Do we want reduced access and less efficiency? GPs are self employed, and they take dividends. Salaried staff are far less value to the state. Politicians are uninformed and short termist..

Especially when there is a shortage, and the politicians have dug their own hole for decades, it is wrong to suggest that highly skilled managers of teams should be punished. The real scandal is the lack of professional staff, and the low salary of the “juniors” who are not partners in the business. The rules allow for GP principals (senior partners) to be asked for accounts to show how much they earn gross, and net from state employment. The gross amount is before staff expenses, practice equipment and utilities. GPs are self employed, and as such they take dividends, not a salary. Most of us former GPs maintain that salaried staff are far less value to the state. Sickness rates in the Health Services are the highest in the world, but the exception (to date) has been GPs and Hospital Doctors. The demands for a salaried service will continue, especially under Labour and in Wales, but the result might be reduced access and less efficiency (Shape of a job). This is a smokescreen trying to get away from poor manpower planning. Indeed, GP profits are falling. GP Trainees are salaried, and may outnumber principals soon! In addition, the location of these “mega practices” managed by  GP experts (managers), is in city suburbs where there is more competition for posts. (Because schools are better there, and provide more places to medical school, and doctors want the same opportunity for their own). The knee jerk response form MPs reveals their ignorance.…… and their short termism.

The various newspapers cover the issue 28th December:

Britain’s highest-earning NHS family doctor rakes in £700000 a …The Sun–28 Dec 2018

The Times: Best-paid GP earns £700k from NHS and today Publish details of doctors‘ pay, MPs demand

GP partner pay drops by 4.3% in the last six months Pulse December 18th

GP premises development frozen, GPs forced to publish pay from 2015: What about comparing overhead?

It’s the shape of the GP’s job that needs to change. The pharmacist will see you now: overstretched GPs get help…The fundamental ideology of the Health Services’ provision. Funding of this type admits 30 years’ manpower planning failure

The Guardian 4th November: Hundreds of trainee GPs facing hardship as a result of salary delays

Bad News: Sharp rise in sick days taken for mental illness – especially in the Health Service Trusts

The NHS culture is sick – and so are its staff – But is there any “quick fix”?

fewer women should be allowed to train as doctors because men are ‘better value for money’… The answer is graduate entry to medical school.

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

The Times summarises in “Healthier and Wealthier” – the Leader 28th December

There is nothing wrong with entrepreneurial GPs earning more than average but when pay is excessive it is likely to be at the expense of patient care

Family doctors may seem an unassuming breed, but some of them have been quietly building empires. Gradually, over the past decade or so, small general practices have been absorbed into super-practices that have merged between two and forty-two surgeries. Many of the local-doctors-turned-tycoons have been doing rather well out of it. A freedom of information request has revealed that one doctor made more than £700,000 from the NHS in 2015-16, one of 200 to earn in excess of £200,000 that year.

The news has angered patient groups, who feel that these salaries are not appropriate, given the health service’s straitened times. The Taxpayers’ Alliance has called the figures evidence that “something is going badly wrong” with GP pay. But some of the sums may be justified if they have incentivised change for the better. Empires can in principle be good for general practice, and where they are, those building them should be rewarded.

Policymakers have long since hoped that enterprising doctors would start to merge practices. They have witnessed the struggle of tiny surgeries that often fail to keep up with the demands of an ageing population. Banded together, surgeries can cope better, as large practices are able to economise on administration costs and through bulk-buying. They can provide better services to patients, too. A larger pool of doctors means more flexibility in the rota, and therefore longer opening hours. At least one super-practice in Birmingham is open seven days a week. Many can afford to offer patients extra services, such as an onsite dentist or physiotherapist.

Large practices may also help to combat the burnout problems that plague the profession. GPs have been quitting the NHS at the rate of more than 400 a month. Many are fed up with the burden of the administrative work involved in managing small practices, along with cramped and inadequate premises. Life at a large clinic can be more varied as well as more comfortable: flexibility means that doctors can spend a couple of days a week pursuing a specialist interest, such as orthopaedics or physiotherapy. And a traditional perk of working at a small practice — rising to be partner more easily — is becoming less important with the proliferation of female GPs who often prefer the part-time options that come with working for a salary, rather than running a business.

The system is not perfect. Although the wealth of a practice, dependent on the number of patients it serves and government targets it meets, is tied to its success, the salary of its senior partner is not. Partners decide how much to take for themselves and how much to plough back into their businesses. The most dynamic are not necessarily those paying themselves the highest sums. An enterprising approach that improves both efficiency and patient care is to be applauded, but doctors who pay themselves very large salaries necessarily take resources from patients. For a GP to earn more than £700,000 seems excessive by any standards. This is nearly double the salary of even the controversially highly paid university vice-chancellors. It makes the case not for enterprise in primary care, but for restraint in GPs’ pay.

The second problem is that pay is not transparent. High rewards for the most enterprising doctors will not work as an incentive to others unless the sums are public and fair. More importantly, they are funded by taxpayers who have a right to know how their money is spent.

It is to be welcomed that GPs can be entrepreneurs as well as NHS employees. Indeed, it is partly for this reason that general practice has adapted to changing demands better than the rest of the health service. As practices have merged, patients are better served than with healthcare elsewhere. The more efficiently GPs’ surgeries are run, the lighter the pressure on the rest of the NHS.

Letters in the Times 30th December: 

GPs’ SALARIES
Sir, GP practices are run on a business model in which earnings are related to meritorious performance and excellence (“Best-paid family doctor earns £700k from NHS”, Dec 29). If a highly paid GP provides exemplary care to his or her patients, should we begrudge the high pay? Further, if a university vice-chancellor can earn nearly £500k, there is no reason why a hard-working and efficient GP should not be paid a high emolument for his service.

With time being limited per patient, GPs are under considerable strain in taking clinical history, both recent and past, examining the patient, ordering investigations and referring to hospital when required. At present, many patients in general practice are elderly and suffer from multisystem diseases. On top of this, the average GP is lumbered with bureaucracy, paperwork and administrative duties. Whether they are in a large practice group or not, GPs work in isolation, unlike hospital consultants who tend to work as a team and referrals to specialised colleagues are relatively simple.

It is a stressful and onerous life for GPs.
Dr Sam Banik
London N10

Sir, What concerns me are not the enormous salaries drawn by a handful of GPs, a negligible consideration in the context of the NHS budget, but the £56,000 a year average pay drawn by non-partner GPs.

It is hardly surprising that we have a shortage of GPs when we pay these highly trained professionals with onerous responsibilities substantially less than a London train driver. Addressing this anomaly should be the priority for the government.
Martin Cragg
New Malden, Surrey

 

The truth will out. Why 2018 will be a very special year for the NHS – and the challenge for Wales is even greater than that for England.

Nick Triggle reports for BBC News 27th December 2018: Why 2018 will be a very special year for the NHS

Next year the covert rationing will get worse….. Access will be worse. Training will be worse. Numbers of professionals will be down, and unnecessary deaths will increase… The Post-Code lottery and the denial of the political classes (who pay privately) will continue. The truth will eventually out, but it looks as if we have to wait for more frail and elderly to suffer (The Telegraph)… There is no perfect system, but the two that were free (Scandinavia and NewZealand) are no longer so. If readers have time revisit Mark Britnell (What would the world’s best health system look like? ) We all need to speak out (About – Speaking out for our NHS ) Even The Sun is beginning to get the point.. We all know surgery is rationed..

The PM exchanged views with Jeremy Corbyn on 2oth December, and emphasised the Welsh Health budget situation. Nick Fahy of Oxford explains why Wales has less wriggle room..

This is a special year for the NHS – it marks its 70th birthday. So expect lots of anniversary events and stories celebrating the success of the health service over the past seven decades.

The big day is on 5 July and word has it that the Chelsea Flower Show and the Wimbledon tennis championships will even be organising their own tributes.

There will also be a ceremony at Westminster Abbey in London and individual health services are being encouraged to hold open days for the public, 70th birthday-themed awards for staff and to help communities organise summer tea parties to mark the milestone.

There is much to celebrate. The NHS has played its part in eradicating diseases such as polio and diphtheria and pioneered new treatments including carrying out the first liver, heart and lung transplant.

And it is also the UK’s largest employer with 1.5 million staff drawn from all over the world.

But what else will the next 12 months hold?

Watching the waiting times

Despite the goodwill and celebration that will surround the 70th birthday, the NHS will also be in for a challenging year.

Scrutiny has never been higher, particularly over what is happening to waiting times. The key targets, covering cancer, A&E and planned operations are being regularly missed across the UK.

In England, Health Secretary Jeremy Hunt has promised the four-hour A&E target will be met by the end of March.

To help, the Treasury pumped an extra £1bn into the council care system this year, in the process tying town halls into working with the NHS to get vulnerable elderly patients in and out of hospital as quickly as possible.

But as things stand currently, twice as many people as should be are still waiting more than four hours.

It will be a difficult task to change that. In fact, NHS bosses have warned that, given the current level of funding, meeting many of their targets may prove problematic.

Sugar, sugar

Britons are known for their sweet tooth, but almost unnoticed the amount of sugar in our food is being reduced – or at least health officials hope it is.

In the summer of 2016 the government set manufacturers a target to reduce sugar content in a range of foods aimed at children by 20% by 2020.

This can be achieved through reducing the actual sugar levels in products, reducing portion size or shifting purchasing towards lower sugar alternatives.

The first progress report on this will be published by Public Health England in March when it will be expected the food industry will have achieved a 5% reduction. If they haven’t, expect ministers in England to come under pressure.

When the child obesity strategy was published last year, the government placed a lot of emphasis on this partnership with manufacturers. Campaigners wanted them to be tougher and legislate.

Care for the elderly

It was one of the key issues of the election. Shortly before publishing their manifesto, the inner circle at Number 10 decided to hatch a new plan for social care in England.

The system in Wales and Scotland has already been changed significantly post-devolution.

But it didn’t go down well. Dubbed a dementia tax, the proposals were widely derided as an attempt by the government to use the wealth accrued by homeowners to fund the social care system, which covers care homes and help at the home for daily task such as washing and dressing. Unlike the NHS, this support is not provided free to everyone.

Within days, the prime minister was rowing back on the plans, saying any costs would be capped. It was perhaps the first sign all was not going well in the election campaign.

The government is now promising a fresh set of proposals in a green paper that will be published by the summer recess.

This administration will not be the first to attempt to reform the system. When Tony Blair came to power in 1997 he talked about it too, as did his successor Gordon Brown and then his successor David Cameron. Ministers should be prepared for a bumpy ride.

Getting answers to the ‘worst-ever treatment disaster in the NHS’

During the summer, the government announced there would be a new UK inquiry into the contaminated blood scandal, often called the worst treatment disaster in the history of the NHS.

At least 2,400 people died after they were given blood products that were infected with hepatitis C and HIV during the 1970s and 1980s.

Thousands of NHS patients with an inherited bleeding disorder called haemophilia were given the plasma products, some of which came from prison inmates in the US.

In the autumn it was given the status of a full statutory inquiry led by the Cabinet Office.

This came after campaigners objected to the Department of Health taking on the lead role – they have argued the department has, in the past, helped to cover up what really went on.

But despite the announcement, the campaigners are still waiting for further details of how the inquiry will be carried out and who will chair it.

Expect ministers to come under pressure to get the inquiry moving early in the new year.

What would the world’s best health system look like? (Mark Britnell)

A reminder in poetry: “I am a child of the NHS”

A poem a day will keep your loss of empathy at bay, doctor

My own family and the NHSrationing_health_care_240212

rationing_health_care_240212NHS rationing – by Julia Manning

The NHS curing all ills

The NHS is being torn from those who have cherished it for decades

Child deaths amongst the worst in Europe (still better than the USA)

The Health Services in “Reality”: even the chief says it’s broken

Public must pay for better NHS, says Stevens to spineless politicians at King’s Fund

The Mirror: NHS chief Simon Stevens says patients should pay for their own hayfever remedies, sun cream and holiday vaccinations.

 

IMF forecast is damning.. A two tier system emerges from denial… A collusion of politicians and leaders…?

A damning forecast by the IMF is accurate, but fails to be honest about the WHO report that there is no NHS. Each Region and Post Code will have different forms of rationing, and no “Noticeboard” warning citizens what they need to plan for …. Even Mr Stevens thinks rationing has to happen – without mentioning the word it seems! The unreal denial in the RCGP and Prescription Charges Coalition documented in the Times is delaying the inevitable, but worse, it stops rationing being planned. Is this a conscious or unconscious collusion of politicians and leaders?

The Economics Editor of the Times, Philip Aldrick reports 21st December 2017: Privatised NHS and tax rises forecast by IMF

Taxes will have to rise if the government is to balance the books by the middle of the next decade and the NHS may have to be privatised, the International Monetary Fund has warned.

Property taxes, the removal of preferential VAT rates for goods such as pasties, and higher national insurance contributions by the self-employed need to be considered if Britain is to have any chance of eliminating its budget deficit by 2025 because spending cuts have gone about as far as they can, the global economic watchdog said in its annual review of the UK.

Weak productivity and the increasing care demands of an ageing population will make deficit reduction harder. Public services such as the NHS may have to be scaled back or privatised, it added.

The warnings are a reminder of the persistent problem of Britain’s public finances almost a decade after the financial crisis caused borrowing to soar. National debt is 87 per cent of GDP and spending on public services exceeds revenue from taxes by more than 2 per cent of GDP.

“Continued deficit reduction is critical to create further room to respond to future shocks,” Christine Lagarde, managing director of the IMF, said. “There is not much space for additional spending cuts and the revenue side of the equation has to be looked at.”

Britain is already forecast to be paying 34.3 per cent of GDP in tax by 2022, more than at any time since the 1950s, but economists estimate that at least £20 billion of extra austerity will be needed to hit the government’s target of balancing the books.

Ms Lagarde said population changes were adding to the problem. “Population ageing is expected to lead to material increases in spending on healthcare, pensions and long-term care, while productivity growth has been slow. And a slowly growing economy means fewer resources will be available to meet increased spending,” she said.

The public spending burden will soon make Britain face some hard choices, the IMF added. “The UK may face difficult decisions about the desired size of its public sector, as well as the mode of delivery and financing of public services. Brexit-related effects may exacerbate the challenge.”

To address the problem, Britain needs to boost productivity. Ms Lagarde welcomed the chancellor’s £31 billion fund for infrastructure investment and focus on technical qualifications because “the UK underinvests in infrastructure and falls short in human capital development”. But she said that more needed to be done “such as easing planning restrictions and reforming property taxes to boost housing supply”.

As well as introducing a land tax, the government should harmonise VAT for goods that get preferential rates and better “align the tax treatment of employees and the self-employed”. Both proposals have proved a poisoned chalice for chancellors. George Osborne tried to harmonise VAT rates for hot food in his “omnishambles budget” and Philip Hammond had to backtrack this year on raising national insurance for the self-employed. The IMF also recommended “reducing the tax code’s bias towards debt” and scrapping the triple lock on state pensions.

John McDonnell, the shadow chancellor, said: “The IMF has played the role of the ghosts of Christmas past, present and future to remind the chancellor that seven years of Tory failure is undermining our economy.”

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

Chris Smyth in the Times 21st December 2017: Treating dandruff takes millions from vital care, NHS chief Simon Stevens warns

Scrapping NHS prescriptions for anti-dandruff shampoo and indigestion tablets could fund thousands of cataract operations and hip replacements, health chiefs say.

Ending routine treatment for coughs, ulcers, piles and other conditions that will get better by themselves could save up to £136 million a year to spend on other care, NHS England calculates.

Simon Stevens, the head of NHS England, signalled the crackdown on over-the-counter remedies last month as part of cost-cutting plans and began consulting on the practicalities of the changes yesterday.

“To do the best for our patients and for taxpayers it’s vital the NHS uses its funding well,” he said. “This consultation gives the public the opportunity to help family doctors decide how best to deploy precious NHS resources, freeing-up money from the drugs bill to reinvest in modern treatments for conditions such as cancer, mental health and emergency care.”

The NHS spends £4.5 million a year on anti-dandruff shampoo, which Mr Stevens said could fund 4,700 cataract operations or 1,200 hip replacements. The £5.5 million cost of treating mouth ulcers could pay for 1,500 hip replacements and the £7.5 million spent on indigestion and heartburn could fund 300 community nurses…..

…Some over-the-counter remedies are cheaper than the cost to the NHS of prescribing, including £2.18 travel sickness tablets that cost taxpayers £35 once the costs of dispensing, administration and a GP’s time are included.

Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said: “Where patients can afford to buy medication over the counter, we would certainly encourage them to do so. There are also many minor, self-limiting conditions for which patients don’t often need to seek medical assistance, or prescribed medication. What remains imperative — and we will be making this clear in our consultation response — is that no blanket bans are imposed, and GPs will retain the right to make clinical decisions.”

Matina Loizou, co-chairwoman of the Prescription Charges Coalition, added: “NHS England has decided to play the role of Ebenezer Scrooge this Christmas by launching this cruel consultation. If seen through, these proposals would be a catastrophic blow to some of the country’s most vulnerable and unwell people who rely on a variety of medication and treatments to live, work and be well.

Destination GP. Perceptions and denigration of GPs needs to stop…. All specialities need some time in GP.

In GPFrontlie produced by the RCGP December issue, you can read how belittled GPs are by their colleagues in Hospitals. Deskilling them by overworking, bureaucracy and ending the regular meetings that went on between consultants and GPs are all partly responsible. Meetings used to occur evenings, and Consultants and GPs took turns in presenting at them. Part time working, bringing up children, and having a home life have replaced the weekly evening meetings we used to have in Pembrokeshire. I expect a similar story nationwide.  All speciality training should experience some time post registration in GP.

Destination GP: medical students’ experiences and perceptions of general practice

5 December 2017

The Destination GP project aimed to build the evidence base on medical students’ perceptions of general practice. A report from the Royal College of General Practice sets out a series of recommendations to tackle the spread of misconceptions and negativity surrounding general practice.

 

Child and Neonatal health, Intrauterine deaths and maternal deaths. How do we compare? Shamed…

Poor results are expressed in increased deaths. The Mail 19th December calls it shaming.

NHSreality has tried to get an answer from our local Trust on the relative rates of Neonatal, Infant and Maternal Mortality through a FOI (Freedom of Information) request. The result is below, but readers can read that it fails to address my questions. I asked for the relative perinatal, infant and maternal mortality rates for Hywel Dda compared to Wales and UK averages.

FOI 255 17 – Final Response Mortaility rates

The failure to answer the question is justified by small and meaningless numbers, BUT if these are consistent and have not improved since 20 years ago this is significant.

Ben Spencer for the MailonLine reports 19th December 2018: Failure on sepsis sees UK plunge in world rankings for child mortality: Britain is 19th in league of 28 EU nations after falling from ninth in 1990

Stillbith attitudes also have to change:

Stillbirths – Janet Scott

FE News 7th December reports: EAC Chair urges Justine Greening to use UN Sustainable Development Goals in National Curriculum

Sarah Kate Templeton on December 3rd in the Times reports: Father’s agony drives bid to cut stillbirths – Health secretary Jeremy Hunt has revealed how meeting a man who had lost his wife and baby son inspired care reforms

A meeting with a father who lost his wife and newborn baby inspired Jeremy Hunt to tackle Britain’s shamefully high rate of stillborn babies.

The health secretary said he would never forget the encounter with Carl Hendrickson, whose wife, Nittaya, and newborn son, Chester, died in 2008 during the scandal at University Hospitals of Morecambe Bay NHS Foundation Trust.

Hendrickson insisted his surviving son, Conrad, who was 11 at the time, attend the meeting so he would “know for the rest of his life that his dad had done that”, Hunt said.

After this newspaper’s Safer Births campaign, the health secretary, who praised our highlighting of the issue, published plans last week to save more than 4,000 lives by halving rates of stillbirths, neonatal and maternal deaths and brain injuries.

Every day, eight babies are stillborn in England, the highest rate in western Europe……

Sarah Boseley in the Guardian April 4th reports: Stillbirth rate in UK one of Europe’s highest, Lancet finds – Report says many of 4,000 babies stillborn each year could be saved with increase in awareness and research

Around 4,000 babies die unexpectedly in the last months of pregnancy or during labour every year in the UK – one of the highest rates of stillbirth in Europe, according to a major new series of reports by the Lancet……

Stillbirth rates by country:

Neonatal death by country:

Infant mortality rates by country:

and by Region in the England (But not able to compare with Wales, Scotland and N Ireland):

 

Causes of Infant Mortality in the UK 2014:

Causes of Maternal Mortality UK:

 

 

 

The National Centre for Disease control and Prevention 2009 shames the USA: 

Behind International Rankings of Infant Mortality: How the United States Compares with Europe

 

Facing an understaffing crisis….. Those rejected during the last 30 years should be asking why?

The Times second leader 20th December is telling, not only that health is second, after defence, but also in telling the truth.  Apart from the fact that there is no NHS, NHSreality concurs on every point. Doctors are “stressed out”. What is omitted is the increasing numbers of women as a percentage of the whole, many of whom go part time. Postgraduate entry would address this gender inequality. As we move further into the understaffing crisis, and those with means elect to go privately in a default 2 tier system, those rejected, in applying to all the medical professions over the last 30 years, should be asking why?.. Even within training we are seeing omissions. The poor results for infant mortality compared to our peers is a result of only half of GPs getting Paediatric experience. A six month post is unnecessary, and 3 month posts could double paediatric exposure. It is not enough to get all children to see paediatricians immediately, as there are not enough of them either. Overseas doctors are declining after the Brexit vote, but many of these will have been trained privately overseas…. the assumption that our medical workforce is there on merit also needs challenging. Our whole manpower system needs re-planning and depoliticising, and to take away the perverse incentives for short term planning..

Doctor, Doctor – Britain needs to train more doctors and nurses to make the NHS sustainable

The NHS is facing an understaffing crisis. A report from the General Medical Council highlights three developments, each of them a surmountable problem on its own, but indicative of a looming problem when taken together.

First, the United Kingdom is deeply dependent on doctors and other healthcare workers who have qualified abroad. In some fields and some geographical areas this is both acute and dramatic. For example, more than half the workforce in obstetrics and gynaecology, and almost half of the nation’s psychiatrists are currently non-UK graduates. Meanwhile, in the east of England, 43 per cent of doctors are not UK graduates. In the West Midlands, 41 per cent are not. In the East Midlands, the figure is 38 per cent.

Britain is an attractive country in which to live and work so it is scarcely surprising that many doctors, who are often relatively young and mobile, wish to do so. Yet an attendant problem is that they wish to do so less and less. Perhaps due to a change in atmosphere since the EU referendum, or perhaps merely due to the falling pound, the number of foreign-trained doctors working in Britain is decreasing, not rising. Between 2011 and 2017, the number of foreign graduates on the medical register has shrunk by 6,000, with the fall coming not only from the EU but also south Asia.

Meanwhile the need for doctors is growing swiftly. Although the number of doctors working in Britain is increasing slowly, thanks to domestic recruitment, the demands of healthcare are rising even more quickly. England, for example, has experienced a 27 per cent increase in patients visiting accident and emergency in the past five years. This places a heavy toll on doctors and other healthcare workers, which in turn makes them less likely to remain in the profession.

Jeremy Hunt, the health secretary, attracted censure when he banged a drum for more British doctors in his party conference speech, but he was right to do so. There is nothing discriminatory about making public services sustainable and if doctors are reluctant to come from elsewhere, they will have to come from here. The Department of Health’s plan to add up to 1,500 more medical training places each year from September 2018 is therefore welcome. The creation of more places should be accompanied by incentives to take them up and to stay beyond the training. This could include easing the burden on junior doctors by providing more training opportunities.

There is also a need to look beyond doctors and traditional nursing roles. The Department of Health should consider a drive to expand the workforce by training more clinical pharmacists, physician associates, and nurses with the ability to prescribe medicines. That would leave junior doctors more time to spend caring for patients and undergoing training, and would lighten their administrative burden. In addition, such a step would provide further incentives for prospective doctors, many of whom are discouraged by rumours of a gruelling lifestyle.

The government is waking up to the need to plan for the staffing of the health service in five to ten years’ time, but there is much more to do if ministers are to fill vacancies quickly enough. There will be little point in giving the NHS its notional extra £350 million a week if there are no staff to spend it on.

Kat Lay reports: Stressed-out doctors have reached breaking point, warns General Medical Council

Doctors who trained abroad account for almost half of all those working in parts of the UK as the profession faces “crunch point” and more young doctors take time out due to stress.

The General Medical Council’s annual report said that many regions and specialities relied on foreign-trained doctors, who could leave the UK. It added that there were too few doctors to treat rising numbers of patients, and doctors were being “pushed beyond their limits”.

The State of Medical Education and Practice showed that 54 per cent of junior doctors took a break after finishing foundation training, a rise from 30 per cent in 2012. “Goodwill and commitment to always go the extra mile” kept the NHS running, it said. “This level of sacrifice is neither right nor sustainable.”

The number of doctors on the medical register has grown by 2 per cent since 2012. Over the same period in England there has been a 27 per cent increase in patients going to A&E, and the GMC said that an ageing population was putting pressure on services.

While the number of UK graduates on the medical register rose by more than 10,700 between 2012 and this year, the rise was offset by a fall of 6,000 in foreign-trained doctors.

Charlie Massey, chief executive of the GMC, said: “We have reached a crucial moment — a crunch point — in the development of the workforce. The decisions that we make over the next five years will determine whether it can meet these demands.”

A fifth of doctors in training said they felt short of sleep while working. In 2014, when 43 per cent of new doctors took a break from training, 22 per cent took a one-year break and 8 per cent took a two-year break. Others may never return. More than half of those taking a break said that it was because of burnout, and most wanted a better work-life balance.

The GMC said that reducing the pressure on doctors and improving the culture and making jobs and training more flexible would be vital to recruiting and retaining doctors.

In the east of England 43 per cent of doctors were trained overseas. In the West Midlands the figure is 41 per cent, and 38 per cent in the East Midlands. More than half, 55 per cent, of specialists in obstetrics and gynaecology trained overseas.

About 14 per cent of doctors in the UK trained in south Asia, but their numbers have dropped by 7 per cent since 2012. The number of doctors from Africa, Australia, New Zealand and North America also fell.

The Department of Health said: “The NHS has a record number of doctors — 14,900 more since May 2010 — and we are committed to supporting them by expanding the number of training places by 25 per cent.” The department was working to improve retention, it added.

BEYOND THE STORY
The health service turned to Britain’s former colonies in South Asia during labour shortages in the 1960s and again in the 2000s when there were too few homegrown recruits.

Today, too, it leans heavily on overseas doctors. A third of doctors in the NHS trained outside the United Kingdom. The reliance has raised concerns that the NHS may be fuelling a “brain drain” in poorer countries where doctors are desperately needed, although others argue that training in the UK can improve those doctors’ skills.

It comes down to the simple fact that the UK does not train enough doctors to meet the demands of its population.

Historically, NHS workforce planning has suffered because it needs to happen over a much longer period than the average lifespan of a government. Last week Health Education England set out the first NHS staffing plan in 25 years, admitting that 190,000 extra frontline staff would be needed.

Failure on child Sepsis: the Mail 19th December

…Office for National Statistics data, for 2015, puts UK under-five mortality at 4.5 per 1,000 births although rates have improved 51 per cent since 1990, when 9.3 children in 1,000 died.

But in Portugal child mortality has improved 76 per cent and by 61 per cent in Ireland.

Professor Sarah Neill of Northampton University, said: ‘Infection is a major cause of avoidable childhood deaths in the UK, particularly in the under-fives, yet we know little about the factors that influence when children are admitted to hospital.’ …

NHS workforce ‘at crunch point’. £25 per head for Welsh citizens is a drop in the ocean…..

The most valuable asset in the UKs Health Services are it’s staff. Recent inducements for GPS to train in unpopular and impoverished areas recognise the deficit. But overall, the staff can only be spread so thinly, and it will take decades to replace with adequately trained British Graduates, even if politicians can depoliticise recruitment. An extra 15,000 doctors is nothing when so many are part time, retiring or emigrating. The extra £25 per head per annum for 2 years for Welsh citizens, who have little choice compared to England, is a drop in the ocean.

BBC News reports 19th December: NHS workforce ‘at crunch point’

The UK’s medical profession is at a “crunch point”, facing the prospect of too few doctors to treat rising numbers of patients, the regulator says.

The General Medical Council says the supply of medics has failed to keep up with demand and warns against the over-reliance on overseas staff post-Brexit.

The GMC’s Charlie Massey called it a “crucial moment” for UK healthcare.

It comes despite government promises in England to increase the number of doctors in training.

The annual report by the GMC highlights four areas of concern:

• Supply of new doctors into the UK has not kept up with demand
• A dependence on non-UK qualified doctors in some specialist areas
• The risk of some overseas doctors being put off working in the UK after Brexit
• An ongoing strain on doctors in training

The report found the number of doctors on the medical register had grown by 2% since 2012, at a time when there has been a 27% increase in A&E attendances in England and a 10% increase in Northern Ireland.

Moreover, the growth in the population of those aged 85 and over – often the most needy in medical terms – is projected to double from 1.6 million to 3.2 million by 2041.

“The medical profession will undoubtedly need to grow to meet this extra demand,” the report found, adding that it must equally consider in which areas, medically and geographically, that growth should be focused – highlighting rural locations where recruitment remains a challenge.

Mr Massey called on the UK government to “think carefully about how many doctors are needed, what expertise we need them to have so they can work as flexibly as possible, and where they should be located given the changes and movement in population expected”.

In addition, the number of licensed doctors who are non-UK graduates has reached 43% in areas such as the east of England, 41% in the West Midlands and 38% in the East Midlands.

Some specialist areas are particularly reliant on doctors recruited from overseas. For example, more than half the workforce in obstetrics and gynaecology are currently non-UK graduates.

While acknowledging the importance of pooling knowledge and experience with other countries, the report questions whether “our reliance… should be reduced in favour of a more strategic and sustainable approach”.

The impact of Brexit too remains a concern.

In 2017, there were 6,000 fewer non-UK graduates on the register than in 2011.

South Asia accounts for nearly half the fall, but surveys taken earlier this year suggest European doctors currently working in the UK are also considering their position, in the light of the UK’s decision to leave the European Union.

“The underlying challenge for all in healthcare is how we retain the good doctors we have right now,” said the GMC’s Mr Massey.

“Everything we hear from the profession tells us that we need to value them more.”

He stressed the need to help doctors “achieve the right balance between their professional and personal lives through more flexible working arrangements”.

Lack of sleep

In the wake of last year’s junior doctors’ strikes and countless media reports, it is clear doctors are unhappy with their lot.

Both those in training and those doing the training complain of their heavy workload, and subsequent lack of sleep.

It has become common for more than half of doctors to take a break after completing foundation training – some do not return.

Welsh budget: Extra £160m for NHS and councils

The finances are in such a mess, that local post code and unexpected rationing is everywhere… The “Rules of the game” need to be changed…..

Vivienne Russell reports 7th December in the Public Finance Review: NHS will be ‘sorely tested’ this winter, say trusts

The immediate pressures will distract from the longer term pressures as there will be no beds for dementing elderly, possibly no beds for fractures, and certainly no beds for children with severe anorexia. One in 4 GP jobs is vacant. YOU the taxpayer and citizen/consumer will never know in advance what you and your dearest will suffer from, so you can never predict whether, in your post-code, the services you need will be unavailable. Imagine the effect this has on staff morale, engagement with change, and managers who know they never lose their jobs. We are in the trenches, and have no way to get out under the present “rules of the game”. The finances are in such a mess, that local post code and unexpected rationing is everywhere… Yes Mr Darzi, we desperately need a new solution…

Andrew Grice in the Independent 27th November 2017: The NHS is about to ration its services due to lack of funding – just before the dreaded winter crisis

The Budget’s gaping hole was on social care; it is close to collapse and putting ever-increasing pressure on hospitals through bed-blocking, but got no extra cash

A debate about rationing the care provided by the National Health Service will be launched tomorrow, when NHS England begins a conversation about what it can and cannot afford to do.

Although there will not be a hit list of cuts at this stage, the implications will be clear enough: the Government has not provided enough money to meet goals including the 18-week target for elective operations; cancer treatment; mental health; public health and obesity and for a creaking social care system. In short, something’s gotta give………

….The Local Government Association estimates a £1.3bn funding gap between what care providers need and what councils pay. Although May acknowledged the problem during this year’s election, she got her fingers burnt with her so-called “dementia tax” and the issue has now been kicked into the long grass. We won’t get a green paper until next summer. That is woeful, given the additional pressure the demographic timebomb will put on health and social care.

While the debate over NHS rationing is inevitable, we need a much wider one about the state’s priorities. The 2010 and 2015 elections were followed by a government-wide spending review. There’s no sign of one now – another example of the reduced capacity of a government consumed by Brexit……

Benjamin Jenkins reports in the London Economic Review 12th December: Shadow Health Secretary tells Parliament of “NHS pushed to the brink” as NHS managers back Kerslake’s warnings

…Lord Kerslake had written in his resignation letter:

“King’s, like many other hospitals, is fighting against the inexorable pressures of rising demand, increasing costs of drugs and other medical supplies, and the tightest spending figures in recent times. It was this squeeze that led Simon Stevens, the chief executive of the NHS, to argue publicly and rightly for an extra £4bn a year in the recent budget. In the event, the extra resources in the budget fell far short of that.”

Kerslake also warned: “Sadly, the reaction of the powers that be is often to shoot the messenger” and quoted the draft report of the independent Care Quality Commission following its recent inspection: “The chair was held in very high regard by staff at all levels… Under his leadership the shape of the board was said to have changed to one where the right skills and vision was present at board level.”….

(Cohendet and Simon, 2007: 595)  Changing the Rules of the Game: Economic, Management  

 

The NHS desperately needs a new vision for the 21st century –  Ara Darzi in the Guardian 17th December 2017

Stephen Hawking joins lawsuit aimed at foiling Hunt’s NHS shake-up … 16th December in the Guardian

We support Stephen Hawking’s legal action to save the NHS – Letter from Melvyn Bragg and

others in the Guardian 17th December in the Guardian

 

The “State of health and care in England” – is declining and worryingly underfunded…

In The BMJ Chris Ham of the Kings Fund reports on the “State of health and care in England.

(BMJ 2017;359:j4799 )  This is worrying and there is inadequate funding, but the word omitted by Mr Ham is “rationing” – of course. 

Services are at full stretch and struggling to maintain standards

The annual assessment of health and social care by the Care Quality Commission (CQC) provides a veritable treasure trove of information about the state of services in England.1 Based on inspections of 21 256 adult social care services, 152 NHS acute trusts, 197 independent acute hospitals, 18 NHS community health trusts, 54 NHS mental health trusts, 226 independent mental health locations, 10 NHS ambulance trusts, and 7028 primary care services over three years, the assessment offers grounds for concern and reassurance in equal measure.

The CQC’s headline finding is that most services are good and many providers have improved the quality and safety of care since inspections. Behind this headline lies a much more nuanced assessment, with variations between and within services and evidence of growing pressures on staff and deterioration of quality in some services. Adult social care is identified as a particular concern, with a reduction in nursing home beds, providers of domiciliary care handing back contracts to dozens of local authorities, and an estimated 48% increase in the number of older people not receiving the help they need since 2010.

The CQC argues that health and care services are working at full stretch and that staff resilience is not inexhaustible. It is hard to escape the conclusion that standards in many services are likely to fall in future as a result of continuing financial pressures. Support for this view can be found in evidence by Simon Stevens, chief executive of NHS England, to the House of Commons Health Committee on the day the report was published. Stevens warned that low levels of funding growth for the NHS in the next two years would result in deteriorations in care, a reminder if one were needed of the dangers that lie ahead.2

Challenges for NHS, government, and CQC

The challenge for the NHS arising from CQC’s assessment is to learn lessons from the experience of NHS trusts that are performing well even in the face of financial and operational pressures. According to the CQC, the characteristics of acute hospital trusts that have improved care include strong leadership, engaged staff, cultures that empower staff to improve care, a shared vision, and an outward looking approach. There is more work to do to embed these characteristics in all NHS providers to ensure that patients receive the best possible care.

The challenge for the government is to find a sustainable solution for the future funding of adult social care, described by the CQC as “one of the greatest unresolved public policy issues of our time.” The promised green paper on adult social care provides an opportunity to tackle this problem if the will exists within the government to examine all the options and to move beyond the sticking plaster solutions like the Better Care Fund that have so far failed to deliver.3 A good starting point is the report of the Barker Commission, which laid out the hard choices on tax and spending that need to be confronted in securing sustainable funding for the future.4

The challenge for CQC is to use the intelligence and understanding it has acquired to support improvements in care and not just to hold up a mirror to how services perform now. It also has more work to do to assess the performance of local systems of care as well as the organisations providing care. Its observation that high quality care is delivered when services are joined up around the needs of people reinforces the importance of work to integrate care through implementing the NHS five year forward and sustainability and transformation plans.5

Continuing to give priority to the development of these new care models will not be easy when so much management and clinical time is focused on reducing financial deficits and meeting waiting time targets. The CQC’s warnings about the perilous state of some services could have the unintended effect of strengthening the focus on these operational matters at the expense of work to transform care. Securing the future of health and social care depends on doing things differently, not doing more of the same a bit better, and leaders at all levels have a responsibility to make sure this happens. This must include providing additional funding to sustain services while options for the longer term are explored in work on the green paper.

 

The implication of treatments for genetic diseases is good news for the UKs Regional Health Services (RHSs) but there will be a cost, and we may have to reduce the expectation for some years as safety is proven, Will we be able to afford the costs and still provide the high volume low cost free treatments for everyone? Will we be able to afford humane care for the elderly and demented? The pace of the advance of technology, and the demographics of old age, are exceeding our ability to cope.

James Gallagher for BBC News 14th December offers: Haemophilia A trial results ‘mind-blowing’

Hannah Devlin in the Guardian 11th December reports: Excitement as trial shows Huntington’s drug could slow progress of disease

Tom Whipple in The Times reports December 8th: Hope of safer cure for genetic diseases

Diseases such as muscular dystrophy, kidney failure and diabetes could be treated more gently after scientists developed a tool that “switches on” genes rather than cutting them.

In the past decade, genetics research has been revolutionised by a technique called Crispr Cas9 that uses a molecule to find a specific stretch of DNA. It then harnesses an enzyme to snip it and so delete or edit it.

The powerful technology poses serious safety concerns if used in humans because of the potential for it to go wrong. Many researchers are wary of cutting DNA because they could accidentally target the wrong bit.

American researchers, however, say they have found an alternative by modifying the Crispr Cas9 system. They describe a safer approach in a paper in the journal Cell.

“Cutting DNA opens the door to introducing new mutations,” Juan Carlos Izpisua Belmonte, from the Salk Institute for Biological Studies, said. “That is something that is going to stay with us with Crispr or any other tool we develop that cuts DNA. It is a major bottleneck in the field of genetics — the possibility that the cell, after the DNA is cut, may introduce harmful mistakes.”

Professor Belmonte and his colleagues use the same molecule to guide the enzyme to the target bit of DNA. Rather than cut it, though, they boosted it. They argued that this meant that they could amplify the signal from genes that combat diseases.

To test the theory, they used mice genetically modified to suffer from diabetes, kidney failure and muscular dystrophy. They then tried to reverse the progress of the diseases by activating genes to mitigate the effects.

It worked. They boosted insulin production, the mice’s kidneys improved, and those with muscular dystrophy saw muscle growth.

“We are not fixing the gene; the mutation is still there,” the professor said. This means it is not a cure, in the way that true gene editing would be. He said, however, that it was sufficient to harness the power already dormant in the genome to reverse the symptoms.

Other scientists welcomed the research. Helen Claire O’Neill, from University College London, said that the research was exciting. “This paper clearly shows the potential therapeutic viability of this technology in human disease models,” she said.

Alena Pance, from the Wellcome Sanger Institute, said that more work was needed to make sure it was safe.

“These results bring hope for a targeted gene therapy and widen the application of the technology,” she said.

“But it is a proof of principle where follow-up of longer term effects . . . are not examined. These issues would need to be investigated in depth before any application in humans is considered.