Monthly Archives: October 2017

Fears of NHS exodus as family doctors vote on going private. The RCGP and Mr Hunt are out of touch with reality..

The RCGP shows how out of touch it is with the feelings and thoughts of the average coal face GP.

Mr Hunt shows how little he understands the nature of self employment and the GP contract.

Chris Smyth reports on the motion before the LMC (Local Medical Committee) conference of the BMA on 31st October in The Times: Fears of NHS exodus as family doctors vote on going private.

NHS reality is not surprised. Northern Ireland has been warning us about this for some time, and although the social conscience of the profession will probably reject the motion, especially in Wales and Scotland, It is a sign of the dissonant views in the profession, and it bodes badly for recruitment. It would not have ben demanded if there were enough doctors, and if the places at medical schools had not been rationed for decades. It will take decades to recover..

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GPs are to vote on quitting the NHS and going private, calling for their union to help them to develop plans for charging patients.

Doctors will also vent their frustration during a conference next week at having to see more patients, insisting they should be able “to say ‘no’ without feeling guilt”.

The British Medical Association (BMA) played down fears that family doctors would quit the NHS en masse. However, doctors are threatening to shut the doors to new patients in protest against rising workloads.

At a conference of local medical committees (LMCs) from around the county next week, delegates from Bedfordshire will say that “a number of GPs genuinely feel that they can no longer operate within the NHS”.

They will propose a motion calling on the BMA “to urgently look at how these GPs can be supported to operate within a private, alternative model”. The group did not elaborate on the specifics of their proposal.

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Update 1st November 2017:

GP leaders warn of deepening GP workforce crisis on ‘Brexit day’

Responding to the publication of a survey from the University of Warwick that shows only two thirds of GP Trainees in the West Midlands intend to work in the NHS, Dr Richard Vautrey, BMA GP committee chair said:

“These findings underscore the mounting crisis that is threatening the delivery of patient care in GP practices across the country.  It is hardly surprising that the next generation of GPs are having doubts about their career in the NHS after a decade of underinvestment that has left many local GP services cash strapped and operating from inadequate facilities. Constant sniping from politicians, who often expect GPs to deliver more on shrinking budgets, has hardly helped the morale of a workforce at breaking point.

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The new Director does not know where to turn to for help. He knows it’s going to get worse….

In a strange way, without using the “Rationing” word, the media is trying to lead us to the conclusion that Rationing is necessary. Whilst manager numbers are rising faster than nurses, the 4 health services are sliding into decline, two tier systems (if one includes private provision) and lowering standards. In the Sunday Telegraph NHS failing to tackle ‘significant safety risks’, warns its medical chief and Medical chief’s solution for NHS ‘safety problems’

On 7th October the Telegraph opined: Time for a grown-up debate about the NHS

We can read and infer how desperate the politicians are, and have finally realised their successors mistakes: B&B indeed..

The national medical director of NHS England warns that the way the health service is organised is putting people at risk. The new one, Prof Baker says (Laura Donelly in the Telegraph 29th October) NHS is not fit for the 21st century, hospital chief inspector warns  

This article is written with good intent but without mentioning rationing. Leading by neglect? He wants to stay in his job.

Sir Bruce Keogh‘s opinion is reported in Sky News Sunday 29th October as “Medical chief’s solution for NHS ‘safety problems'”

The national medical director of NHS England warns that the way the health service is organised is putting people at risk.

The way the National Health Service is organised is putting patients’ lives at risk, according to the national medical director of NHS England.

Professor Sir Bruce Keogh said a central system is needed to oversee patient safety across the NHS.

He said because the nature of the current system was made up of hundreds of organisations, measures introduced to improve patient safety or address specific issues were not put into practice across the whole service.

Sir Bruce said there needs to be a way of ensuring those directives were taken up across the industry.

He told the Sunday Telegraph: “People accept that their disease has risks, they accept that the treatment may carry some risks.

“What they should never have to accept is that the way we design and deliver our services adds to that risk.

“Where there are solutions to significant safety problems, I would like to see a system that mandates the use of those solutions through the NHS.

“The difficulty that we have is that the NHS is a conglomerate of hundreds of organisations, all of whom have their own boards and people in them with their own views.”
Sir Bruce stressed their needs to be a way of “being clear” about when recommendations to implement new solutions – in the form of new devices or technology – “should override the financial considerations”.
Inspectors have said the NHS is struggling to cope with staffing shortages, rising demand and increasing numbers of patients with preventable illnesses.
A Care Quality Commission (CQC) report warned that services are at full stretch and the quality of future care is precarious.

Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it

The WHO will be reporting on the gross overall outcome comparators of different health systems and the next time they do, it will not be on the British “National Health System” but on the 4 Principalities in charge of their own health budgets. The long term rationing of medical school places, and the generalised under-capacity, mean that post code rationing is reality for a common and serious illness. More will follow. It’s going to get worse because none of the profession would have started from here. The BMA has been asking for more medical school places for years…. and only now are applications rising – we have to wait 10 years or more for most of the new entrants to be useful.

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Dennis Campbell in the Guardian reports 1st October 2017: Stroke patients in Wales ‘could die’ because thrombectomy not available Acute shortage in NHS of specialist doctors who undertake life-saving treatment means hospitals cannot provide it

Stroke patients in Wales are being denied a life-saving pioneering treatment after the surgical team providing it had to be mothballed because of an acute NHS shortage of the specialist doctors who undertake the procedure.

Internal NHS emails obtained by the Guardian reveal that health service bosses in Wales are pleading with hospitals in England to perform mechanical thrombectomy on their patients to save them from disability and death.

And they show one senior doctor warning Welsh NHS officials that they have “not got a grip on the situation” and deserved to be “the laughing stock of the international neurovascular community”.

Doctors who specialise in stroke care are warning that the inability of the NHS in south Wales to offer patients what they say is a “game-changing” operation illustrates a chronic UK-wide lack of consultant interventional neuroradiologists (INRs).

They perform both thrombectomy and a similar emergency procedure, called endovascular coiling, on patients deemed at imminent risk of suffering a stroke.

However, there are just 70 consultant neuroradiologists working in the NHS across the four home countries – barely half the number the Royal College of Radiologists says is needed to cope with the rising demand for mechanical thrombectomy in particular.

That shortage means a number of hospitals are unable to provide the operation themselves and must send patients elsewhere.

University Hospitals Coventry and Warwickshire NHS Trust, which is struggling to fill several vacancies for INRs, has been sending stroke patients who need coiling 50 miles north to Royal Stoke University Hospital since January and sends mechanical thrombectomy cases 20 miles away to the Queen Elizabeth hospital in Birmingham.

The Stoke hospital, which in 2009 became the first in the NHS to offer mechanical thrombectomy on a 24/7 basis, has also been treating patients from six hospitals in the east and west Midlands, and north Wales, since 2010.

Patients from Middlesbrough who need emergency stroke treatment travel the 47 miles to Newcastle to have it rather than the town’s James Cook hospital, which cannot recruit enough INRs to offer its own local population that service.

Glasgow has also had recent problems offering mechanical thrombectomy to its citizens, some of whom have instead gone the 50 miles to Edinburgh for treatment.

The problems underline the NHS’s deepening staffing crisis, which hospital bosses claim is now a bigger issue day to day than lack of money. They also threaten NHS England’s ambitious plans to hugely increase the number of patients who undergo thrombectomy as part of its plan to reduce avoidable mortality.

During a thrombectomy doctors remove a blood clot from someone’s brain using a stent. That gives patients a much better chance of walking out of hospital unaided and disability-free rather than ending up with significant paralysis, or dying. Evidence suggests it is more effective for some stroke patients with a blood clot than solely undergoing thrombolysis – receiving clot-busting drugs – which is the traditional treatment.

Cardiff and Vale University Health Board launched Wales’s first clot-retrieval service, covering the bulk of the country’s 3 million population, last August. However, it had to stop functioning in May this year when one of the three doctors providing it retired, another got a new job and the third went on sick leave, and no replacements could be found.

Stroke specialists warn that patients from south Wales could die because they can no longer have a thrombectomy. Efforts by senior NHS officials in Wales to persuade hospitals in England to perform the procedure on patients from south Wales have so far failed to lead to any formal cross-border care agreements.

The NHS in Wales estimates that 500 people a year from the country would benefit from undergoing thrombectomy. Yet hospitals in England have made clear that they already have too many cases of their own, and too few beds and staff, to help on more than an occasional ad hoc basis.

In a testy email to Welsh NHS officials last month about the disappearance of the Cardiff service, Crispin Wigfield, the North Bristol NHS Trust’s stroke lead, told them: “At the risk of being blunt most frontline clinicians think that you have not got a grip on the situation and if it wasn’t so serious Wales would be the laughing stock of the international neurovascular community.”
His hospital at the time had no spare intensive care beds to be able to accommodate stroke sufferers from Wales, he told them.
In another email Dr David Rosser, the medical director of the Birmingham trust, told Welsh NHS officials that “we are, sadly, unable to support this [request for a cross-border thrombectomy] service as we do not have the capacity [to take extra patients].” He declined Welsh colleagues’ offer to pay for the opening of extra beds, explaining that his hospital was already “opening every bed we can get staff for”.
Doctors in south Wales can only seek help from a few English hospitals because doctors have ideally between four and six hours in which to perform a thrombectomy or the chances of a patient receiving real benefit fall significantly.
Twenty stroke patients from Wales have undergone coiling since May in hospitals in Birmingham, Bristol, Oxford, Plymouth and Southampton. The Cardiff service has recruited one new INR, but does not expect to resume offering thrombectomy for some time.

Terrifyingly, according to the World Health Organisation definition the UK no longer has a NHS

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Record numbers apply for Oxbridge and medicine

 

Counting the cost: NHS cuts to cataract surgery can be fatal

We were made with two eyes, and two ears for a purpose. Reducing vision to one eye means there is less visual stimulation, and the same is true for only one ear or hearing aid. Besides the falls and accidents, there is a possible dementia potential…

In the kingdom of the blind, the one-eyed man is king. - Desiderius Erasmus

Chris Smyth reporting in the Times October 26th 2017: Counting the cost: NHS cuts to cataract surgery can be fatal

If analysis of cost effectiveness is a little technical for most patients, then it does not get any starker than this: cutting back on cataract surgery could cost lives.

The latest research from the US does not prove that fixing cataracts directly cuts the risk of early death by 60 per cent — but patients whose cataracts are not treated are known to injure themselves more and generally disengage from the world. It is powerfully plausible that for some this proves fatal.

The study appears just as the National Institute for Health and Care Excellence publishes guidelines that tell the NHS that rationing is unjustified. Its calculations are unequivocal: fixing cataracts is almost always a good use of NHS money.

The problem is that the NHS’s resources are being spread ever thinner. It is striking that health officials no longer bother to dispute the evidence nor claim that their policies are not really about cost cutting. With admirable honesty, they now simply say they cannot afford to treat everyone who needs it, even for something as basic as 20-minute cataract surgery. Even if it means those patients are more likely to die early.

So far voters have tacitly accepted this. The big political question is: for how much longer?

The Telegraph: Stop rationing cataracts until patients are nearly blind, NHS warned

The Mail: End of the cataract postcode lottery: NHS are told to halt rationing

Doctors forced to plead with NHS for treatments for patients, BMJ finds …Growing healthcare rationing means GPs are having to submit exceptional requests for treatments including cataract removals and new hips and knees

Many NHS trusts ‘rationing cataract surgery’ – BBC News

Hearing loss and dementia: more research is needed. Patients with hearing aids in hospital need special consideration, and for over 70s, that’s over 60% of us …

 

We are wasting money because politicians cannot think longer than 4 years..

The result of accidental under-capacity in a market controlled entirely by government is higher locum fees.. The answer is over-capacity, but which party has the guts to advocate this solution, and appoint enough places in Medical Schools?

Medical Schools can be re-vamped, and zero budgeting applied once the power of the Deanery is reduced, and appointments can be throughout a Region (such as Wales) and a virtual medical school becomes reality. There is no good reason, given modern communications, that a doctor cannot be trained in his local DGH and GP practices completely.

These are our health services, and it is our money which is being wasted because politicians cannot think longer than 4 years. They ration medical places. A new system of electoral government is required, with any form of PR better than what we have now. Personally I prefer the Single Transferrable Vote as it is clearer.

In May Abi Rimmer reported in the BMJ: Locum pay since the cap, but things have got worse since then, as expected.

Chris Smyth for the Times October 23rd reports: Locum pay up 6.3 per cent since tax dispute

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Locum pay jumped by a record 6.3 per cent over the summer after a row in which doctors demanded higher fees to compensate for controversial tax changes.

Doctors’ leaders are threatening to take hospitals to court, claiming that they are bringing too many locums within rules that treat them as permanent employees and force them to pay more tax.

In the three months after the rules were introduced, average pay increased to £70.41 per hour. Consultants were paid an average of £96 an hour, with some getting up to £213 an hour, or £1,700 for an eight-hour shift, according to Liaison, which processes payments.

This is more than double the rate at which pay is meant to be capped under a drive to cut spending. One in 14 shifts now costs more than £120 an hour, up from one in 20 in the previous three months. One locum working 80 hours a week is set to earn £409,000 this year.

Since stricter Revenue & Customs definitions of self-employment known as IR35 rules were introduced in April, more than 80 per cent of locum shifts are now paid through PAYE, whereas in the previous three months 88 per cent were paid through personal service companies.

The British Medical Association said: “IR35 has been an administrative disaster for the NHS and, as these figures show, it hasn’t reduced spending. The real question is why there is such an over-reliance on agency staff. Locums are a vital part of the NHS but cannot fill long-term gaps. The problem is many hospitals can’t attract staff to take up permanent posts due to being forced to work under extreme pressure.”
Taj Hassan, president of the Royal College of Emergency Medicine, said that he recently agreed a deal to train hundreds of A&E specialists over the coming years but said hospitals would still be reliant on locums this winter.
A spokesman for NHS Improvement said that locum spending was down £169 million in a year as shifts were reduced and more doctors were being brought in-house.
• Patients will be delayed by red tape when they go into hospital under rules that come into force today demanding proof of address to deter health tourism, the British Medical Association warns. Chaand Nagpaul, its chairman, said there was a lack of clarity about the rules that could create confusion and an administrative burden.

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Bullying is a sign of desperation. It is caused by circumstances.. These will get worse… Dead patients don’t vote…

The temperature is rising in some parts of the country. Services are failing as doctors leave, and now patients also are “leaving” to get better treatment abroad. Polly Toynbee is correct, but although the doctors are leaving, and commissioners and those that remain know what is happening, the politicians are protected by large incomes and private options. Surgeons and administrators don’t start off as bullies. It is circumstances that drive them to desperate measures. In North Wales the GPs are at desperation level: GP surgery blasts ‘bullying’ health board over claim it’s ‘at risk’  – Betsi chiefs deny claims they want to ‘destroy independent general practice’ across North Wales (Steve Bagnall reports) 

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In Northern Ireland BBC News reports: “NHS surgery waits run into years in Northern Ireland” and NI has never met key NHS cancer target

In Scotland the Telegraph: Bed blocking costs Scottish NHS more than £100 million a year and The Times Daniel Sanderson reports: ‘Brain drain’ as doctors abandon Scottish NHS in their thousands

And in the Telegraph more bullying, this time by Surgeons: Badly-behaved surgeons are ​putting patients’ lives in danger ​due to ‘culture of bullying’, report finds 

Tom Martin in the Express 23rd October reports: NHS crisis: SNP warned over doctor ‘brain drain’ which has seen THOUSANDS moving abroad – MINISTERS have been urged to tackle a medical “brain drain” amid warnings up to 3,000 doctors have quit Scotland’s NHS to work abroad over the past decade.

Laura Donnelly in the Telegraph reports 22nd October: Soaring numbers flying abroad for medical care as NHS lists lengthen 

The number of patients leaving Britain and flying overseas for medical treatment has trebled as NHS waiting times reach a record high, a Telegraph investigation has revealed.

Government data shows the number of people going abroad for healthcare has increased from 48,000 in 2014 to almost 144,000 last year as the health service struggles to cope with demand.

Polly Toynbee has it right when she writes in the Guardina 17th October: While all eyes look to Brexit, our NHS is about to collapse

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The Observer view on NHS funding Observer editorial Rationing care to smokers and the obese will not solve its financial crisis

The Observer Editorial on Sunday 22nd October 2017: – Rationing care to smokers and the obese will not solve its financial crisis

Since June last year, Brexit has dominated the government’s agenda, absorbed the bulk of ministers’ energy and been the focus of civil servants in Whitehall. This state of affairs will continue for at least the next few years. Yet from the welfare state, to prisons, to our schools and hospitals, there is mounting evidence that a state that first started to founder seven years ago, is now running aground.

Last week, this was most visible in the planned expansion of universal credit. For months, MPs and charities have warned that the minimum six-week delay before claimants can receive their first payment will cause low-income families to fall into debt – leading to evictions, homelessness and destitution.

The government is still pushing ahead, despite being so uncertain of quashing a parliamentary motion calling for a pause that it imposed a three-line whip on Conservative MPs, instructing them to abstain.

But it’s not just the benefits system: it’s every part of the state that is creaking at the seams. Last week, the BBC released a new NHS tracker that highlights just how much hospitals are struggling to cope with rising demand. Only one NHS trust in the country has managed to consistently meet the national targets for accident and emergency, cancer and routine operation waiting times over the last year. In England, the NHS hit these monthly targets 86% of the time four years ago; over the last year, none at all.

This is just the latest in a series of alarm bells that the NHS, currently experiencing the tightest financial settlement in its 69-year history, is stretched to breaking point. The last 12 months have been filled with stories of missed targets, deteriorating care and growing deficits. Given this constant drip of warnings, it’s easy to become immune to the latest signal that something is very amiss.

That would be a mistake. The NHS is slowly but surely becoming less national, and less universal. It was founded on the principle of free care at the point of delivery to anyone in need, regardless of circumstance. In truth, its resources have never been infinite, and so the rationing of care and postcode lotteries have always, to some extent, been an everyday reality. But as its funding is becoming more and more stretched, we are seeing a financially driven, under-the-radar scaling back of treatment that increasingly undermines that founding principle that is so cherished.

For months, doctors have been warning about increased rationing in the NHS by arbitrary or inappropriate criteria. A year ago, the Royal College of Surgeons found that more than one in three NHS commissioning groups were denying or delaying routine surgery such as hip and knee replacements to the overweight and smokers until they lost weight or stopped smoking. Since then, more have adopted these types of restrictions.

Last week, the Health Services Journal revealed that health commissioners in Hertfordshire will deny non-urgent surgery to smokers unless they pass a breathalyser test to show they have not smoked for the last eight weeks. Other areas are inappropriately using pain threshold scales – not designed for this purpose – to limit non-urgent surgery to people experiencing only debilitating pain. In February, health commissioners in West Kent suspended all non-urgent surgery altogether until the start of the new financial year in April.

For some patients, particularly the very obese, there may be good clinical reasons to delay surgery until they have lost weight. But these restrictions are not being imposed on clinical grounds, in the best interests of an individual patient. They are often blanket restrictions that contravene the official guidelines of Nice, the health regulator.

There is no evidence to suggest that denying surgery to those who smoke or who are obese is an effective way to encourage them to change their lifestyle. On the contrary, it can leave people in greater pain and with greater risks to their long-term health due to immobility. While NHS England has warned commissioners against restricting access to non-urgent procedures based on arbitrary criteria, one of its senior directors, in a leaked letter to commissioners in Rotherham, appeared to back this approach.

These sorts of restrictions are not only cruel and inhumane, leaving people in pain sometimes for months before they are operated on, they end up costing the NHS more in the long term. Leaving conditions to get worse before treating them not only can carry health risks, but also means patients need pain medication and physiotherapy for longer.

What makes so-called “lifestyle rationing” particularly insidious is there is a pronounced social gradient for both obesity and smoking. The link between poverty and childhood obesity has only got stronger over the last decade; children living in the poorest areas of the country are twice as likely to be obese as those living in the most affluent. The prevalence of smoking is similarly linked to income and social class. Rationing treatment to smokers and the overweight will inevitably mean that it is those who are poorest who have their access most impeded.

This is one of the serious consequences of the NHS deficit, which stood at just under £4bn in the last financial year in England, and will be even higher next year. Everywhere you look in the NHS, there are others. This Friday, a report by the Care Quality Commission will warn that children with mental health issues are having to wait up to 18 months for treatment, putting their health at serious risk.

Ward staff are becoming increasingly stretched due to a shortage of nurses, compromising the quality of care. The independent health thinktank, the King’s Fund, has warned that health trusts across the country are planning on cutting too many beds from hospitals in their areas, further restricting capacity in a system whose average bed occupancy was 92% between January and March this year – far above the safe level of 85%.

The NHS is far from perfect: the terrible quality of care once on offer at Mid Staffs is testament to that. But it has been declared one of the best health systems internationally, despite spending much less per head than many other wealthy countries. That is being jeopardised by the government’s sustained underfunding.

There are difficult choices the government should be making in the forthcoming budget to alleviate the pressure on public services from hospitals, to prisons. At the very least, it should abandon all further planned tax cuts, and divert the savings to patching up some of the damage that has already been done. But the risk is that just as Brexit will continue to dominate the political debate in the years to come, so it will frame the economic decisions that will shape the health of our public services over the next decade.

Things are bad, but the depressing truth is, the worst could yet be to come.