrospective for a GP… If only there was adequate (or over) capacity and enough time to consult with your GP – instead we have had rationing by deliberate undercapacity.

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Chris Smyth in the Times 25th April reports: Thousands of cancer cases found at A&E

Thousands of patients have cancer diagnosed in hospital accident and emergency departments because they have not managed to see a GP, a study has found.

Men and the poor are particularly likely to fall into this category, as well as the elderly, who tended to “normalise” their symptoms, the researchers said.

Previous research has found that about a fifth of the 357,000 cancer cases seen in Britain each year are picked up in A&E. By this time cancers are often advanced, cutting the chances of successful treatment and survival.

In the new study of the 4,647 patients whose cancers were picked up in A&E, 1,349, or 29 per cent, had not seen a GP. This was most common with cancers such as brain tumours, which have few early symptoms. Nearly half of these patients had not seen their doctor before visiting hospital.

Of those who had seen a GP before A&E, 41 per cent had done so three or more times. Lung cancer patients were more likely to have symptoms missed by family doctors, as were those suffering from multiple myeloma, a type of bone marrow cancer.

About a third of prostate cancer patients had sought help three or more times, suggesting that GPs are not spotting those cases that do not have typical symptoms.

Georgios Lyratzopoulos, of University College London, senior author of the paper, said: “A lot of these patients [who have not seen a GP before] will have tumours which had given very little or nothing away before they came in as an emergency. The classic scenario is that someone is well, then has an epileptic fit and are diagnosed with a brain tumour.”

He added that “your propensity to seek help is determined by who you are. The fear of wasting the doctor’s time could be at play . . . Certainly for older people that may be part of the problem.”

Dr Lyratzopoulos said that his study could not directly look at the effect of a lack of appointments at GP surgeries, but he argued that “different people’s different tolerances of waiting times” could explain why some gave up if they were faced with a wait of days or even weeks to see their doctor.

Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “GPs take their role in diagnosing cancer as early as possible very seriously and we would urge patients who experience any concerning or persistent symptoms to book an appointment with their GP. Family doctors would be helped by increased access to new and improved diagnostic tools.”

 

The 10 minute consultation… Will there be a change or will brutalising the doctor-patient relationship continue?

Generations of GPs have been taught around the 10 minute consultation, and for emergencies and children 5 minutes. The RCGP exam is predicated on a 10 minute appointment.. Traditional teaching gives the doctor a choice if he needs more time: either take more and catch up later, or bring the patient back for a second/third/subsequent appointment. Old people with complex multiple morbidities and with undressing issues, often in rural branch surgeries, need much longer than 10 minutes… If they are asked to make another appointment usually there wont be one for 5-6 weeks!

We have been excluding doctors who cannot work fast enough for years. Is the tide going to turn? Will doctors who take longer be rewarded the same? Will there be an exam for them to take?

Some Doctors in London are having an interesting appointment system to reduce non-attendances. They have same day emergencies and appointments for the next working day only..

One other problem: as Nurse Practitioners see more children with minor illnesses and ear infections, the more complex problems are concentrated with the GP. So he/she gets no short cases to relax, and allow catch up.

Is the 10 minute GP consultation model fit for purpose?

The 15 minute consultation (BMJ 2012;344:e3283 )

Sofia Lind in Pulse 2014: Ten-minute consultations ‘must go’, says NHS England director

RCGP Journal – “10-minute consultation no longer fir for purpose, says college!. GP patient times are some of the shortest in Europe….

 

 

 

 

 

Even the most confident, dedicated, altruistic, obsessive and motivated professionals are making mistakes..

I have no specific evidence for this statement – only the anecdotes I am hearing from former colleague and friends. It appears that now, even the most confident, dedicated, altruistic, obsessive and motivated  professionals are making mistakes.. In one year alone these pressures have helped close 181 practices. A year ago NHSreality reported on “The sick parade – of GP closures. This list heralds the end of the health service as we knew it. ” Private Medical Practice is becoming more attractive. Patients should make alternative arrangements before premiums are raised in view of the change in the Ogden discount rate formula “Now the Ministry of Justice has decided to reduce the discount rate from 2.5% to minus 0.75%.”,,,, As for the professional indemnity insurance for doctors, don’t believe the government when it says it will address this and compensate doctors. It has not got the tools (rules of the game)  and it cannot afford to even if it had changed the rules and bought in no fault compensation…..

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Hospital doctors are leaving and  General Practice is closing down.

Nick Bostock for GPonline reports 19th Jan 2017: Nearly 200 GP practices closed in 2016 alone, NHS data suggest – Up to 181 GP practices closed in the 12 months to January 2017, official data show.

Data on GP practice populations released by NHS Digital this month list just 7,532 GP practices – down 181 from the total a year earlier in January 2016.

Part of the drop in GP practice numbers in the NHS Digital data is likely to be driven by mergers, which could mean that some of the practice locations no longer listed in official figures remain open, but under the wing of a larger group.

However, BMA leaders have warned that closures are at ‘record levels’ and the latest figures suggest that the trend is not slowing down as GPs wait for government pledges of investment through the GP Forward View to take effect.

GP funding

Health minister David Mowat pledged in November that 1,000 practices would receive support in the current financial year from a £16m tranche of the GP resilience fund that CCGs must spend by the end of March. But since the GP Forward View was launched in April 2016, GPs have repeatedly warned that support is not coming through fast enough.

Responding to the latest figures, GPC deputy chair Dr Richard Vautrey said: ‘This is yet more evidence of the crisis facing general practice right around the country and is a direct result of unsustainable and unsafe workload pressures, and failures to attract enough doctors in to general practice so that it’s increasingly hard for practices to replace retiring GPs.

‘Every closure will impact on groups of patients who will worry about the loss of the relationship they had with their GP. There is now all the more urgency to invest in general practice and deal with unsafe workload levels.’

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GP crisis

GPonline warned in November that 5m patients in England could be forced to look for a new practice because one in 10 GPs said their practice was at risk of being forced to close over the coming year.

A GPonline investigation published last summer revealed that one in 20 GP practice contracts in England had been terminated since 2013. The findings showed that 140 contracts ended because of practice closures in the three years to March 2016, while 264 contracts were terminated because of a merger. A further 26 contracts were terminated and reprocured under a new provider.

Brian Milligan for BBC reports 27th Feb 2016: Insurance premiums ‘set to soar’ after compensation changes

Ben McLure in Investopaedia: Discount Rate Accounting

Paul Lucas in Insurance Business 30th Jan 2017 : What’s going on with the personal injury discount rate?

GPonline: Guide to new care models and your medical indemnity

Record Level of claims Inflation – £1000 each taxpayer per annum: How to solve the indemnity crisis

The public will only miss what they had – when its gone. GP indemnity fees spiral out of control with 25% rise last year..

Time to stop the indemnity circus

The Medical Press is scathing – and acknowledges the deconstructed Health Service(s)

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Natural childbirth lobby putting babies at risk, warn parents

Medical students find it difficult to get meaningful access to pregnant women, and even harder to perform deliveries. The “protection” that the midwives offer to patients is worse for male medics than for female, but exists for all. As more women have fewer children at an older age it gets more risky… It is safer to concentrate care… Junior doctors are being deskilled in Maternity… and this needs to be reversed.

Chris Smyth reports 20th April 2017: Natural childbirth lobby putting babies at risk, warn parents

Babies are dying because maternity services have been “hijacked by militant natural childbirth promoters”, bereaved parents claim.

An investigation is under way into a cluster of baby deaths involving the same avoidable mistake by midwives at an NHS trust that has been accused of being “in denial” about repeating the error.

Campaigners say the failings illustrate broader problems of a “deep-rooted ideology” in midwifery that prioritises “normal” childbirth, without medical intervention.

Last week Jeremy Hunt, the health secretary, ordered an investigation into seven avoidable baby deaths in two years at the Shrewsbury and Telford NHS Trust.

Five of the deaths involved failure to monitor the baby’s heart rate properly and regulators will look at whether the deaths were investigated properly to help avoid repeating the problem.

The deaths took place between 2014 and 2016. The parents of Kate Stanton-Davies, who died at the trust’s Ludlow community hospital in 2009, said action should have been taken long ago.

An independent review concluded last year that Kate’s death had been avoidable but the trust “abdicated its responsibility” by failing to investigate properly.

“What these deaths show is that this trust is in denial and from what they are saying they honestly don’t believe there is a problem,” Kate’s mother, Rhiannon Davies, said. Deaths include those of Ella and Lola Greene, twins who were stillborn at the Royal Shrewsbury Hospital after delays in spotting heart-rate deterioration.

A baby’s brain can be starved of oxygen if doctors do not hasten birth when its heart rate deteriorates, causing death or brain damage. The Times revealed two years ago that a quarter of NHS maternity negligence payouts involved such failures, costing the health service £268 million in 2015.

Ms Davies said: “This is not just about how a heart monitor is used, this is all about a top-down toxic culture. As well as understaffing there is a seeming disregard for mothers’ wishes during childbirth. The midwives’ role has been hijacked by militant natural birth promoters. They are not listening to mothers’ concerns and are pushing for natural birth at any and all cost. Babies are dying . . . because of the agenda.”

Midwives are taught to encourage women to have “normal” births, without anaesthetic, forceps, induction or caesarean. Many such births happen in midwife-only units or at home.

A major review concluded the practice was generally safe but two years ago a review into the death of 11 babies and one mother at the Morecambe Bay trust condemned midwives’ pursuit of natural childbirth “at any cost”.

James Titcombe, who pushed for that inquiry after the death of his son Joshua, said the events at Shrewsbury and Telford “have all the hallmarks of being another Morecambe Bay”.

The trust declined to comment yesterday.

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If maternity care is getting riskier, it seems safer to concentrate it..

Short journeys become longer: 40% of maternity units are inadequately staffed (and some are so old they need replacing).

This weeks rationing. The elderly, Maternity care and IVF. Abolish the Welsh Assembly?

“Reducing the ratio (of maternity staff in Surrey) to balance the books is the worst of all decisions.”

Its the start that matters. Maternity and child care is important and plans to fund child care will help… but “Britain has one of the lowest breast-feeding rates in the world, with only 50 per cent of mothers managing it for six weeks”

75% of “minority staff” are not bullied…

Surprised? NHSreality is surprised that the bullying is not much higher!

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Chris Smyth reports in the Times 20th April 2017: Quarter of minority staff in NHS are bullied

Patient care is suffering because ethnic minority NHS staff are so fed up with routine discrimination and bullying, an official report has warned.

Health service data revealed that ethnic minority staff in the NHS were 56 per cent more likely to be disciplined than their white counterparts. More than a quarter said they had been bullied by their colleagues in the past year, with one in seven saying their boss had discriminated against them.

Simon Stevens, chief executive of NHS England, said that “no one should yet be comfortable or satisfied with what these figures show”. He ordered the health service to do more to harness the skills of minority staff, who make up almost one in five of the health service’s 1.2 million staff, but just one in 15 of top managers.

An official report on race equality in the NHS asked for data from all hospitals and local trusts and analysed data from the staff survey of more than 400,000 workers, which defined race by skin colour alone, with many foreign staff counted as white.

Yvonne Coghill, who oversaw the project, said: “We are concerned because if you have a more engaged workforce it improves patient care.”

NHSreality response to the RCGP Questionnaire into the future of Welsh health and social care

This is NHSreality (my own) response to the questions asked by the RCGP in Wales:

1. What matters most to you about health and social care services, and what should we concentrate on to make things better?

An honest language in health and social care rationing. We need to make it clear to citizens what is not available. This might be different for people of different means, but it needs to be overt. (We also need exit interviews conducted by an outside and independent Human Resources body, reporting both to the WG and to the Media in a depersonalised way.)

We need more doctors and nurses, physios and psychologists, all trained in the UK.

2. What do you see as working well?

Very little. Every service is under strain. What continues to work well is the denial of politicians and administrators, the gagging of staff, and the inability of the press and media to sustain a debate on a complex subject.

3. Can you think of any new ideas and good practice you have seen, that could be copied more widely?

I was in the habit of offering “open access” to psychiatric patients before I retired, on a Friday afternoon. I believe all practices would reduce their suicide attempt rate if this was accepted as normal practice. In hospitals I found that Friday afternoons were inadequately staffed (Flexitime?) and so if I was a CEO I would ask that all departmental meetings were ion a Friday afternoon, and have random phone checks on staff to see if they were present.

4. What problems are there in the current systems, and how do they show through in the services people get?

Everyone educated knows that the health systems of the Uk are unsustainable. What they do not know is the different rights of patients, outcomes, mortality and complication rates. These will become more evident over time as the WHO reports on 4 rather than one health system. Devolution has failed for Wales. Free prescriptions discourages autonomy. These problems show through in a disengaged staff, gagging and bullying, lack of exit interviews, particularly for consultants, top nurses and trust board members, but in general for all staff.

5. What do you understand by integration of health and social care and what do you think a fully integrated service looks like in practice?

There are risks in integration. These are made worse if rationing is not overt. Whilst the average citizen feels that he is covered for “everything for everyone for ever”, we will not get progress, or reality. I think that if we continue down the way we are, civil unrest is likely as systems fail, and important treatments are unavailable. Elderly, terminal, palliative, and mentally ill people are politically soft targets compared to those who will vote for many years.

6. What do you think stops improvement from happening and how could this be overcome?

Dishonesty and lies. Top officials unable to lead by articulating the truth. Disengaged staff who realise the whole of their health safety net is founded on sand, and holed.

This can only be overcome by new leadership, an honesty which is seen as a summary of the “hard truths” of a society where the technology is advancing faster than our ability to pay for it. This needs p[political permission and a long term approach to subjects such as manpower provision. The long term means longer than one or even two terms of office. Giving the people of Wales the opportunity to vote on reversal of devolution, returning to England and Wales, and having more money for health and education might help.

7. What more can people do to look after their own health and well-being?

Bring back prescription charges. Introduce ID cards with tax status on them, and a scale of fees related to income. This means waiting lists will have to be mush better/shorter and therefore such a  system can only be introduced once there is an “excess” or overcapacity in trained UK doctors. (preferably graduates)

8. What improvements can be made to information and advice to help patients make decisions with professionals about care?

The rules of the game need to change.. Look at NZ and Scandinavia.. for sustainability.

A limited list of drugs. if patients prefer off the list they pay. Many more therapists as an option instead of (not as an adjunct( to drugs. More public health consultants. One IT notes system in Wales, starting with General Practice, and then expanding into A&E, etc. It will spread like a cancer.

9. Please tell us about any ideas you may have that you think could deliver real improvements to services.

Focus on Friday afternoons. Have a Full Time service until 17.00 at least, and until 22.00 hrs for Psychiatry. Allow GPs to escape from QOF. Performance related pay is all very well for a short period of time (2-3 years) but after that it demotivates.

10. What do you think should be covered by national rules and what should be left for local managers and professionals to decide?

Local rationing of services has to come, and should apply to high volume low cost items. National rationing should be about (as few as possible) high cost and low volume services. In this way there is local “choice”, but as little post code rationing differences of important and fearful conditions as possible. Co-payments according to means could work once waiting lists are short and there is an oversupply of doctos. If patients are on the lowest possible income and unemployed they should still pay something for everything, but get it back in their next Social Security payment. the cost of all services should be on the obverse or at the bottom of the paper. Eg Out patients, Scans etc.

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