Monthly Archives: February 2018

Choice and self determination in palliative care. Those in charge of us think they know our “will” better than we do…

There are many misconceptions about death, There is no need to die in pain, and there is no need to be taken from home to hospital or hospice if the preparation is well done. Most of us will have to change our perceptions as without the money, nursing homes  will be unaffordable in the UK. Alternative solutions have to involve families (where possible)  and every tone and city is going to need volunteers if we are to remain a civilised society. Finlay does not represent the people or the doubt views are polarised on this but can ]we not agree to self determination and choice for the individual?

On the 29th February 2018 the Thundered leader was Baroness Finlays opinion that The right to die is not the same as the right to be killed in response to letters of support published 17th Feb.

Assisted dying and the role of palliative care.

ir, Mark Taubert and his colleagues (letter, Feb 14) question whether “legalised assisted suicide” works well elsewhere in the world. The US experience of aid-in-dying, which began in Oregon more than 20 years ago, has been overwhelmingly positive. My experience over the past year and a half of law change in California has been of a law that both empowers and protects physicians and patients alike.

If it were any other way, why would palliative and hospice care organisations in Oregon, Washington and California support aid-in-dying as one of the choices that should be open to patients in their care? Why would the state of Colorado vote two to one to legalise it in 2016, and why would Canada and Australia join in legalising aid-in-dying among other end-of-life options?

Doctors in the UK ought to listen to their own patients, who want this choice for themselves.

Dr Catherine Sonquist Forest
Family medicine physician, San Francisco, and clinical associate professor, Stanford School of Medicine

Sir, Further to the letter from Mark Taubert and other palliative care consultants, those of us who have carefully examined the laws in Oregon and other places see that giving patients access to an assisted death improves honesty and clarity in conversations at the end of life. It also leads to greater uptake of palliative care and offers reassurance for those who want to have choice and control over their suffering in their final days.

It would be beneficial for the debate if those of us who have experience in palliative care would be open and honest about the limits of our abilities to relieve suffering at the end of life. We cannot pretend to be miracle workers and must be humble enough to learn from other countries that have taken the lead.

Richard Scheffer
Retired hospice medical director and consultant in palliative medicine, North Whilborough, Devon

Sir, Just before I retired as a rural GP the invariably helpful Macmillan nurse came to tell me that one of the nurses looking after a terminally ill patient in her home was unhappy to give the dose of diamorphine (heroin) that I had prescribed “because it was a lot”. The said nurse had seemingly not read the clear written statement in the house with respect to the patient’s wishes on her pain. I went to see the patient, who was shouting in pain, and the consultation was broken by a phone call from a doctor from the local hospice whose organisation had no responsibility for either the patient or the nurses. He asked me whether I realised that diamorphine was a strong drug and could depress the patient’s respiration. I had to point out that the screaming in the background was related to an inadequate dose of painkiller.

The problem for many doctors is that their duty of care to patients is trumped by fear of the opinions of others, including palliative care doctors and the General Medical Council.

Michael G Bamber
North Witham, Lincs

Sir, I suspect that those opposing assisted dying may have their views shaken when they are facing death themselves. I am facing a death sentence as a result of a diagnosis of cancer. I find that I don’t mind the thought of death at all, but I do dread what I may be made to suffer unnecessarily at the end.

Anthea Watson
London WC1

THis was followed by correspondence: Scare tactics and the right to die on 19th Feb.

Sir, Baroness Finlay of Llandaff (Thunderer, Feb 19) is right to highlight the illusory “safeguards” of Oregon’s Death with Dignity Act. Such laws are merely a foot in the door. If a “right to die” gives competent “terminally ill” people a right to physician-assisted suicide, why deny those who cannot kill themselves even with assistance and who want a lethal injection; those who face many years of suffering; and those who are suffering but lack the competence to ask for death?

Booth Gardner, the former governor of Washington state who campaigned for its Oregon-style law, admitted it was “a first step”, that gradually “the nation’s resistance will subside, the culture will shift” and more permissive laws would follow.

Parliament, the courts and medical profession have been wise to resist the temptation to take the first step.
Professor John Keown
Kennedy Institute of Ethics, Washington DC

Sir, It is remarkable that Baroness Finlay should accuse those of us who want terminally ill patients to have a choice in the manner and timing of their death of “scaremongering” while suggesting that an assisted dying law would make doctors “agents of death” and would lead to doctors “disposing of the patient”. As for what doctors think about assisted dying, we have no idea as no one has asked us. The opposition of the British Medical Association is the result of the votes of only 198 doctors, hardly a fair basis for Baroness Finlay’s conclusions. The BMA did review its policies on death and dying in 2016 but its remit around assisted dying was very narrow. Indeed, the BMA reaffirmed its position on assisted dying before even debating the contents of the review and only after very narrowly deciding to discuss the issue at all.

We know that more than 80 per cent of the public support legislation for assisted dying; we as a profession should be listening to them.
Dr Jacky Davis
Member, BMA council; chairwoman, Healthcare Professionals for Assisted Dying; board member, Dignity in Dying

Sir, Baroness Finlay is right to be concerned about scare tactics in the campaign for assisted suicide. Some of the worries of my patients and their families flow from being told that life with a terminal illness has to be painful and undignified and that death is inevitably distressing unless its timing is artificially controlled. We cannot legislate to control illness but we can help people to manage it and live with dignity. We do not control the timing of death any more than we control that of birth, but that need not prevent it being peaceful. I have my hands full dealing with fears about death while doing all I can to help people live well. Campaigning is one thing but doing it by stoking those fears does not help.
Dr Idris Baker
Consultant in palliative medicine, Swansea

Sir, Professor Rob George (letter, Feb 19) writes that morphine doses need to be titrated carefully to control a dying person’s pain. He works in a hospice where no doubt the skill to do this is readily available, as it is in a hospital. However, many terminally ill patients die in nursing homes, where doctors are not on hand 24 hours a day and where nurses are understandably wary of increasing morphine levels in case they are held legally responsible for accelerating death. This can lead to unnecessary suffering.
John Sharpe


The reducing standards…. Improvement service “unsafe for children….”


It is not just young children services which are declining. Adolescents with eating disorders are also suffering, and adolescent mental health is in crisis. Referrals are being screened and rejected, sometimes by doctors in referral centres, and sometimes by untrained administrators. What happens depends on your post code..

Caroline Wheeler reports in the Sunday Times 35th Feb 2016:NHS Improvement: service ‘unsafe’ for children amid lack of nurses

NHS services for children are substandard in every region of England owing to nurse shortages and safeguarding failures, the NHS regulator has revealed.

NHS Improvement says that “few” children’s services are “safe or well-led”. The regulator reviewed 96 hospital and other NHS services for children that had failed inspections by the Care Quality Commission last year.

It found that 54 children’s wards fell short of expected standards and, when reinspected, only two had improved and four had deteriorated further.

The report, which will be sent to all parts of the NHS with guidelines to help trusts improve, lists unfilled nursing posts as the top concern from the review of failed inspections. Low staff levels and high medical vacancy rates were cited as the most common reason for poor ratings in all four regions covered by the report, the Midlands and east, the north, the south and London.

The disclosure comes days after NHS Improvement’s quarterly performance report for the three months to December revealed 100,000 NHS jobs in England are unfilled — including 36,000 nurse vacancies.

Last night Jonathan Ashworth, the shadow health secretary, demanded action from ministers, adding: “Not only is it a massive worry for parents everywhere that so many children’s units are dangerously understaffed, it’s totally unacceptable too.”

Fiona Smith, of the Royal College of Nursing, said the shortage of nurses applied “across acute, mental health and community services”.

Saffron Cordery, the deputy chief executive of NHS Providers, the association for NHS trusts, said children’s services had not been made a priority. “They are under-funded and fragmented. In this report although most services scored well for treating people with kindness and compassion, there were serious failings, which were clearly unacceptable.”

A spokeswoman for the health department welcomed the new framework but said more than 90% of children surveyed by the Care Quality Commission reported being well looked-after in hospital.

Britain’s newborn death rate higher than in Belarus or Cuba




Compassion needs to be tempered with honesty.

We need more compassionate care of the dying and elderly for whom there is no curative treatment.  If we are to improve patients’ experience and quality of life in the last few months, as well as saving money, we will need more trained primary care people explaining what is going to happen when the time arrives. Compassion needs to be tempered with honesty, and this needs to come from a doctor you know. Unfortunately there are fewer rather than more, of these individuals, and less and less time to discuss choices with patients. A good professional handover to adequate numbers of staff with good language and cultural awareness would negate this “need”, but whilst standards fall it is for the greater good. More patients die in Hospital than at home, and their desire is the other way round. This good news initiative needs integration into Primary Care…

Kent and Canterbury begins “compassion” symbol.

The Pilgrims Hospice logo which is being used for compassion signs on hospital wards

Chris Smyth reports 19th Feb 2018: “compassion” symbols alert hospital staff to dying patients.

Dying hospital patients will be marked with “compassion” symbols to encourage staff and visitors to be more respectful.

Hospitals in Kent have begun placing the symbol on bedside curtains or on doors next to people expected to die within days.

The project, thought to be a first in the NHS, is in use in 50 wards after managers found that it went down well with grieving families by encouraging a more dignified atmosphere on wards.

Annie Hogben of Pilgrims Hospices, which runs the project with East Kent Hospitals University NHS Foundation Trust, said: “How a loved one dies can have a profound and long-lasting impact on those who are left behind. Therefore it’s essential that staff and visitors are sensitive to the needs of the person who is dying, and their loved ones at all times.”

The hospital insists that symbols are only displayed with the consent of patients and relatives, and are not designed to single them out or chastise rowdy visitor.

Dying hospital patients will be marked with “compassion” symbols to encourage staff and visitors to be more respectful.

Hospitals in Kent have begun placing the symbol on bedside curtains or on doors next to people expected to die within days.

The project, thought to be a first in the NHS, is in use in 50 wards after managers found that it went down well with grieving families by encouraging a more dignified atmosphere on wards.

Annie Hogben of Pilgrims Hospices, which runs the project with East Kent Hospitals University NHS Foundation Trust, said: “How a loved one dies can have a profound and long-lasting impact on those who are left behind. Therefore it’s essential that staff and visitors are sensitive to the needs of the person who is dying, and their loved ones at all times.”

The hospital insists that symbols are only displayed with the consent of patients and relatives, and are not designed to single them out or chastise rowdy visitors.

“It would never be done without consultation and is really about raising awareness among other visitors to the ward that someone is receiving end-of-life care and to encourage an atmosphere of quiet dignity and respect in that area,” Steve James, a spokesman, said.

Almost 300,000 people die in hospital every year and the NHS has been criticised for not taking end-of-life care seriously enough. A review by the Royal College of Physicians two years ago found that thousands were dying thirsty and in pain because doctors and nurses were terrified of talking about death.

Bill Noble, medical director of the charity Marie Curie, said that compassion was an “essential part of palliative care”, but urged the hospitals to learn the lessons of the well-intentioned Liverpool Care Pathway, which was scrapped after patients were left thirsty and suffering because of misuse of the end-of-life protocol.

“This [compassion symbols] appears to be excellent idea but like all interventions of this nature it requires evaluation. We have learned there are unintended consequences of labelling people as requiring end-of-life care,” Dr Noble said.

The logo, featuring a stylised pair of hands cupping a person’s face, is also used on bags containing property of patients who have died that is awaiting collection by relatives.

Andrea Reid, from Folkestone, said that the sign made a big difference to her aunt’s final days. “The nursing staff all hesitated at the door, explained why they needed to come in and gave us time to either leave the room or move out of the way with a calm, unhurried air,” she said.

“Our hospital staff are often working in a pressured and high-speed environment but the small and unassuming compassion symbol is just enough to trigger a pause and a moment’s consideration for those dealing with the worst news possible.”

Sue Cook, a palliative care nurse and the trust’s end-of-life clinical lead, said: “Those of us who work in the NHS have a duty to ensure that our patients are cared for with dignity, respect and compassion until they die. That’s why the Compassion Project and its symbol is so important to us and all who help those approaching the end of their lives.”


Standards “Going into reverse”….There is no button to push… we need tens of thousands of staff

Chris Smyth reports in the Times on the reality of the staff shortages, which are worsening as those who failed to move on to pastures new fail to manage the brutal workload. “100,000 job vacancies as  NHS pushed to limit” in the Times 22nd of Feb 2018. Stories of leaderless dysfunctional consultant teams spread over wide regions, of GPs who take sabbaticals being shocked that even after a break they cannot cope, and resulting early retirements are legion. There are only politicians to blame, as the administrators are only doing their behest. There is a risk of anger, walkouts, burnouts, and serious mistakes through a collusion of denial and disengagement. Exit interviews conducted by an outside and independent HR department are now an essential and emergency need.

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About 100,000 NHS posts are vacant and hospital deficits are twice as high as planned even after a winter bailout, according to official figures.

A rapid financial deterioration means that hospitals have overspent by £1.3 billion so far this financial year while waiting times have not improved.

Patient numbers continue to rise, with 5.6 million A&E visits in the three months to December, a quarter of a million more than in the same period the previous year.

Despite efforts to improve links with social care, patients spent almost half a million nights stuck in hospital over the quarter.

One in 11 NHS posts cannot be filled amid a shortage of doctors and nurses. In London, one in seven nursing posts is empty, rising to almost a quarter in the ambulance service. Overall 35,000 posts for nurses are vacant and 9,500 for doctors.

Janet Davies, chief executive of the Royal College of Nursing, said: “All the evidence shows that standards of patient care rise and fall as nurse numbers do. That was the lesson from Mid Staffordshire and we cannot afford to forget it.”

Nigel Edwards, chief executive of the Nuffield Trust think tank, said that the “dangerous” shortage of nurses was more worrying than worsening NHS finances.

“Shortages of nurses damage patient care and make working life harder for those who remain, potentially driving them away too,” he said. “We can bring back more money onstream if the will is there, but there is no button to push which will suddenly bring us tens of thousands of qualified extra staff.”

Hospitals warned that they were being “pushed to the limit” by rising patient numbers. “Having one in eleven posts vacant makes it much more difficult to provide high-quality care,” Saffron Cordery, of the lobby group NHS Providers, said. “There is an increasing feeling among frontline trust leaders of ‘We cannot carry on like this’.

carry on like this’.“The NHS has shown extraordinary resilience in sustaining performance in the midst of an unprecedented financial squeeze. We have managed to keep the show on the road. But the warning signs are now clear and in plain sight. The time to act is now.”

Officials pinned the blame for worsening finances on a minority of hospitals that were overspending by far more than planned. However, Richard Murray, director of policy for the King’s Fund, the independent health charity, said this “raises serious questions about how reasonable the financial targets were in the first place . . . these are not pressures that have sprung up in the last few months and [they] show no sign of abating.”

Ian Dalton, chief executive of NHS Improvement, the financial regulator that published the figures, said: “More people than ever before are going to emergency departments up and down the country at a time when providers are already having to tighten their belts. It would be unrealistic to assume the demand, which has been building for a number of years, is going to reverse.”




A bigger and bigger deficit in West Wales…… Now at £600 per head……

Pembrokeshire, Carmarthenshire and Cardiganshire are broke. According to the latest published overspend for Hywel Dda we have used £400 per head, extra, over the last three audited years. We are nearly at the end of another unaudited year, and can expect the overspend to top £70m this year alone. If we total the last 3 years it comes to £150m, and divide by 372,320 population of Hywel Dda we get to a figure of £402 each. If we add this year, another £200 is minimum… In 3 years time £1000 per head is predictable. We should stop making comparisons with the USA, but make comparisons with Canada, Germany, France or Holland. Even Ireland has a system which spends little to give very reasonable results… and is financially sensible. There is no perfect system, but there are examples of excellence in many. Spending less (with consent) as a % of the total in our last year of life is also important. The decisions taken in Scotland will be a sign of whether “reality” has sunk in to their politicians. Sustainable solutions are beyond our current leaderless houses..

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BBC News reports 8th Feb 2018: Hywel Dda health board facing bigger deficit

The health board in Wales with the highest level of overspending has seen its financial situation worsen.

The projected deficit this financial year at Hywel Dda, which covers west Wales, has increased to nearly £70m.

The health board blamed increased pressure on services in the autumn for the overspend, which follows deficits of £49m in 2016-17 and £31m in 2015-16……

on 6th February the BBCs “Reality Check Team” (Nick Triggle – did he pinch reality from NHSrealaity?) published: Reality Check: Does UK spend half as much on health as US?

If you look at all healthcare spending, including treatment funded privately by individuals, the US spent 17.2% of its GDP on healthcare in 2016, compared with 9.7% in the UK.

Chart showing health spending as proportion of GDP shows US spends more than UK

In pounds per head, that’s £2,892 on healthcare for every person in the UK and £7,617 per person in the US.

So as a proportion of the value of the goods and services produced by all sectors of the economy the UK spends a bit more than half what the US spends, and in spending per head it’s a bit less than half.

Bar chart showing spending per capita is higher in US than UK

The difficulty is, when it comes to comparing healthcare in different countries, you’re never exactly comparing like for like.

Almost all health systems are a mixture of public and private – it’s the ratio that varies.

In the UK, the public health system can be accessed by all permanent residents, is mostly free at the point of use and is almost entirely paid for through taxation.

Americans are far more likely to rely on private insurance to fund their healthcare since accessing public healthcare is dependent on your income.

Many European countries, meanwhile, have a social insurance system where insurance contributions are mandatory. This doesn’t fall under general taxation but is not dissimilar from paying National Insurance in the UK and means everyone can access healthcare….

Safety, affordability and efficiency

In the summer, US think tank the Commonwealth Fund ranked the NHS the number one health system in a comparison of 11 countries for safety, affordability and efficiency. It did less well when it came to cancer survival

The US was ranked last out of the 11 countries.

The American health system came off badly in comparison when it came to infant mortality, life expectancy, and preventable deaths, but did relatively better on cancer, heart attack and stroke survival.

Meanwhile, the UK’s cancer survival rates have historically been below the European average, although they are improving for certain cancers.

The UK has fewer doctors, nurses and hospital beds than the OECD average.

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Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.

If the NHS really is the envy of the world, why don’t countries copy it?

Performance relative to other countries. Commonwealth fund “mirror”.

Self Sufficiency is a dream Mr Hunt. Rationing of Med Students means it will take over 15 years – starting now  – April 2017

Oh dear. More money from Taxation will make no difference.. Digging the hole deeper?

Why NHS money matters

In Search of the Perfect Health System – a new book reviewed

Not many first world countries have gone backwards in health provision, population health and life expectancy. The UK may be the first…

Life would be better if we faced up to death…. important conversations are put off until too late

NHS in Scotland must face up to “difficult decisions” to remain sustainable BMJ 2018;360:k567

Time is rapidly running out for Scotland to develop and implement solutions that will create a sustainable health service, a high level report warns.

The report,1 from the Royal College of Physicians of Edinburgh and the Good Governance Institute, makes key recommendations for securing the NHS’s future in Scotland, including difficult decisions about what the NHS can afford in the future….

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Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians… “Wise doctors will retreat from the front line now?”

Jenni Russell reports in the Times 8th Feb 2018: Wise doctors will retreat from the front line now

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians for their long term rationing, denial, and collusion of anonymity. Other countries and their leaders cannot understand us, including Mr Trump. (Stephen Glover in the Daily Mail)

Overwork and the risk of negligence cases make safer specialisms preferable to acute medicine

I was once responsible for a patient’s death. Or that’s how it could have been seen. It was years ago, in a gap year job, but the experience was so searing I can relive it with terrible clarity.

I was working as a nursing auxiliary on a hospital ward. At 9pm all the nurses were gathered in the sister’s office, two doors and 30 metres away, handing over to the night team. A physio was with an elderly asthma patient when she threw open the curtains around the bed and shouted: “Resus! Nurse, get the resus trolley!”

She meant me. I was the only person in a nurse’s uniform in sight or earshot. I ran. The heart resuscitation team was bleeped. I dragged the trolley, which was new on the ward that month, to the bed. I unwound the electric cable, seized the plug, looked around for a socket. And looked. And looked.

This was an old ward in a crumbling outbuilding and there was nothing logical about its power points. As the newest and most junior person on the team, no one had thought it necessary to show me where they were. While I hunted, with rising panic, ducking between beds, the old lady’s heart began to fail. The heart team arrived, a nurse grabbed the plug from me, the old lady died.

Was this my fault, or the system’s? If I had been faster that woman may have lived. Is someone who tries their best when they don’t have adequate backup the guilty party, or is the system around them also responsible, for not providing the support they need?

Any sane person would think the latter, but thanks to the punitive decisions of the GMC and the High Court in pursuing the striking-off of Dr Hadiza Bawa-Garba after an error which led to a child’s death, every doctor and nurse in the country now fears that they may lose their jobs, futures and reputations for a single serious mistake.

The doctor was under extreme pressure, covering for an absent registrar while overseeing six wards on four floors, on a relentlessly demanding twelve-hour shift. It was her first day back after maternity leave and she had had no induction training. The nursing rota was understaffed and the IT system was down for hours, meaning blood test results were critically delayed. Her consultant wasn’t present. All the evidence given testified to her being a committed, above-average doctor, and yet she has been thrown out of the profession.

The chilling lesson of the Bawa-Garba debacle is that context, character, remorsefulness and a good record will be no defence.

The unintended consequences of this hardline decision by the GMC are going to damage the NHS, not protect it. Doctors across the country are aghast, feeling, as an editorial in the BMJ said, that “there but for the grace of God go I”. Furious senior doctors are reporting themselves to the GMC for long-ago errors, to make that point. Newer doctors are now afraid to admit to theirs in case it backfires on them. And the devastating practical effects are now unfolding, unseen.

“I’m practising defensive medicine now,” one doctor told me. “We all are. I’m not taking risks. If someone turns up with a non-specific lump, I might before have used my judgment, said wait and see. Now I’m sending them for scans, second opinions, follow-ups, blood tests. Lots of that will be unnecessary, the NHS is already overloaded, and I’m adding to that. But I feel now I’ve got no protection, I’ve got to watch my own back.”

His fears are widely shared, an A&E consultant tells me. It’s going to cut the numbers willing to work in areas of acute medicine that are already routinely understaffed, like paediatrics or emergency medicine. If doctors know, as they do, that those are the jobs where they must take what are now career-threatening high-risk decisions, while covering rota gaps, fewer people will apply. “They’ll retreat to safer options — dermatology, genito-urinary clinics, specialisms like that.”

He warns that it’s going to mean a rise in staff going off sick in high-pressure disciplines, as people assess the new pressures of being conscientious. Instead of putting the patients first, many doctors will choose caution. “If you’re feeling a bit off, why would you risk putting yourself in the firing line? It’s going to be a lot safer to stay at home.”

There is particular fury at the GMC’s attempt to cover its back by issuing guidelines telling doctors that if they are in understaffed, unsafe environments they must create a paper trail flagging that up. As one enraged doctor pointed out to me, hospitals already know exactly when their rotas are missing staff. And as a fine column in the BMJ by the consultant in geriatrics David Oliver points out, now we are ordering overworked doctors to spend more of the time they don’t have in documenting that they haven’t got it. It serves literally no purpose, since if nothing goes badly wrong on their shifts nobody cares that they were overloaded, and if something does go wrong, that record won’t protect them.

The NHS is clearly alarmed by what has been set in train here, with many hospitals declaring they stand by their staff and the health secretary Jeremy Hunt setting up an inquiry into the implications of the Bawa-Garba case. But warm words mean nothing laid against the cold legal danger doctors are now in. They need safer staffing levels and an absolute assurance that when they make mistakes their institutions will share responsibility too. Until they get that, the health service is going to be weakened by this cruel and foolish pursuit.

Laura Donelly in the Telegraph 6th February reports: Hunt orders review of Medical Malpractice and Doctors Outcry  over manslaughter case:

Dr Hadiza Bawa-Garba was struck off the medical register after she was found guilty of mistakes in the care of a six-year-old boy who died of sepsis.

The case has been met with a backlash among medics, with thousands sending letters of support for the doctor, saying the decision ignored NHS failings and staff shortages which contributed to the death.

Dr Bawa-Garba was originally suspended from the medical register for 12 months last June by a tribunal, but has now been removed from the medical register following a High Court appeal by regulator the General Medical Council (GMC).

The GMC said the the original decision was “not sufficient to protect the public”.

Mr Hunt had already expressed unease about the situation, saying he was “totally perplexed” by the actions of the watchdog.

In particular, he raised concerns that doctors would no longer be open about errors, and be honest in their self-appraisals.

In a statement to the Commons, the Health and Social Care said clarity was needed about  drawing the line between gross negligence and ordinary errors.

Speaking in the House of Commons today, Mr Hunt said Sir Norman Williams, former president of the Royal College of Surgeons, will lead a national “rapid review” of the application of such laws.

He said Sir Norman will review how “we ensure there is clarity about where the line is drawn between gross negligence manslaughter and ordinary human error in medical practice so that doctors and other health professionals know where they stand with respect to criminal liability or professional misconduct”.

Mr Hunt said the review will also look at the role of reflective learning, to ensure doctors are able to open and transparent and learn from mistakes.

The review, which is due to report by April, will also consider lessons to be learned by the GMC and other regulators.

Charlie Massey, chief executive of the General Medical Council said: “We welcome the announcement today from the Secretary of State to conduct a rapid review into whether gross negligence manslaughter laws are fit for purpose in healthcare in England. The issues around GNM within healthcare have been present for a number of years, and we have been engaged in constructive discussions with medical leaders on this issue.”

He said the watcdog was committed to examining the issues, and to ensure fair treatment of doctors working in situations where the risk of death is a constant and in the context of systemic pressure.”

“Doctors are working in extremely challenging conditions, and we recognise that any doctor can make a mistake, particularly when working under pressure. We know that we cannot immediately resolve all of the profession’s concerns, but we are determined to do everything possible to bring positive improvements out of this issue,” he said.

The GMC is carrying  out its own review, and would endure the findings from the new review feed into it.

Dr Bawa-Garba was struck off over the death of Jack Adcock, aged 6, at Leicester Royal Infirmary in 2011.

The child, from Glen Parva, Leicestershire, was admitted to the hospital in February 2011, his sepsis went undiagnosed and led to him suffering a cardiac arrest. The courts heard Dr Bawa-Garba, a paediatrician, committed a “catalogue” of errors, including missing signs of his infection and mistakenly thinking Jack was under a do-not-resuscitate order.

But they also heard the doctor was working amid widespread staff shortages, with IT failures and delays in test results

At the time of the ruling, Jack’s mother, Nicola, said: “We are absolutely elated with the decision. It’s what we wanted.

“I know we’ll never get Jack back but we have got justice for our little boy.”

The Medical Protection Society, which represented Dr Bawa-Garba, said at the time: “A conviction should not automatically mean that a doctor who has fully remediated and demonstrated insight into their clinical failings is erased.”

An online appeal set up by concerned doctors has raised more than £320,000 to help pay the legal costs of Dr Bawa-Garba.

Agency nurse Isabel Amaro was also convicted of manslaughter on the grounds of gross negligence relating to the same incident and struck off by the Nursing and Midwifery Council.

The blame game. The proliferation of compensation claims – needs a “no fault compensation” cure, possibly through a social insurance fund.

TA friend told me that three nurses had resigned on their ward last week. I can bet they wont have exit interviews. We do not have a learning  organisation. Any solution to the litigation culture will be complex, and it needs to be long term. Longer than the horizon of the average politician, and the media too have an interest in de-bunking something that will remove headlines and conflict.  No fault compensation has been proposed by NHSreality since starting 5 years ago. The financial cost will be worth it long term, but it will hurt short term. We have rationed it out for 40 years, and eventually it needs to happen. The projected cost for each member of society averages at £1000 each, but it could save professionals from leaving as early as they are..

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Clare Foges opines in the Times 5th Feb 2018:  Many NHS victims should settle for an apology -As litigation costs soar and doctors quit, it’s time to kick back against the compensation culture

…..The headline figure is eye-watering enough, but it doesn’t cover half the impact that clinical negligence claims are having on the NHS. Doctors and nurses have always worked with the fear of being sued hanging over them; now the sword of Damocles is tickling their scalps. This leads to a defensive way of working that is costly and, sometimes, harmful.

Several doctors have told me it is now the norm to request tests that are highly likely to be unnecessary. One says that if a patient had turned up with mild abdominal pain 20 years ago they would have been sent home and told to come back if it got worse; now there will be blood tests and probably an ultrasound.

According to a recent survey, a fear of being sued has led 84 per cent of GPs to order needless tests or refer patients to consultants when it isn’t necessary. It is impossible to calculate the cost of all this to the NHS, but we can assume it is high…..

…Then there is the effect of the litigation culture on morale and staff retention. Years of training and dedication will not stave off the paranoia that one day you may overlook something that will destroy your reputation.

Research published this weekend found that GPs were leaving the profession at an increasing rate, partly driven by the risk of being sued. All doctors must pay large sums to insure themselves against litigation costs too, by being a member of either the Medical Defence Union or Medical Protection Society. The cost increases along with the responsibility: junior doctors start by paying about £1,000 a year, registrars about £2,000 a year and consultants even more….

..There is much that the government should look at: a minimum threshold for claims; more realistic calculations of future earnings; fixed costs for minor incidents; cutting back on the vast sums that the legal industry makes by dragging out cases (legal costs account for about a third of the bill).

We also need a wider conversation about the fact that mistakes can happen and that the apportioning of blame and seeking of retribution are not always healthy or helpful.

It’s not enough to look at this ballooning bill — and the lawyers getting fat on it — and remark that the NHS must get its house in order. For patients, doctors and taxpayers, we need to rethink this system, and urgently.

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The letters on 6th Feb all fail to mention “No fault compensation”……

Sir, Medical negligence litigation depends more on its economic drivers than on clinical practice or patient expectations (“Many NHS victims should settle for an apology”, Clare Foges, Feb 5). Most claims are funded by no-win, no-fee arrangements. Many cases need to be investigated to find a sustainable one, and there is payment only on winning. Litigation provides independent, robust, expert scrutiny of medical care according to professional norms. It is free for any claimants at the point of need.

The NHS pays compensation in more than 80 per cent of claims where legal action is commenced — claims that could have been settled before legal action. NHS lawyers are paid on every claim, win or lose (up to £200 per hour). This incentivises “delay, deny, defend” behaviour, and rewards failure. Payment for NHS lawyers should be result based; it would save delay and costs.
Dr Anthony Barton
Solicitor, Medical Negligence Team

Sir, There is no expectation on the NHS to be infallible. Accidents and mistakes happen — they cannot be avoided. But only last week it was reported that hundreds of men have had the wrong testicle removed. These are not mistakes, they are negligence. Those men face a lifetime of sterility because someone failed to take enough care to identify the correct body part.

Perhaps an injured patient or grieving family would accept an apology if apologies were ever forthcoming. It is already established that parents enduring the agony of a stillbirth that is entirely avoidable are often forced down the legal route in search of answers, because they cannot get them any other way.

If what Clare Foges says is correct, there is a profound need for the NHS to overhaul its approach and attitude towards patient care. The motivation for investigating stomach pain should be to improve the patient’s health and wellbeing in keeping with the NHS’s mission statement. To avoid being sued is the wrong incentive.
Brett Dixon
President, Association of Personal Injury Lawyers

Sir, Clare Foges provides a stark account of the proliferation of compensation claims, in particular for smaller sums to cover “minor delays and inconveniences”. Clearly a reformed claims procedure is required. Rather than ask patients to settle for an apology in such circumstances, might the government not insist that if patients want to sue the NHS, they need to have taken out a form of social insurance policy with a new health service mutual beforehand? Patients would be welcome to put in a claim but they would need to have paid in to the system first. The poor would have their contributions credited, and would thus be covered.
Frank Field, MP House of Commons

Sir, The point Clare Foges makes applies to all walks of life where only total inertia can prevent mistakes. No one is perfect and fear of litigation leads to covering even the least likely and most expensive possibility. It also leads to obfuscation and delay in righting what is wrong. The only winners are opportunist lawyers; the change in the law that allowed advertising had something to do with it. Patients signing a disclaimer? That could make for gung-ho practices, but something has to be done.
Dr Robert J Leeming
Balsall Common, Coventry

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This is starting to add up. Overseas patients, fraud and litigation… are costing us all dearly.

With increased stress, litigation, complaints and expectations, all doctors know they are at risk of burnout or mental illness.

Litigation has the potential to kill the Health Services: More than 800 women sue NHS and manufacturers over vaginal mesh implants

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

Oh dear. More money from Taxation will make no difference.. Digging the hole deeper?

NHSreality has spoken out against hypothecated taxation on several occasions.  This is at least a recognition of crisis, but the solution proposed will never work as the pace of technological advance and demographic change (more elderly) exceeds the ability of the state to pay for them. The solution proposed, without overt rationing, will be digging the hole deeper..

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BBC News reports 5th Feb 2016: NHS ‘should be funded by new tax’

A new ring-fenced tax to fund the NHS and social care has been proposed by a panel of health experts.

The panel, set up by the Liberal Democrats, says the NHS in England should be given an extra £4bn on top of inflation in the next financial year.

It has suggested replacing National Insurance with the new tax to close the funding gap.

A Department of Health and Social Care spokesperson said NHS funding “is at a record high”.

“[It] was prioritised in the Budget with an extra £2.8bn, on top of the additional £2bn already provided for social care over the next three years, and an additional £437m of funding for winter,” the spokesperson said.

The future of NHS money has been hotly debated as hospitals struggle to cope with the pressure on resources.

Last month, tens of thousands of non-urgent operations were delayed.

The 10-member panel included former NHS England chief executive Sir David Nicholson, Peter Carter, former chief executive of the Royal College of Nursing and Clare Gerada, former chairwoman of the Royal College of GPs.

It said on top of the £4bn extra needed for next year, an additional £2.5bn would be required for both 2019 and 2020.

Prof Gerada said that one of the issues is that working people over the age of 60 benefit from a significantly reduced National Insurance contribution, and people over 65 do not pay it at all.

She said National Insurance, which currently funds the NHS and social care, is inadequate as older people are living longer, and not contributing to the ring-fenced tax.

She said: “Old age is now between 85 and 95, so old age has significantly moved.

“Why shouldn’t I pay for my fair share of contributions if I’m working?”

As part of the recommendations, the panel also suggested reinstating a cap on the costs paid by individuals on social care.

In December, the government scrapped proposals to cap fees at £72,500.

It supported creating an office for budget responsibility for health and called for a series of incentives to get people to save more towards their adult social care.

The idea of a levy dedicated to funding the NHS was also suggested by former minister Nick Boles.

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How do we end the culture of fear? Doctors and families must be able to work together for safer care….

Much as I agree with Ms McCartney, I also believe that Exit Interviews by an independent third party HR company is essential. These need to be amalgamated, themes exposed, and discussion to be open about how to change, redress, and correct. The ideology has to be seen to be “built on a rock”, both financially and ethically before the professions are on board.

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Margaret McCartney: writing in the BMJ ( BMJ 2018;360:k443 ) opines: How do we end the culture of fear? Doctors and families must be able to work together for safer care

A little boy, Jack Adcock, is dead. This is horrendous, and accounts of the background to the case clearly show mistakes and shortcomings that could and should have been avoided. But how?

Jack’s treatment included clinical mistakes and numerous systemic ones, particularly regarding staff absence and IT systems. This was the “Swiss cheese” model writ large and fatal: the holes in the system aligned and let tragedy happen.

The overwhelming feeling among many doctors reading accounts of the case background1 is, “There but for the grace of God go I.” There’s no suggestion that Hadiza Bawa-Garba was doing anything except working hard, with two doctors down, covering six wards on four floors, and providing medical advice to other professional groups.2

Will striking her off the medical register ensure that a death like Jack’s can’t happen again? I don’t believe so. Professional regulation and accountability are vital. So, too, is patient safety. But the way we administer the two are often at odds.

The regulation of doctors is an adversarial system that seeks to deliver blame and sanctions to individuals. Blame and sanctions clearly have their place. But it’s taken a long time for us to regard human factors as the problem in many medical errors and safer systems as the solution—as well as outstanding efforts by people such as Martin Bromiley, who founded the Clinical Human Factors Group,3 a charitable trust that promotes best practice around human factors. As the group says, “A safer, more reliable and efficient NHS will remain a pipe dream until we create a culture where human error is seen as normal, inevitable, and as a source of important learning.”4

As Bawa-Garba’s reflective notes were used as evidence against her in court, such a culture is unlikely any time soon. And the words of Mr Justice Ouseley, giving the leading judgment on the case in the High Court, are of particular concern: “There was no suggestion, unwelcome and stressful though the failings around her were, and with the workload she had, that this was something she had not been trained to cope with or was something wholly out of the ordinary for a year 6 trainee, not far off consultancy, to have to cope with, without making such serious errors.”5 This seems to imply that doctors can be trained to have limitless capabilities. None of us can be.

There must be a better way to investigate deaths—one that examines human factors and systemic problems, which doesn’t only insist on evidence based change but can also command the confidence of bereaved families, as well as honesty from the medical profession.

A culture of fear is looming, but it needn’t be this way. Doctors, patients, and families should be able to work together to make systems safer. We need to move forwards, but this judgment risks taking us far back.

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Editorial: Criminalising doctors by Navjoyt Ladher, Fiona GodleeBMJ 2018;360:k479  )

What must we learn from Jack Adcock’s death?

Fear is toxic to both safety and improvement, and health systems must abandon blame as a tool. So wrote Don Berwick in his report after the Mid Staffs care scandal.1 He called for a commitment to learn from mistakes and to act on that learning. “Rules, standards, regulations and enforcement have a place in the pursuit of quality,” he said, “but they pale in potential compared to the power of pervasive and constant learning.”

Recent events have set those wise words at nought. Last week the tragic case of 6 year old Jack Adcock, who died from sepsis in 2011, reached what may be its final punitive phase, with the erasure of a trainee paediatrician from the medical register. Jack Adcock’s mother has said she wanted justice for her son and to ensure that no one else would suffer in this way.2 Sadly the opposite is more likely. This case, and a growing number of others,3 risk driving doctors towards defensive medicine, discouraging them from discussing errors, and denying health systems the chance to improve.

Hadiza Bawa-Garba was convicted of gross negligence manslaughter in 20154 and later temporarily suspended from practising medicine by a medical practitioners tribunal. But the General Medical Council wanted her struck off and has now won its appeal against the tribunal’s decision. Her criminal conviction and the GMC’s actions have caused an outcry among doctors, distressed that one doctor has been made a scapegoat and understandably fearful that they too are now vulnerable to criminal charges if they make mistakes.

Should this case ever have gone to court? Not if Berwick’s report had been acted on. “Recourse to criminal sanctions should be extremely rare and should function primarily as a deterrent to wilful or reckless neglect or maltreatment,” it said.1 No one in possession of the facts and an open mind could call Bawa-Garba wilfully or recklessly neglectful. Delays in assessment, acting on test results, and administering antibiotics meant that the diagnosis of sepsis and recognition of the seriousness of Jack’s condition came too late. Also, when Jack arrested soon after he was given enalapril by others without her knowledge, Bawa-Garba mistakenly interrupted resuscitation, having confused him for another patient. But she was doing two doctors’ jobs, managing acutely sick patients across four floors, with no breaks in her 12 hour shift, juniors doctors who had both recently rotated onto the team, agency nurses, breakdowns in IT, and inadequate senior cover.

However, the jury weren’t told about many of the corrective actions subsequently deemed necessary to make the hospital safe. The prosecution argued that these weren’t relevant to the circumstances in which Bawa-Garba was practising on the day.5

Many questions remain. Was it not the consultant’s, medical director’s and management’s responsibility to ensure adequately supported medical and nursing provision? Given the hospital’s inherent conflict of interest, why was there no independent review? Why did the GMC feel compelled to pursue an appeal? It says it could not allow its tribunal to go behind the decision of a jury in a criminal case and wanted to avoid a loss of trust in the profession.6 But the Medical Practitioners Tribunal Service (MPTS) was able to hear about important system factors that the jury in the criminal case was not,7 and other doctors with criminal convictions have been allowed to continue to practise.8

By the GMC’s reasoning, it now seems impossible for the MPTS to consider any options other than erasure in cases where doctors have been convicted of gross negligence manslaughter, whatever the circumstances.

In an unprecedented show of support, crowd funding has raised over £200 000 for Bawa-Garba’s legal representation, so her criminal conviction may yet be overturned. And perhaps most importantly of all, people from across the health and regulatory system are now talking to each other about what needs to change.

Much credit for this must go to Jenny Vaughan, a consultant neurologist who clinically led the successful appeal of conviction of David Sellu.9 She cofounded Doctors and Manslaughter ( and has worked with the Ministry of Justice, Department of Health, Crown Prosecution Service, and royal colleges to highlight the negative impact of criminalising healthcare.3 A recent meeting at the Royal Society of Medicine discussed a range of measures to ensure that the right cases come to court in future—those involving persistent dishonest or malicious practice rather than unintended honest errors.10

It is tragic that a child has died. But no one is served when one doctor is blamed for the failings of an overstretched and understaffed system. We must channel the sadness at Jack Adcock’s death, and the anger at Bawa-Garba’s fate, into positive change for safer patient care.

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President Trump is not always wrong. His harsh reality, or hard truth, is what many professionals feel.

Some 4 years ago a large number of GPs were considering retiring. Now their 2014 thoughts have become reality. The neglect of Primary Care by politicians who are afraid to discuss the truth is endemic, and the distraction of Brexit has not helped. Aneurin Bevan’s great idea is dying from a political collusion.. Exeter University research tells the citizen how it is, but they don’t really want to hear. The living prefer to forget about the dead, and dead patients don’t vote. The harsh reality is pushed home by a US President …

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BBC News today 5th Feb 2018: GPs leaving profession: ‘We’re not valued’

GPs are leaving the profession at an increasing rate because they feel “undervalued”, research by the University of Exeter Medical School has found.

Doctors have spoken of concerns about the risk of litigation and problems with their own health due to work pressures.

Dr Charlotte Ferriday (pictured) quit her GP partnership in Devon in 2015. She said the job left her burnt out.

“I woke up one Monday morning and I couldn’t get out of bed,” she said. “For six weeks it was difficult to leave the house and it was catastrophic.

“I found it was increasingly difficult to do the job because I didn’t have the resources and services that supported my patients.

“It felt like we were ignored and GPs were not valued by the government.”

The government says it has committed to an extra 5,000 GPs by 2020.

Sick Notes g2 column 160615 Ian Wiliams

The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

In Wales they really can waste money: £68m unveiled for health and care hubs

The decline of General Practice.. Bribes may be too late…

GP practices close in record numbers – Wrexham patients protest about GP staffing levels. This is only the beginning…

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

Six in 10 family doctors considering early retirement  March 2014 – 4 years ago

President Trump: NHS ‘going broke and not working’