Monthly Archives: March 2018

Five new Medical Schools: better late than never. Lets hope selection criteria are different from before..

Beginning to realise the mess they are in, New Medical Schools have been announced, which will produce new doctors in 6-10 year’s time. The full details have yet to be announced, but there will be less wastage, more efficiency, more long term work hours, if the places are predominantly for graduates. It’s still not enough, and why didn’t we do it 20 years ago? The rejection of 9 out of 11 candidates for years is unforgiveable. Lets hope the new Deans listen to Dr Cairns advice (see letter below)

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BBC News 20th February: Under-doctored areas to get new medical schools

…Places at existing schools are also being increased as part of the government’s commitment to increase student places by 25%.

It will mean by 2020 there will be 1,500 more students each year.

Health Secretary Jeremy Hunt said the new schools were being targeted at parts of the country where it “can be hard to recruit and attract new doctors”.

Overall 90% of the new places will be outside London.

“It will help us deal with the challenges of having around one million more over 75s in ten years’ time,” added Mr Hunt….

Alex Matthews-King in the Independent:Emphasis on training doctors in areas with staff shortages will expand university places in Sunderland, Lancashire, Canterbury, Lincoln and Chelmsford

The Lincolnite: New Medical School to address staff shortage.

Chris Havergil in the Times Educational Supplement: 5 new Medical Schools

Chris Smyth in the Times: More medical schools to fill NHS gaps

Five new medical schools will open in the next two years to train doctors as fears grow about NHS staffing gaps.

Anglia Ruskin University will train medical students at its Chelmsford campus from September, followed by the University of Sunderland and a partnership between Nottingham and Lincoln universities next year. Schools will open in Canterbury and at Edge Hill University in Lancashire in 2020.

The NHS is short of thousands of doctors and ministers have promised to increase training places by a quarter. Health chiefs say that staff shortages are rapidly overtaking money worries as the biggest threat to care.

Jeremy Hunt, the health secretary, said yesterday: “Setting up five new medical schools is part of the biggest ever expansion of our medical and nursing workforce, which will help us deal with the challenges of having around one million more over 75s in ten years.”

The 33 existing schools take 6,000 doctors and the 1,500 places Mr Hunt promised have been allocated, giving priority to areas where shortages are worst. The Chelmsford school will take 100 this autumn and there will be 530 more at existing schools. Places will increase by 690 next year and 180 in 2020.

Comment from a Dr Andrew Cairns in the Times 21st March 2018: MEDICAL ATTRIBUTES
Sir, I hope that the introduction of new medical schools to train 1,500 more doctors each year (report, Mar 20) will bring with it a review of selection criteria. Too many medical students have been high-achievers throughout their short lives and have not experienced failure. When this occurs, as it inevitably will in a medical career, they may not have the resilience to cope. The academic bar should be lowered and attributes such as common sense, stamina, resilience, a sense of humour, dexterity and interpersonal skills encouraged.
Dr Andrew Cairns (retired GP)

Petersfield, Hants

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Dying NHS chief wants GP’s help to end agony

NHSreality supports Dr Cosford, and would ask for exactly the same treatment and expectations… What a pity that our elected representatives are afraid to take action in the same way that Canada has. And if we don’t address the issue many doctors fear using the palliate care painkillers in appropriate doses, as they can then be accused of accelerating death.

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Dying NHS chief wants GP’s help to end agony – Sarah Kate-Templeton in the Sunday Times March 18th 2018.

The man responsible for improving the nation’s health has been diagnosed with incurable cancer and has revealed that he would like “a quiet chat” with his GP when his time is nearly up.

Professor Paul Cosford, director for health protection and medical director of Public Health England (PHE), would like to be able to ask his family doctor for enough medication to ease his pain — even if this hastens his death.

In a frank account of his illness in a blog on a medical website, he wrote: “I wish I could have a quiet chat with my GP and ask him to make it easier when the time comes.

“That is not a conversation you can really have these days. In the past, easing the process of dying with sufficient medication to ease symptoms but which might also hasten your passing was generally accepted but it seems difficult to have this conversation now because there have been so many legal concerns raised.”

He told The Sunday Times: “It feels to me as if we trusted the relationship between a doctor and a patient much more and now there is a temptation to put a legal framework around everything.

“Sometimes people are so concerned about the legal consequences that we forget about good, humane, personalised medical care.”

Cosford, 54, has lung cancer. He has never smoked and realised he was ill only when he could not complete a 600km (372-mile) cycle ride.

Following his diagnosis, his interest has turned to the quality of life for the terminally ill. Addressing a meeting of the Royal Society of Medicine in February, he said: “Thinking that I might have some control at the end of my life allows me to focus on living life well now.

“I will probably be able to make that happen as things currently stand because of my knowledge of the system, but it is apparent to me that this is not the same for everyone.”

Cosford, a father of four who is married to a doctor, needs to know that he could “bring things to a conclusion” if he loses all hope.

He told the meeting that he wanted to “develop a tacit understanding that, at the point that all my reasonable options run out and, if it is all too much for me, I will have the wherewithal to bring things to a conclusion myself . . . And I sort of assume I might have a syringe driver and will just need a bit extra available if I need it.”

Keeping life as normal as possible, he continues to work in his high-powered role. He believes passionately in the health benefits of exercise and still completes one 100-mile cycle ride a month. He hopes that if he continues to receive the latest treatments he will live another three or four years.

He can also laugh at the absurdities of terminal illness. When inquiring about travel insurance, he was asked if he had a date for his death.

“I said, ‘I have an incurable cancer, are you meaning that that is terminal and would that exclude me from your policy?’ The person on the other end of the line said, ‘Well, have you been given a date for your death?’”

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A sign of falling morale (and standards), and lack of “buy in” to the health service philosophy…?

Doctors don’t go on strike easily. Junior doctors are 80% women, and they strike less easily than men. The strikes of 2017 have been replaced by “legal action”. Is this not a signal to politicians, of falling morale, and lack of “buy in” to the health service philosophy…? In other countries, Germany, USA, Canada etc. the doctors work harder and longer hours. So this case may be a proxy for general discontent. Who amongst them has had an exit interview, and who would trust an HR department to report feedback dispassionately. Only this week I heard of a consultant offered (rare event) an exit interview, and he is thinking hard about it. Could he be punished when he is a patient (downside risk)? Will he be taken seriously? Is anything likely to change as a result? He would certainly tell them standards were falling..

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Junior doctors take trust to court for denying them breaks every four hours (BMJ 2018;360:k852 ) Clare Dyer

A junior doctor has accused her former employer of breaching her contract by not allowing breaks every four hours, in a High Court test case with reverberations throughout the NHS.

Sarah Hallett is acting on behalf of herself and another 20 junior doctors who trained with Royal Derby Hospitals NHS Foundation Trust in 2013-14, when she was in her foundation year. In a case supported by the BMA they argue that they did not receive the breaks they were entitled to.

At the Royal Courts of Justice in London, where the four day case opened on 20 February, John Cavanagh QC, representing Hallett, said, “This case is of general public importance . . . It is a test case which is of significance across the NHS.”

He told Mrs Justice Simler that NHS trusts were obliged to allow junior doctors a 30 minute rest period after every four hour working period. “If they do not have the opportunity to take these breaks, this affects their safety and welfare, with consequent effects on patient safety,” said Cavanagh.

NHS trusts that did not comply with the rules had to pay juniors double their normal rate for missed breaks, he told the court. But Hallett’s primary objective was not money, he said, but to make sure that NHS trusts met their contractual obligations.

“It is the responsibility of trusts to make sure that they do not run overly fatiguing or unsafe rotas,” he added. “Junior doctors who have to work for many hours in very stressful and high pressure conditions without even a short break will be exhausted, and this will potentially lead to risks to patient safety.”

If Hallett, who is a deputy chair of the BMA’s junior doctors committee, wins her case and the 21 doctors claim compensation for the lost rest periods it could cost the trust £250 000 (€283 000; $349 000). Richard Leiper QC, representing the trust, said, “The potential cost to the trust, let alone to the NHS as a whole, would be dramatic.”

A trust spokesperson said, “This trial is simply about how Derby Teaching Hospitals monitored junior doctors’ working hours back in 2013. The approach we took mirrors that taken by a significant proportion of NHS trusts up and down the country.”

Junior Doctors strikes had significant impact on patient care – Paul Gallagher 19th February 2018 I news who also reports 18th March 2018 on the increasing death rate “Stunning figures reveal more than 10,000 excess deaths”…


Consultancy firms make hospitals worse

This article represents the opposite of rationing: wastage. When you are wriggling on the hook set by an unsympathetic and “in denial” political administration, you reach desperately for anything: a straw is no help in this slow motion disaster.

Chris Smyth in the Times reported 21st Feb 2018: Consultancy firms make hospitals worse

The hundreds of millions of pounds the NHS spends on management consultants actually make it less efficient, the first study of its kind has concluded.

Not only are hospitals wasting their money but the consultants appear to make finances marginally worse.

Researchers said that “inefficiency is the norm” in NHS consulting projects.

Health unions reacted furiously to the “scandalous” findings, urging ministers to divert money from management consultants to doctors and nurses. Hospitals and consultants insisted that external advice was needed, but conceded that the results underlined the need for clear measures of value for taxpayers’ money.

Andrew Sturdy, professor in management at Bristol University, who carried out the study, said: “Our research has clearly shown that management consultants are not only failing to improve efficiency in the NHS but, in most cases, making the situation worse . . . this is money which, many argue, could be better spent on medical services or internal management expertise.”

Despite consistent political criticism of management spending from both main parties, the cost to the NHS has increased under both, reaching £640 million in 2014 before falling to £263 million in 2016-17.

Professor Sturdy gathered data on 120 NHS hospitals over four years, comparing spending on consultancy with an efficiency measure recording how much it cost them to carry out standard procedures. Each £100,000 spent on management consultants led to extra costs of £880, he concluded in the journal Policy & Politics.

The average trust spent £1.2 million a year on management consultants and afterwards became less efficient by about £10,600 a year. Professor Sturdy said: “The big question is what that money could have been spent on instead.”

He also tracked efficiency changes after the consultants were brought in, to rule out the possibility that the worst hospitals needed more outside advice. He found no clear effect of consultancy spending on quality of care.

“What stands out is how widespread that increase in inefficiency is across the board. Inefficiency is the norm,” Professor Sturdy said. He argued that British hospital bosses, unlike those in places such as Germany, seemed to “default to external management consultants” and needed to be more rigorous about their use. About a third of a subset of hospitals seemed to improve efficiency using consultants he said, adding that he wanted to find out what could be learnt from them.

“There will always be a role for external management consultants. A lot of people will say don’t use them at all but this isn’t the conclusion of this study. The message here is the need to assess and be more cautious and sceptical,” he said.

“Clearly an organisation like a hospital does need management advice, the big question is what terms is it on.”

Chaand Nagpaul, head of the British Medical Association, said: “At a time when patients are enduring long waits due to overstretched hospitals and GP surgeries, it is scandalous that huge sums of money are being spent on management consultants in the NHS. This is not just a waste of taxpayers’ money — these findings show that they lead to a rise in inefficiency and are actually making things worse.”

Janet Davies of the Royal College of Nursing said that her members would be “exasperated” by the findings.

However, hospitals defended the use of management consultants, saying they had been told to lay off so many managers that some projects could only be done with outside help.

A spokesman for NHS Improvement, the financial regulator, said: “We are working with all trusts on reducing their costs which includes spending less on management consultants; and have had some success . . . in future, we will continue to work with trusts on keeping their consultancy spending to a minimum, and on commissioning it better.”

Behind the story
There is nothing management consultants love more than a data-rich analysis — except, it seems, when it comes to their own performance (Chris Smyth writes).

Even though such consultancy has been embedded in the NHS for decades, there has been little published research on whether it works. If this study does nothing else, it throws down the gauntlet to management consultancies to demonstrate which of their efforts really do justify their fees.

Much of the scepticism comes from a suspicion that when managers reach for outside consultants, it is simply because they do not have any better ideas, or to legitimise a decision they have already reached. It is striking that the researchers behind this study say that the answer to wasteful consultants might be not to spend the money on doctors and nurses, but to use it hire more permanent managers who know what they are doing.

Consultants say they are already trying to prove their worth with contracts that link their fees to the money they save, or the clinical results they improve. The NHS must explore this. But at a time when the NHS is struggling to implement its long-term strategy for joined up care, there is a more fundamental question: how does the NHS make the change it needs to survive? Anyone who can crack that question will be worth the money.

Is the minister going to panic – no way. He is in denial

If I were the minister of health, especially in England, I would be panicking. There is more and more evidence of rationing, and the euphemistic platitudes used to deny this are increasing. Prioritisation, restriction, exclusion, listing, processing etc. The safety net has more and more holes in it, and you don’t appreciate the holes until you need the particular service. Waiting on trolleys in A&E is also increasing, so that the emergency services are being seen as “second rate”, as well as the colder orthopaedic (waiting lists and infections) and cancer (exclusions and waiting times). As staffing levels fall, so do standards. (NHS ‘dangerously’ short of 100000 staff).

Women could be denied IVF treatment on the NHS in Trafford to save money – Lisa Meakin in the Greater Manchester news 18th March 2018

There’s a shortage of GPs causing CONCERN in Tyneside – Gareth Crickmer in the Shields Gazette 6th November 2017

Rationing of health care starts to bite across the district – Sarah Page in the West Sussex County Times 18th March 2018

A range of health treatments are now being rationed to people in Horsham, Crawley and Mid Sussex. Patients are being told that ‘minor’ operations – from investigative joint surgery, haemorrhoid removal, skin lesion treatment and treatment for varicose veins – are no longer being routinely funded by the NHS. There are also restrictions on a number of other conditions including cataract removals, female sterilisation and hysterectomies. The Crawley, Horsham and Mid Sussex Clinical Commissioning Groups – which are responsible for paying for local health services – have drawn up a ‘list of clinical policies’ outlining the treatments which will no longer be routinely funded…..

GPs (once again) offered cash to refer fewer people to hospital. Denis Campbell 28th February 2018 in the Guardian

GPs are being offered cash payments not to refer patients to hospital, in a move which leading family doctors have criticised as ethically questionable and a risk to health.

NHS bodies in four parts of England are using schemes under which GP practices are given up to half of the money saved by sending fewer patients to hospital for tests and treatment……

The Independent 3 days ago had as its editorial: The future of the NHS requires an informed debate from the public and politicians alike.

There are, as there always have been, trade-offs between types of care, between types of patient, geographical areas, and class. We can vary the weights given to public health, cancer care, social care, mental health or NHS dentistry, to name but a

‘Worrying’ rise in patients forced to pay for cancer drugs

‘I had no option but to spend £10000 for my hip op’

Official figures mask A&E waiting timesBig rise in A&E trolley waits at Shropshire hospitalsWoman dies after paramedic finds her on A&E trolley in cardiac arrest & Man left in agony in hospital corridor for more than 20 hours (Southmead)



So, you did not think there was post code rationing of cancer care?

Kat Lay reports 12th March 2018 in the Times: “UK behind on cancer guidelines” (she means treatments)

It may be very sensible to refuse treatments for which there is a poor return, and serious side effects. The spending of state money has to be rationed, but NHSreality maintains that this should be overt, and universal for the low volume high cost treatments. Aneurin Bevan talked about In Place of Fear ( A Free Health Service 1952 Chapter 5 In Place of Fear ) but we are doing our best to bring back fear. There are four British health café systems, each rationing differently. In each we pay up under the same tax rules. The UK is also behind on introduction of new drugs – for good reason. Mark Littlewood doesn’t believe is deserves the taxpayer funding it gets! The Times also explains why and how more people are having to pay for cancer treatments which are excluded. Sarah Kate-Templeton reports on the current private income from treating cancers privately in 2017: £360m

British cancer guidance is less likely to recommend innovative drug treatments for patients than versions used in other parts of Europe, a study has found.

Researchers at King’s College London evaluated clinical practice guidelines issued by different national bodies, finding that UK examples were more likely to focus on surgery, and slower to pick up on new research.

Their study comes after several high-profile cases where patients have had to travel abroad for treatment.

The Home Office is considering allowing a medical cannabis trial to treat Alfie Dingley, a six-year-old boy with epilepsy, who travelled to the Netherlands to take a cannabis-based medication last September. Jessica Rich, one of two sisters with Batten disease, a genetic disorder that kills sufferers before they reach their teens, has to fly to Germany for treatment with a drug that Nice will not fund and Ashya King, now eight, was taken to the Czech Republic by his parents for proton therapy on a brain tumour, against the recommendation of doctors in Southampton in 2014. Earlier this month his family announced that scans showed he was free of cancer.

The study, published in Esmo Open BMJ, found recommendations in continental Europe tended to focus on the use of new chemotherapy agents or targeted treatment, while UK guidelines tended to focus on surgery, screening or radiotherapy.

Mark Baker, director of the centre for guidelines at Nice, insisted the research was “poorly undertaken” and misrepresented its guidance .


No good news for those who think money is the answer….

Oliver Wright reports in the Times 12th March 2018: Hammond pledges cash for NHS but no end to austerity

Philip Hammond will open the way for a multibillion-pound investment boost in the NHS when he announces better than expected public sector finance figures tomorrow.

The chancellor is to use his spring statement to reassure Tory MPs that he is preparing to scale back austerity with significant public spending announcements in the autumn budget.

However, he will warn his critics that money must still be set aside to pay down the deficit and that there will be no immediate easing of government purse strings.

Mr Hammond hinted that spending on the NHS would take precedence and announced that the government was close to a productivity deal with health service staff that could see pay rises of up 6.5 per cent.

He also said he was looking to fulfil Conservative manifesto pledges to reduce taxation in the autumn while also announcing new money for post-Brexit infrastructure.

The chancellor made clear that there would be no new tax or spending commitments this week and the statement would be focused on the fiscal forecasts and a number of new consultations — including for a litter levy — before the budget.

“As we come to the autumn budget, if we at that point have some fiscal headroom, we will use it to keep reducing the deficit so that debt falls, but we’ve also got to support our public services,” Mr Hammond told ITV’s Peston on Sunday programme.

“There’s a negotiation going on between the unions and the management for a pay deal for nurses and [other NHS workers], and I very much hope if the management and the unions can reach a deal which through workforce restructuring, pay restructuring, efficiency gains, can deliver product improvements to the NHS, then we will put extra money into the NHS next year to fund this.”

In a message to his critics, including Theresa May’s former chief of staff Nick Timothy, who have called for an end to the age of austerity, the chancellor said that increased public spending would not come at the expense of paying down the deficit.

“I’m afraid Nick Timothy’s ignoring the debt,” he told the Andrew Marr Show on the BBC. “We have a debt of £1.8 trillion, 86.5 per cent of our GDP. All the international organisations recognise that that is higher than a safe level and this isn’t some ideological issue. It’s about making sure that we have the capacity to respond to any future shock to the economy.”

He added: “There is light at the end of the tunnel because what we’re about to see is debt starting to fall after it’s been growing for 17 continuous years. But we are still in the tunnel at the moment. We have to get debt down. There will be economic cycles in the future. We need to be able to respond to them without taking our debt over a hundred per cent of GDP.”

The litter levy that Mr Hammond is expected to announce could result in takeaway food containers being taxed for the first time. Chewing gum, which is not water soluble and takes months to decompose, is regarded as a single-use plastic in some countries.

Treasury officials are contemplating including the product in the public consultation document on a future litter tax, meaning gum manufacturers would be subjected to the sort of levy that being considered for plastic cups, cutlery, crisp packets, bottles, foam trays and other single-use plastics.

Mr Hammond has described waste from single-use plastics as “a scourge to our environment” and aides say that he wants to “put the weight of the Treasury” behind attempts to solve the problem.

John McDonnell, the shadow chancellor, accused Mr Hammond of allowing austerity to reduce UK growth. “Last year we had the lowest economic growth in the G7 countries [and] austerity is holding growth back,” he said, adding that the savings that had allowed the government to reduce the deficit had been made at the expense of those least able to cope.

“What he’s done, very cleverly, is shifted the deficit on to the shoulders of NHS managers, on the shoulders of head teachers and on to the shoulders of not just the poorest but those just about managing, who are going to be hit next month by the cuts in the support that they get through the benefit system. So this isn’t a matter for celebration.”

“…health could be a casualty of Brexit.” Too true.

The NHS and Brexit. A letter in the Times from Professor Martin McKee and numerous other professors. March 12th 2018.

All the points raised are valid, but omitted is the drop in the value if the pound, and consequently our ability to buy in medical supplies.


Sir, The prime minister has repeatedly said that Brexit must respect the will of the people. While there has been much debate about what that means, one thing has been clear since it was invoked in a slogan on the side of the Brexit bus. This is the high priority that the public places on health. Yet there have been concerns that health could be a casualty of Brexit, including loss of NHS staff, problems obtaining medicines, weakening of public health protections and damage to medical research. Lord Warner, Lord Hunt of Kings Heath, Lord Patel and Baroness Jolly have tabled an amendment to the EU Withdrawal Bill that would ensure that the existing health protections in the European treaty continue to underpin measures repatriated into UK law. As senior health professionals, we urge the government to resolve the present uncertainty and accept this important amendment.
Professor Martin Mckee, London School of Hygiene and Tropical Medicine; Professor David Adams, University of Birmingham; Professor Sir George Alberti, former president, Royal College of Physicians; Professor John Atherton, University of Nottingham; Professor Philip Baker, University of Leicester; Professor Raj Bhophal, University of Edinburgh; Professor Sir Nick Black, London School of Hygiene and Tropical Medicine; Professor Carol Brayne , Cambridge University; Professor David J Burn, Newcastle University; Professor Sir Harry Burns, former chief medical officer Scotland; Professor Iain Cameron, University of Southampton; Sir Iain Chalmers, James Lind Library; Professor Sir Cyril Chantler , formerly University of London; Professor Dame Anna Dominiczak, University of Glasgow; Professor Carol Dezateux, Queen Mary, University of London; Dr Clare Gerada, former chairwoman of the Council of the Royal College of General Practitioners; Sir Muir Gray, University of Oxford; Professor Trisha Greenhalgh, University of Oxford; Professor George Davey Smith, University of Bristol; Professor Sir Andy Haines, London School of Hygiene and Tropical Medicine; Dr Iona Heath, former president of the Royal College of General Practitioners; Professor Andrew Hassell, Keele University; Professor Jenny Higham, St George’s, University of London, Chairman Medical Schools Council; Professor Richard Horton, editor, The Lancet; Professor John Iredale, University of Bristol; Professor Neil Johnson, Lancaster University; Professor Ann Louise Kinmonth, Cambridge University; Professor Louise Kenny, University of Liverpool; Professor Peter Kopelman, St Georges, University of London; Professor Sudhesh Kumar, University of Warwick; Professor Deborah A Lawlor, University of Bristol; Professor Keith Lloyd, Swansea University; Professor Una Macleod, Hull York Medical School; Professor Patrick Maxwell, University of Cambridge; Professor Sir Robin Murray, King’s College London; Professor Pascal McKeown, Queen’s University Belfast; Professor Sir Michael Owen, University of Cardiff; Professor Dame Pamela Shaw, University of Sheffield; Professor Rosalind L Smyth, UCL Great Ormond St Institute of Child Health; Professor Robert Sneyd, University of Plymouth; Sir Richard Thompson, former president, Royal College of Physicians; Professor Tony Weetman, University of Sheffield; Professor Sir Simon Wessely, Kings College London; Professor Moira Whyte, University of Edinburgh; Dr Graham Winyard, former deputy chief medical officer, England

Its not just GPs: “Critical Care units are turning away patients.”

Charlie Parker reports in the Times 8th March 2018: Critical Care units are turning away patients.

When the “rules of the game” don’t allow the overt rationing of care, then prioritisation and restriction are the only methods of rationing available to them. Its cause is really little different to GPs restricting numbers to be seen, but it is covert and you won’t know until you need it for you or your family, whether it is or is not available. Like private emergency care, private critical care will start to happen in big cities first.

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Four in five NHS intensive care units are turning away patients because of bed shortages.

A survey of ICU consultants by the Faculty of Intensive Care Medicine, their professional body, found that 62 per cent of the units were unable to provide adequate care because of nurse shortages. Some 210 intensive care units across the UK were each short of 12 nurses on average, leaving patients whose lives were at already at risk more vulnerable.

The findings, which were shared with The Guardian, also revealed that patients were being transferred from one ICU to another for non-clinical reasons in 80 per cent of hospitals.

Carl Waldmann, the dean of the faculty, said: “Especially at this time of year, when winter pressures exacerbate an already beleaguered system, critical care services come close to the absolute limit of their ability to provide good patient care.”

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Another form of rationing: restriction of GP access should be blamed on politicians

Chris Smyth reports on March 7th 2018 in the Times: GP leaders draw up plan to turn away excess patients

This is merely another form of rationing: restriction of GP access should be blamed on politicians. They have inadequately planned for the increasing demands of an ageing population. They have mismanaged the manpower planning – for 10 successive administrations. They have ignored the work-life-years lost by the gender imbalance, and they remain in denial. The unreality of 5000 new GPs…. and killing the geese that laid the golden eggs of efficiency. (GPs)

Family doctors will be able to turn away patients once they have done 35 appointments in a day under plans drawn up by GP leaders to deal with overwhelmed surgeries.

Once doctors have exceeded a safe daily number of consultations, extra patients would be sent to an overspill centre further away in a system modelled on the “black alerts” that allow overstretched hospitals to divert ambulances elsewhere.

The British Medical Association (BMA) insists that the plan will make patients safer because they will no longer be treated by exhausted doctors who are more likely to make mistakes. It also argues that capping workloads will prevent the GP system from collapsing as doctors fed up with rising patient numbers increasingly desert the NHS.

However, patient leaders attacked the “dangerously crude” plans and NHS chiefs insisted they must not go ahead.

Ministers have accepted that GPs can no longer cope with a “hamster wheel” of rising numbers of older, sicker patients and have promised an extra 5,000 doctors by 2020. However, GP numbers fell by more than 1,000 last year, fuelled by rising numbers of early retirements. Patient satisfaction with the GP service dropped 7 percentage points last year to a 35-year low of 65 per cent.

The BMA acknowledges that there is “surprisingly little” evidence defining when a GP’s workload becomes unsafe, but suggests that anything below 25 routine appointments a day is fine, with danger levels reached at 35, or 15 more complex consultations. It says that local areas should be able to set their own limits.

A poll by the health magazine Pulse this year suggested that GPs did an average of 41 appointments or phone calls a day, with 1 per cent dealing with more than 100 patients daily.

Richard Vautrey, chairman of the BMA GP committee, said: “GP workloads have become increasingly unmanageable owing to the demands of more complex patient needs, widespread recruitment issues and years of underinvestment, all of which takes a toll on GPs’ physical, mental and social health.

“There is an urgent need for cultural shift. Having a system of overworked and undervalued GPs is unsustainable, and a change to safe working practices is vital to ensure the survival of general practice.”

In a report, the BMA acknowledges the practical difficulty of finding somewhere else to send patients, proposing a system of local “overflow hubs”. It also concedes that many doctors will be reluctant to turn patients away, saying that the black alert system “will require a cultural change to remove the current noble but potentially self-destructive urge within general practice to simply work harder and longer to meet patients’ needs.”

The Royal College of General Practitioners is supportive, with its chairwoman, Helen Stokes-Lampard, saying: “Hospitals have ‘black alerts’. They don’t use them when they don’t need to — they only use them when they can’t cope, to protect patient safety. We don’t have an equivalent in general practice, but we need one, as it is not safe for patients to be seen by fatigued doctors and their teams.”

However, a spokesman for The Patients Association said: “Blanket decisions not to see patients above a fixed number would seem dangerously crude, and guarantees cases of people not getting treatment and care at critical times, with serious consequences for their health.”

NHS England said: “While arbitrary caps on patient appointments would breach GPs’ contracts, we understand the pressures general practice is facing. That’s why the NHS is investing £2.4 billion extra in GP services, growing the number of new doctors entering general practice and rolling out evening and weekend appointments to patients across England over this coming year.”