Monthly Archives: April 2018

Do you have a right to forbid your notes to be filed electronically? We don’t know..

Whilst GPs have relatively well proven and secure IT systems, with a limited number now offering a high standard service, Hospital systems are multiple and disconnected. They are different to GP systems in that they do not collect all the social data, family history and accumulated evidence of years of family general practitioners. My own practice computerised fully in 1988. Hospital records are still kept on paper in out patients in our local DGH. It is worrying to think of the potential for mistakes in disconnected systems, and Chris Smyth in the Times alerts us on April 18th 2018: Every hospital tested for cybersecurity has failed

Is the potential risk from poor systems greater than the gain to the patient? I have never been asked if I give permission for my hospital notes to be on computer. Patients in GP do have a right to exclude their notes from being shared. Do you have a right to forbid your notes to be filed electronically? We don’t know.. Surely it’s time for my notes to be on a “card”, which when I pass to the doctor, is giving permission for access?

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All 200 hospitals and other NHS organisations that have been tested so far have failed cybersecurity checks, according to a report by MPs.

Some hospitals have not fixed the original vulnerability that led to last year’s cyberattack and NHS chiefs are not working fast enough to protect the health service, even though a repeat is a matter of “when, not if”, the public accounts committee (PAC) says.

Despite promises that lessons had been learnt from the WannaCry ransomware attack nearly a year ago that crippled a third of NHS hospitals, a report released today finds there is still “a lot of work to do” to avoid more disruption when they are targeted again.

Yesterday spy masters in Britain and the US issued an unprecedented warning that tens of thousands of devices had been targeted by Russian hackers preparing for an attack on British infrastructure. Security chiefs are braced for cyberattacks on vital services, including the NHS, as relations with Moscow deteriorate over the nerve agent poisonings in Salisbury and a suspected chemical weapons attack by the Russian-backed Syrian regime.

Ministers accept that “cyberattacks are now a fact of life and that the NHS will never be completely safe from them”, the PAC reports.

Although almost 20,000 hospital appointments and operations had to be cancelled during last year’s attack, today’s report says that the NHS was “lucky” and if it had not happened on a Friday afternoon in May, and the virus had not been quickly disabled, the effect would have been far worse.

Meg Hillier, chairwoman of the PAC, said: “Government must waste no time in preparing for future cyberattacks — something it admits are now a fact of life. It is therefore alarming that, nearly a year on from WannaCry, plans to implement the lessons learnt are still to be agreed.”

All 200 trusts tested on cybersecurity by NHS Digital have failed, the MPs said. “We are told that this was because a high bar had been set for NHS providers to meet the required standard but some of the trusts had failed the assessment purely because they had still not patched their systems — the main reason the NHS had been vulnerable to WannaCry,” they added.

“I am struck by how ill-prepared some NHS trusts were for WannaCry, in many cases failing to act on warnings to patch exposed systems because of the anticipated impact on other IT and medical equipment,” Ms Hillier added.

Today’s report details how staff had to resort to using WhatsApp to communicate because they had shut down emails as a precaution, while some hospitals called the police because they did not know who to speak to in the NHS.

Matt Hancock, the secretary of state for digital, culture, media and sport, said on BBC Radio 4’s Today programme this morning: “There’s clearly much more that needs to be done. The NHS has made improvements since the WannaCry attack last year, but one of the challenges in cyber security is that the criminals and the malicious actors who are trying to harm our cyber security are moving fast, and you have to run to stay still. You can’t just make one update, you’ve got to constantly be updating.”

Lord O’Shaughnessy, the health minister, said last night: “We have supported [cybersecurity] work by investing over £60 million to address key weaknesses and plan to spend a further £150 million over the next two years.”

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Hywel Ddda on the way to the roasting oven of political dissent and civil unrest?

The medical model is changing. More specialisation raises standards, and chances of a long life.  Specialist units with teams of professionals raise standards quicker than smaller units. Recruitment of altruistic young doctors, and other staff,  is easier in specialist (tertiary) units. Hywel Dda has none of these.

In my own area, a rural English speaking part of West Wales, with a population 3 times the size in summer, the threat to close our hospital is about to cause civil unrest. A new build in Pembrokeshire would reassure the Medical Executive Committee of local consultants, but the politics of Wales mean that it could be over the border in Carmarthenshire. This is a completely different area, and the two tribes are separated at County Council as well as Hospital. The majority English speakers feel threatened by a minority Welsh speaking “caste” taking over the culture of their hospital. This may not happen, but it is the perceived threat. In addition there is difficulty recruiting doctors to West Wales, Carmarthen more so than Pembrokeshire, and the lack of choice for patients within their post code rationed region, is demoralising. It splits the population.

The demographics, and especially in the future, mean that more and more elderly will retire to Pembrokeshire. There are two towns with building consent to expand in the National Park, Freshwater East and Broadhaven. This is where the population will expand. This is where demand will come from.

The poor road and transport links, and the absence of a routine air ambulance, mean that if services are moved East of Narberth, patients from Dale and St David’s will have too far, too slowly, to travel.

The sensible option is to close Carmarthen, (already falling down), and Llanelli, which is near to Swansea, and to combine the Swansea and Hywel Dda trusts. In this way there would be more choice for patients, and recruitment would be less of a problem. If the trust insisted appointees did some of their time in Withybush there would be fairness and service. But this is not one of the options offered by Hywel Dda, as this would require a change in the rules of the game, decided by the Welsh Government. Indeed, common sense would make all of Wales into one trust. Then there would be maximal choice (In Wales) and although there are two waiting lists (one for English – fast, and one for Welsh – slow) at Oswestry, it would enhance choice and standards.

My solution puts the Welsh speaking area of Carmarthen between two larger English speaking areas, which would not be politically acceptable.  It has to have stroke thrombolysis and stent insertion, as well as radiotherapy services.

In the 1970s a new DGH was built to replace the old first world war “county Hospital”. The population supported Eirian Williams in his endeavours to keep Pembrokeshire’s hospital. Not many of his supporters are still alive, but the principle he applied still remains: there is more pride and cultural affinity with ones own hospital. In the future many services will be in the community and closer to the patient. Whatever decision is taken is relatively short term, as we have to start putting money into community care. If the new hospital goes ahead, then the former DGHs could be reclassified as “community care” and rehabilitation and recovery can happen at these places. In the end we can only have quality care in hospital if there is enough capacity to leave the hospital.

BBC News 24 hrs ago: New hospital and Withybush changes in Hywel Dda shake-up plan by Owain Clarke

The Western Telegraph reports 19th April: Withybush to lose A&E under new plans.

Local politicians, without a utilitarian approach, are always going to object. (Tenby Observer)

Look at the Hywel Dda site for “transforming” services”, and fill out the feedback Questionnaire.

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

Families asked to feed dementia patients…. How do we design a system that is fair to both the well spread, and the very locally based families?

Redefining the relationship between doctors and patients… When not to put the patient at the centre of your concern…

 

 

Computer flaws ‘cause hundreds of NHS patients to die each year’

This news item begs the question: “Do I have a right to refuse hospitals to record my notes on computer? or Can I insist on a paper record for my notes”? Most hospitals have both paper and IT, which is a wonderful recipe for mistakes. Informed patients are at an advantage in a failing health service, but a new form of “Iatrogenesis” is computer and technology driven. Some patients and their families are taking photographic copies of paper notes so that any amendments, if there are problems, will be self evident.

Kat Lay reports in the Times February 7th: Computer flaws ‘cause hundreds of NHS patients to die each year’

Hundreds of NHS patients die each year because of computer problems including bugs, viruses and design flaws, a report has claimed.

Experts said that there was “not a word to describe how bad” the computers that hospitals relied upon were. These computers were used for vital tasks such as keeping records and delivering cancer drugs, academics from Oxford and Swansea universities said.

While it was possible to write software that was “correct, safe and secure”, there was little incentive for manufacturers if it was not a precondition of the packages being bought by NHS bodies, they said.

Martyn Thomas, a visiting professor in software engineering at Oxford, and Harold Thimbleby, a professor of computer science at Swansea, were speaking before a Gresham College lecture at the Museum of London yesterday. A typical NHS trust has 150 types of computers for administration, communication and professional support and many more embedded in medical equipment.

The extent of poor IT leaves hospitals vulnerable to cyberattacks that could kill “a lot of people”, Professor Thomas said. The researchers argued that on a “conservative” estimate bugs, viruses and design flaws in those systems led to between 200 and 880 deaths each year.

The Grenfell Tower fire last year killed 71 people, the Ladbroke Grove train crash in 1999 killed 31 and the 1988 Piper Alpha disaster killed 167, they said, and all prompted public inquiries. “What will it take before we get our public inquiry? When will we have the ‘radical changes’ in healthcare regulations?” they asked. They offered examples of poor IT harming patients. In North America the Therac-25 radiation therapy machine overdosed and killed patients between 1985 and 1987. In Britain an error, since corrected, in the QRisk calculator used by doctors to predict a patient’s risk of heart attack or stroke is feared to have led to the incorrect prescribing of statins to thousands of people.

They said that nurses and doctors were often blamed for errors that had been caused by the computers they were using. Simple design features could be adopted, they said, that have been proven to reduce errors. For example, if nurses use a numeric keyboard to enter numbers into a computer they make twice as many errors as when they use arrow keys to adjust the figure shown on a screen.

The Wannacry cyberattack last year, in which hackers encrypted NHS records and demanded a ransom to unlock them, led to almost 20,000 hospital appointments being cancelled. “There were lots of problems, and that was not even an attack on the NHS — they were just collateral damage,” Professor Thomas said. The researchers said that the regulation of computers used in hospitals was inadequate.

A spokesman for the Department of Health and Social Care said: “Patient safety is our priority, and our £4.2 billion investment in technology will help eliminate avoidable harm. It’s encouraging that there were no reports of patient harm or of patient data being compromised in the Wannacry attack. We are re-doubling our focus on cybersecurity with an extra £46 million to improve resilience in major trauma centres and support at risk organisations, with a further £150 million committed by 2020.”

Meningitis B vaccination rationed. If you have a large family consider purchasing.

Meningitis B vaccine has come in recently, and at a cost approaching £100 per shot. Newborn infants get it early, along with Meningitis C and other vaccines. If you have a large young family it is well worth considering purchasing the vaccine privately. Although the risks are low, could you live with yourself if you could have avoided a case in your children?

The response to the debate on Men B is summarised by a disappointed “Meningitis Now”. They are most disappointed that rationing has continued despite a petition of 820,000 people.

Kat Lay reported in the Times 4th April 2018: Warning as Hector Kirkham, 3, dies of meningitis

The parents of a three-year-old boy who died 12 hours after showing symptoms of meningitis B have warned other families to look out for signs.

Hector Kirkham’s parents, Charlotte and Lee, said: “Hector became very poorly very fast from contracting meningococcal septicaemia. Hector’s symptoms of sickness and a temperature only presented 12 hours before we sadly lost the love of our lives.

“We urge all parents to be vigilant about any symptoms that point towards meningitis. Please, please seek urgent medical advice, don’t delay.”

A second boy, aged four, was also taken to hospital with the illness and discharged yesterday. Both children attended Little Learners nursery and preschool in Galgate, Lancashire, and were taken to hospital on March 27. They are said to have been to the same birthday party.

Babies under one have been vaccinated against meningitis B since September 2015. It is spread by coughing and sneezing and symptoms include fever, headache, heavy breathing, vomiting and cold hands and feet. About one sufferer in ten will die.

Staff and children at Little Learners have been offered antibiotics.

 

 

Personal, continuing care….. is going the way of the dodo. Basingstoke represents the rest of the country.

Basingstoke is a popular and affluent place to live. NHSreality has declined to post all of the threats to close primary care premises, as the point has been well made. The drivers for change in Basingstoke are unknown to me personally, but I suspect multiple part time workers who are dissatisfied with the shape of their job, to be the main cause. Have any of those who retired recently had exit interviews? Of course not.. The hospital medical model is changing because of technology: tertiary care centres provide the best chance of survival with least complications for state funded patients. In General Practice it is not technology which drives the change, but capacity, and frustration. There is no reason, apart form poor manpower planning, that citizens cannot have personal continuing care. It might have been shared by just a few, but now it is going to be shared by so many that it is impersonal.

CONCERNS for the future of healthcare in Basingstoke have been raised following the news of a proposed merger of three surgeries.

As previously reported in The Gazette, the Gillies and Overbridge Medical Partnership, in Brighton Hill, Camrose Medical Partnership, in South Ham, and The Hackwood Partnership, in Essex Road, are intending to merge later this year.

The move to provide a more cost-effective service would affect more than 44,000 patients.

However, one ward councillor has raised concerns saying that there needs to be full transparency during the consultation period.

“It appears that money is being put above the interests of patients.

“This may be the expectation of the government, but we believe the interests of the patient should always come first, and that means maintenance of existing services and not rationing them to single sites serving 44,000 people.

“No mention is made of closing sites, but that surely must be the next step under this “amalgamation”.

“We have already seen the Overbridge and Hatch Warren surgeries close as a result of previous “amalgamations”.

“Yet the number of patients requiring treatment, and the demands placed on health services by an ageing and increasingly obese population, are still increasing.”

In the proposals put forward, all patients would remain at their registered GP but it is planned certain services will only be offered from each individual site.

For example, respiratory nurse appointments will be run out of the Hackwood site, family planning and woman’s health and minor surgery will be based at the Camrose clinic, and a diabetes clinic will be hosted at the Gillies site, which would mean patients would have to travel to each dedicated surgery.

Project manager Amy Taplin said: “The main driver for the merging of the three practices is to ‘futureproof’ the services being offered to our collective patient populations.

“There is currently a GP recruitment and retention crisis affecting general practice across the country.

“If we do not merge, it is quite likely that at least one of the practices will not survive the next three years due to the inability to recruit and retain GP partners.

“All routine GP appointments will continue to be offered from all three sites so patients will still be able to request and book routine appointments with their usual GP at the site at which they are currently registered.”

She added: ” there are no plans to close any of the three sites”
To find out more about the merger proposal go to camrosemedical.co.uk/2018/01/08/the-primary-care-home-tri-practice
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Like the Health Service you are in, you need to “Check the small print” for exclusions. If you travel, make sure your health cover is for the best hospital care,…

Even the Private Travel Insurance industry is trying to ration. Like the Health Service you are in, you need to “Check the small print” for exclusions. If you travel, make sure your health cover is for the best hospital care,…

Andrew Ellison reports in the Times 18th April 2018: Travel insurers ‘ban private hospitals to keep costs down’

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A British doctor on holiday in Thailand says he almost died because his travel insurer insisted that he transfer from a private hospital to a state-run hospital after he fell desperately ill.

The man, who had a policy with a £10 million medical emergency limit, says he only survived because he was able to identify the severity of his condition and transferred himself back after a five-hour wait for treatment.

The case illustrates how the trend among insurers to use small print to cut standards of cover puts holidaymakers at risk. Analysis by The Times of policy documents at Britain’s ten biggest travel insurers reveals that half effectively ban travellers from using private hospitals, even in developing countries, except in exceptional circumstances.

Campaigners say people visiting far-flung destinations where state-run care is often of a questionable standard must no longer assume their policies cover them to go to the nearest or best hospital. James Daley, of Fairer Finance, said: “This is part of a drive to keep costs down. In most medical emergencies, you go to the nearest facility or the one recommended by someone locally. Insurers should be making these sort of terms crystal clear up front.”

The doctor, who does not want to be named, went to the nearest hospital to the resort where his family were staying about 50 miles from Bangkok after experiencing abdominal pains. Surgery was necessary so he rang the 24-hour emergency number supplied by his insurer, HolidaySafe. He knew his life was at risk but he says the service was staffed by non-medics who sent him to a government hospital further away.

After travelling there by taxi, he says he was made to wait almost five hours in a corridor without water, sustaining kidney damage. Realising that he would probably die if he stayed there, he took another taxi back to the private hospital and was treated before being transferred to the capital for surgery.

A spokesman for HolidaySafe said: “We never insist or demand that customers receive treatment at particular centres and we did not do this in this case. Our view is it is the patient’s choice where he or she seeks treatment. However, we do give recommendations and those include public hospitals in many areas of the world.”

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Trials of personal budgets will have long term perverse outcomes in an ageing society. Health costs are rising, and geographic variations will become greater….

Health costs are rising. Even in Australia, a relatively rich 1st world country, citizens are “struggling to afford their cover”. The safety net afforded by the current 4 health UK services may be holed, but it is not yet “absent”. In London, where it costs most to live, but where people earn more, residents who can afford to pay for private health Insurance (PMI) are being charged more than others around the country. This simply reflects the general inflation in health costs, and the likelihood of a claim. If less people are paying for PMI, then those that pay up are going to be those more likely to make a claim. As the population ages, the same is true. Each individual is, on average, going to cost more…Imagine a country where everyone needed “personal health budget”: what happens when the emergency operation is needed and the budget is spent? The Times leader  16th April supports individual budgets..(see below) .

The only virtue of personal health budgets for chronic conditions is that it is part 1 of over rationing.

The whole idea of a National Health Insurance scheme is to mutualise risk. Once rationing is overt and honest, each citizen and family can plan for what is excluded. It should be possible to make different thresholds for exclusions based on wealth/means. This would be fair. If we keep wriggling on the various hooks that try to avoid rationing, we will get perverse behaviours and outcomes.  These have yet to be seen, but they will bankrupt us whilst we remain in denial. Trust boards and commissioners should wait for the long term effects of these “trials” before following..

Londoners will consider having their knees replaced in Wales, or India, more frequently. Paying directly seems the answer. Is it more important to pay for a very large mortgage in London, or to have good affordable health treatment? By this means, the rich can subsidise the poor. Where health insurance is cheaper, so people are poorer.

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Ruth Emery reports in the Sunday Times 16th April 2018: Sick of the rising cost of health cover

Londoners are paying almost twice as much for medical insurance as policyholders in other parts of the country

When Stacie Coates received a letter from her healthcare insurer, Vitality Health, saying her premium was rising by 11% to £148 a month, she decided it was time to do something about it — especially as it followed a hike of 15% the previous year.

Coates, 43, of Chelsea in southwest London, turned to a broker, who found a similar policy with the healthcare giant Bupa that cut her monthly payment to £124 — plus she got two months free.

“I’d been with Vitality Health for three years but never claimed,” she explained. “It’s not right they kept putting up my premium.”

Coates works for herself, running the Chelsea Windowbox Company, and believes health cover is important. “What if I had an accident? I can’t afford a long wait on the NHS, such as having to wait for a knee operation for six months. The NHS is so squeezed right now. If you can afford it — and you find a reasonable price — health insurance makes sense.”

However, Coates may not be pleased to find out that, even with her new deal, she will be paying substantially more for her cover than people elsewhere in the country…..

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Christopher Knous for the Guardian reports 29th March 2018: Three-quarters of Australians struggle to afford private health insurance – Choice

Premiums cited as second greatest cost-of-living expense concern after electricity

Chris Smyth in the Times 18th April 2018: Patients will decide how they spend NHS money

Huge expansion of personal health budgets…

Money Well Spent – Personal health budgets can transform nightmares into lives worth living – The Times leader 16th April

When Jackie Kennedy developed epilepsy as a result of an assault at work, for a while things looked very bleak indeed. She lost her mobility, could no longer work as a police officer, went into a severe depression and considered suicide. Fast-forward to the present and her life looks rather different. She has a full-time canine helper (a highly trained black lab called Kingston), two part-time human ones and part-time voluntary work of her own. She’s thinking of going back to university.

The transformation has been made possible by a personal health budget of £50,000 a year arranged by an initiative called NHS Continuing Healthcare. For now only 23,000 people in the country have personal health budgets funded by the state. That is set to expand more than tenfold to include several new categories of people, among them those with mental as well as physical illnesses, dementia sufferers and military veterans.

There have been stories in the past of patients using money meant for their care on holidays and games consoles. There will be more. Jeremy Hunt, the health secretary, and Simon Stevens, head of the NHS, will have to take them on the chin. They are supporting the expansion of this scheme on the sound basis that as long as experts are also involved, no one is better placed to decide what to prioritise in complex treatment programmes than patients themselves. That principle can be taken a step further: who honestly is in a position to tell a recent amputee that a season ticket to his or her favourite football club, or indeed a holiday, might not be the best defence against depression?

There is evidence that personal health budgets improve long-term outcomes and bring overall cost savings. The plan is that they will also merge NHS and social-care spending, accomplishing on an individual scale exactly what is needed on a national one. From such acorns, oak trees grow.

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Update: The Times letters, on this issue, 17th April reveal a Liberal minister unwilling to see further than the ideology of Liberalism, to the benefits of utilitarianism. In this case the two conflict, and the latter takes precedence. This is exactly the sort of idealism, and lack of pragmatism which keeps the middle party out of office.

PERSONAL HEALTH BUDGETS
Sir, The idea of increasing “personal budgets” to manage health and social care may look politically attractive but it will not benefit everyone, particularly older people who have complex health care needs (report and leader, Apr 16). Indeed, lessons will need to be learnt about why they have not been a success to date.

At Independent Age we hear about the immense difficulties that older people face trying to access healthcare and support and it is questionable whether personal budgets will make life easier. The vast majority of older people want health and care provided through the NHS and social services in their area. They are not experts in brokering care packages, negotiating contracts or assessing quality. Personal budgets may also create an external market that is driven by price and profit, rather than meeting the diverse and complex health needs of an ageing population. Although some people will benefit from personal budgets, it is not a silver bullet. No one should be disadvantaged by not taking them up, but crucially the government must also address the funding crisis in the NHS and social care, and end the disjointed fragmentation of support across the two systems. Personal health budgets should not be seen as a substitute.
George McNamara

Director of policy, Independent Age

Sir, The chief objection to personal health budgets expressed in your report was that feckless patients might spend their money on world cruises and football tickets. The real risk, however, is that they will use their budget to fund so-called alternative medical treatments that have been proven to be ineffective or even dangerous. I fear this is yet another gimmick on the part of the government to divert attention from their underfunding of the NHS, but the effect will be to increase the funding shortfall.
Dr Bob Bury

Leeds

Sir, Plans to expand the use of personal health budgets should be welcomed by all those who believe in the liberal principle of giving people more control over the public services they use. As health minister I extended the right to a personal health budget to everyone receiving NHS continuing healthcare. There is evidence linking these with better outcomes for patients, while concerns that the system would be open to widespread abuse have proved unfounded.

However, the government’s commitment rings hollow when many patients already report having their personal budgets trimmed without any medical justification. This includes people with debilitating progressive conditions such as spinal muscular atrophy, who have been left unable to pay for the level of support they need. Personal budgets have the potential to transfer power to patients, but that potential will only be realised if there are sufficient resources for people to exercise that power effectively.
Norman Lamb, MP
Care and support minister 2012-15