Monthly Archives: November 2018

Late cancer diagnosis… and poor cancer care. Let GPs have access to tests, and when there are enough, involve them in key treatment decisions.

Its not only the late diagnosis of cancer, influencing outcomes, which annoys NHSreality, but also the pretence that cancer and terminal care are under control in an ageing population. The opportunities to improve quality of life in the last few weeks and months is a great one. The subject of “advanced directives” or living wills is hardly discussed in society. This desperately needs to change… Teams of clinicians involving oncologists, GPs and Palliate Care consultants need to review far more cases together, and much earlier.

BBC News 26th November 2018: Cancer care: England still lagging behind the best

GPs need better test access to improve cancer diagnosis
OnMedica27 Nov 2018

Cancer patients wait more than a year for diagnosis
The Times22 hours ago

Early cancer diagnosis rates drop in several areas
Health Service Journal26 Nov 2018

Cancer care still falling behind in England

Letter in the Times 28th November 2018:

CANCER DIAGNOSIS
Sir, As senior academic GPs working in cancer research, we agree that the UK’s performance in timely diagnosis of cancer is distressingly poor but contend that the solutions proposed in your leading article (“Catch Up on Cancer”, Nov 26, and letters, Nov 27) are flawed. Patients with possible cancer are often older, most have at least one pre-existing long-term health problem and many have complex medical histories. These are the very patients that the providers of online diagnostic services prefer to avoid. A straight-to-specialist service will shunt the workload of sorting out patients with non-specific symptoms on to NHS specialists, whose capacity is under at least as great a pressure as general practice and who generally lack a broad expertise outside their own discipline.

GPs are highly skilled at making diagnoses, despite the pressures they work under, and their referrals for suspected cancer have doubled in number since 2009. However, they need the same access to sophisticated diagnostic tests as their counterparts enjoy in other high income countries and they don’t need the downward pressure on referrals being increasingly exerted by our NHS. At the same time research is urgently needed to develop new diagnostic tests that work well for ruling out cancer, and to translate them into clinical practice, so that GPs can more efficiently select those patients who do need specialist assessment.
Professor Greg Rubin, FRCGP
; Professor Willie Hamilton, FRCGP; Professor Richard Neal, FRCGP; Dr Fiona Walter, FRCGP

Seeking informed consent on Brexit

Many discussions around informed consent relate to the GMC, the duties of a doctor, and centre around whether the patient has been offered all choices, and the different risks involved in each choice. In politics, no less and no more. Citizens need to be aware of the reality of their decision, short term and long term if that can be assessed. Several of my Brexit friends are claiming that another vote will mean civil unrest. I ask them whether that depends on the result or not, and they of course answer yes. Why are they so afraid of another vote. It will either cement their position and unite the country in Brexit, or it will have changed. The same friend says that more people have died who voted Brexit, and more people have gained the vote who will probably vote remain. My argument still stands… We could well “die anaesthetised” if the politicians don’t vote the deal out, and ask for another referendum.

Image result for informed consent cartoon

Tom Moberley opines in the BMJ: Seeking informed consent on Brexit

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4816 (Published 15 November 2018) Cite this as: BMJ 2018;363:k4816

Despite all the diverging views on Brexit, few people would accuse the government of demonstrating skill, or even competence, in its handling of either negotiations on an exit settlement or preparations for the departure itself. These failings raise the risk that the UK will leave the EU without any deal and that whatever arrangement is reached will be unlikely to satisfy either leavers or remainers.

This week in The BMJ we take a close look at what Brexit will mean for the NHS, examine the arrangements needed ahead of 29 March 2019, and ask what doctors can do to mitigate the effects on health.

Niall Dickson, chief executive of the NHS Confederation and co-chair of the Brexit Health Alliance, warns that disruption to healthcare from a bad Brexit will risk lives (doi:10.1136/bmj.k4770). A series of features show how poor preparation for Brexit threatens the supply of blood products, insulin, and radioactive isotopes and the treatment of patients with rare diseases (doi:10.1136/bmj.k4724).

Amid all this concern and uncertainty, The BMJ, the BMA, and the Royal College of Nursing argue that doctors should support calls for a new referendum on the final deal agreed for the UK’s withdrawal from the EU. Fiona Godlee, The BMJ’s editor in chief, Chaand Nagpaul, the BMA’s chairman, and Donna Kinnair, acting chief executive and general secretary of the RCN, make the case in a joint editorial (doi:10.1136/bmj.k4804). They argue that the public must be allowed to make an informed choice on issues that will affect the UK for generations to come.

Meanwhile on BMJ Opinion two doctors who are currently MPs also argue that the public must be allowed to have its say. The Conservative Sarah Wollaston, who chairs the health and social care select committee, and Labour’s Paul Williams, a fellow committee member, liken the situation to a patient consenting to an operation (https://blogs.bmj.com/bmj/2018/11/13/there-is-no-version-of-brexit-which-will-benefit-the-nhs-only-varying-degrees-of-harm/). “To proceed without informed consent would not only be grossly unethical, it would also place the blame for the unintended consequences squarely at the feet of all those politicians who allowed it to happen,” they say.

Godlee, Nagpaul, and Kinnair ask doctors to consider adding their voice to this call for a people’s vote by telling their MPs that they want an informed choice on the final Brexit deal.

“You could also share this information with your colleagues and patients,” they say. “We believe the evidence of a detrimental effect on the nation’s health is clear. Please join our call for a people’s vote on the final Brexit deal.”

Image result for informed consent cartoon

Bullying and harassment cost NHS over £2bn a year, – It’s got that bad, and that expensive!

NHSreality has covered bullying, harassment and whistleblowing many times. We are of the opinion that only a form of “zero” management, by which I mean removing all performance targets, and allowing management to do its own thing as it wishes for a few years, will work. Once morale has improved and a new culture of trust has been established, mutually agreed performance indicators can be addressed again. It’s got that bad, and that expensive!

Ingrid Torjesen in the BMJ reports; Bullying and harassment cost NHS over £2bn a year, study suggests  BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4463 (Published 24 October 2018) Cite this as: BMJ 2018;363:k4463

The consequences of bullying and harassment in the NHS cost the service in England at least £2.28bn (€2.58bn; $2.96bn) a year, an analysis suggests.1

Researchers used data from NHS Digital to gauge the impact of bullying and harassment on sickness absence, employee turnover, productivity, sickness presenteeism, and employment relations. The authors described the final £2.28bn figure as an “extremely cautious” estimate, as several costs lack reliable evidence.

The analysis, published in the journal Public Money and Management,1 estimated that the cost to the NHS from sickness absence due to bullying is £483.6m a year. This assumes that the 24% of NHS staff who are bullied will “conservatively” have 71% more time off (seven extra days a year) on top of the average 9.36 sickness days. The average daily pay rate of the 1.046 million NHS staff is £140.12.

Staff absences are estimated to cost the employer an additional 62.5% on top of the salary costs of absent staff members, equal to an extra £302.2m. This cost largely reflects the agency staff and overtime required to cover for absent staff.

The cost of “presenteeism”—the productivity lost when staff continue to come to work while being bullied and are more prone to making mistakes—was estimated at £604.4m, twice as high as the costs of absenteeism due to bullying harassment.

Of the 24% of NHS staff who reported being bullied, an estimated 15% (3.6% of staff overall) consequently left their employment. The cost of replacing each of these 42 681 staff is £5614.00—a total of £231.9m. The reduced productivity of the new staff replacing them is estimated to cost £13 489 each while new employees get up to speed, equal to £575.7m overall.

Annual industrial relations, compensation, and litigation costs from bullying and harassment are estimated at £83.5m. This is based on a predicted 8.5 cases of bullying and harassment at each of the 234 NHS organisations a year, each costing an average of £41 963.

The authors suggest improving existing staff surveys to better capture the types of behaviours attributable to bullying and to understand how staff feel about current procedures to tackle workplace bullying. With a better idea of the effectiveness of current strategies, improved methods could be developed, they say.

Duncan Lewis, professor of management at Plymouth University and one of the authors, said, “Research has increasingly demonstrated the risks to patient care and safety but not addressed the cost to the organisational effectiveness of the NHS. We hope this study kickstarts serious attention to the substantial diversion of funding away from patient care that current levels of bullying cause.”

Image result for work bully cartoon

BMJ Leader: End the culture of fear in healthcare

Stalling life expectancy in the UK

Stalling life expectancy in the UK

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k4050 (Published 27 September 2018) Cite this as: BMJ 2018;362:k4050 by Veena S Raleigh, senior fellow at the Kings Fund

We must look at austerity and beyond for underlying causes

The stalling of improvements in life expectancy in the UK since 2011, highlighted again in the most recent data,1 has prompted much comment and speculation about the causes. Longevity is the ultimate measure of health, and the flatlining of life expectancy after decades of steady improvement has unsurprisingly led to calls for action.2 The Department of Health and Social Care has belatedly commissioned a review by Public Health England (PHE).

The negative effect of post-2008 “austerity” on health, social care, and other public spending is cited as a potential cause in studies examining temporal associations between mortality trends and markers of NHS performance and public spending.34567 Other features of this complex mortality story also warrant consideration, including the parallels with what’s happening elsewhere.

International parallels

Several high income countries have seen a slowdown in longevity improvements since 2010.89 As in the UK, the slowdown is greater at older ages, especially among women, and is driven by some similar causes of death (although the contribution of opioids to falling life expectancy in 2015 and 2016 is so far unique to the US).8 Two parallel but distinct developments warrant further consideration: an underlying deceleration in the rate of improvement affecting most ages, and periodic mortality peaks—mainly affecting older people—that compound the general slowdown.

The decelerating rate of improvement in mortality from cardiovascular disease is a substantial contributor to the steady slowdown in longevity improvements.89101112 The underlying causes are unclear and could include changes in risk factors such as obesity and diabetes and the diminishing effects of primary and secondary prevention strategies. In the UK, improvements have also slowed for several other causes of death—for example, chronic respiratory disease. Adding to the complexities of interpreting changes in cause of death is the rising proportion of deaths attributed to dementia and Alzheimer’s disease (resulting partly from diagnostic and coding changes), many of which are associated with other conditions.

Alongside this general slowdown are annual fluctuations in mortality, notably the sharp fall in life expectancy in many European countries in 2015 (which was greater in France, Germany, and Italy than in the UK), with a recovery in 2016.8 Such large, abrupt, and widespread increases in mortality followed by a recovery are unprecedented in recent years and suggest a common cause. Deaths from respiratory disease had an important role.8 The mortality monitoring agency EuroMOMO (www.euromomo.eu) reported excess winter deaths in 2015 across much of Europe, including the UK. Most of these were in older people and were attributed largely to flu, based on corroborative information on morbidity, the flu strain in circulation, and low efficacy of the vaccine.1314 The pattern of excess winter deaths reported for other years is also similar across much of Europe and points to the role of flu, pneumonia, and respiratory disease more generally in some years.

Understanding the underlying causes

In summary, the general deceleration in mortality improvements in many high income countries since 2010 has been compounded by periodic bad winters. The slowdown has different components, affecting different age groups and sexes differentially,10 but with some similarities across countries. Austerity probably hastened and caused some deaths in the UK, especially among elderly people. It doesn’t explain why similar mortality trends are seen elsewhere, and why the slowdown in, for example, Germany, Sweden, and the Netherlands—which experienced little austerity—has been greater than in Greece, Spain, Portugal, and Ireland, where austerity was most severe. The causes are likely to be multifactorial and need further deconstruction.

Unpacking the causes of the multiple concurrent changes is complex but essential for tackling the underlying drivers. Learning from international experience should be part of this. Furthermore, analyses that aggregate multiple years mask annual fluctuations in mortality that are key to understanding what’s happening in both “good” and “bad” years. For example, just as 2015 was a “bad” year in many countries, life expectancy in several countries including the UK increased sharply in 2014. This was possibly aided by 2014 being a benign year for flu, as reported by EuroMOMO.

Looking ahead, PHE and EuroMOMO report substantial excess winter deaths for 2017-18, largely attributable to flu, and deaths from flu and pneumonia were at or above epidemic threshold for 16 weeks in the US last winter, one of its longest flu seasons.15 Like 2015, 2018 could be a poor year for some countries, including the UK.

Annual mortality changes therefore need closer scrutiny, as do secondary causes of death—for example, comorbidities associated with dementia deaths and cardiovascular and other deaths precipitated by acute respiratory infections. The dataset for England linking hospital patient records with mortality records16 could provide additional, valuable insights into comorbidities and causes of death, including by deprivation level. The effect of widening inequalities on the mortality slowdown also needs closer examination. Timely analysis of such factors should become routine for PHE and the Office for National Statistics (ONS).17

The UK’s life expectancy is below that of many comparator countries, especially for women, for whom there has been no improvement since the slowdown started in 2011. Inequalities are widening, and the UK’s healthcare expenditure and resources are below those of comparator countries. Beyond learning from international patterns, PHE and ONS need to examine urgently why the UK’s life expectancy is falling further behind—including through collaboration with international agencies where appropriate.

 

Doctor shortages in the valley town that inspired the NHS

Doctor shortages in the valley town that inspired the NHS BMJ 2018; 362 

The recruitment crisis in Aneurin Bevan’s hometown and the surrounding south Wales area exemplifies the challenge faced across the country and rest of the UK. Jenny Sims reports from Tredegar

The birthplace of the NHS is generally acknowledged as Trafford General Hospital, Manchester, officially opened by Aneurin Bevan as Park Hospital on 5 July 1948. But 70 years on, it is still Bevan’s home town of Tredegar, southeast Wales, that can be regarded as where the service was conceived.

Bevan, then health minister, openly boasted that he was basing his ideas for the NHS on the Tredegar Medical Society, which provided free healthcare in the town for iron, coal, and other industry workers, who paid a halfpenny a week into a “sick fund” to run it. “All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to Tredegar-ise you,” said Bevan, according to a quote etched on a plaque in the town.

That meant providing free services for all at the point of delivery, based on clinical need not ability to pay. But today, Tredegar, like many towns throughout the UK, is struggling to meet those needs and provide those services.

Major sustainability concerns

The population of around 14 000 is served by two general practices, one of which, the Tredegar Health Centre, was handed back to Aneurin Bevan University Health Board on 1 April because its two GPs want to retire.

A report to the local council in October 2017 described Tredegar as an area with “high levels of deprivation, unhealthy lifestyles and associated ill health.” It said, “The current GP premises are outdated and not fit for purpose. They do not facilitate multi-professional working, [are] lacking in expansion space and are not conducive to deliver modern primary care.”1 It went on to warn there was major concern about GP sustainability.

Gwent local medical committee chair, Deborah Waters, whose practice in Pontypool, less than 15 miles from Tredegar, has had a GP vacancy since September, is blunt: “Primary care is in crisis because we can’t recruit enough GPs or retain them. It’s not just a problem for Tredegar and the other valley towns, but throughout Wales.”

A BMA “heat map” shows that 74 practices across Wales are in danger of closure because of recruitment challenges (fig 1).2 It’s a message Waters has given to two Welsh health secretaries over recent years. “This one [Vaughan Gething] seems to be listening,” says Waters.

Fig 1

BMA heat map of Welsh general practice using data collected between October 2015 and April 2017 (Other=practice has indicated its future is uncertain or has scored high on the sustainability risk matrix). Further details are available at https://www.bma.org.uk/~/asset/4/30168.ashx4

Raft of policies

Gething, who has been health secretary since 2016 and was made additionally responsible for social services in a cabinet reshuffle in November last year, has called for radical change in how both services are run to ensure the survival of the NHS in Wales. Recognition that this overhaul is necessary is evidenced by a raft of Welsh government policies and service reforms aimed at integrating health and social care, expanding medical education, and providing new funding for various services—all aimed at improving people’s health and wellbeing and easing doctor shortages.

These include the creation of Health Education and Improvement Wales, a single body to develop the Welsh healthcare workforce that comes into effect on 1 October, and a long term plan for health and social care, A Healthier Wales.3

They build on other policies launched when Gething was deputy health secretary. For example, the 2014 primary care plan,4 which promoted physical, mental, and social wellbeing rather than the absence of ill health, and The Well-being of Future Generations (Wales) Act 2015, which requires public bodies to take an integrated and collaborative approach to find shared solutions, looking to the long term needs of future generations.

To help implement these policies, the country has been split into locality networks, with some GPs working collaboratively in 64 clusters with other health and care professionals to support them plan and deliver health services. In Blaenau Gwent county a health and wellbeing centre (an integrated health and social care model) is planned in Tredegar, into which the Tredegar Health Centre will relocate.

Selling the lifestyle

Many recruitment campaigns aimed at attracting doctors to Wales focus on lifestyle and quality of life, as well as career opportunities. Two Welsh doctors who have returned, partly for the quality of life are David Baker, a consultant trauma and orthopaedic surgeon at Neville Hall Hospital, Gwent, and Rebecca Nicholls, who has just started a three year specialist training post in forensic psychiatry in Bridgend.

Baker, born in Tredegar, left at 18 for medical school in Leicester, did his registrar training in London, and worked “all over the place” in England. He says: “I wanted to come back to my roots and connections. People are friendly and welcoming, the countryside’s great, and there are lots of opportunities.” (His wife, a former school teacher, is also from Wales.)

One reason Nicholls chose psychiatry over general practice was for the longer consultation times with patients. Born in Ebbw Vale (Bevan’s parliamentary constituency, just over three miles from Tredegar), she admits one of her reasons for choosing to go to Bristol Medical School was: “I wanted to get out of Wales.” But five years after returning to train and work in Wales, she and her husband have decided to stay. “We have friends and families here, people are friendly—and houses are cheaper.”

For the future, there is consensus that the best chance of retaining doctors in Wales is for medical schools to train more students from Wales. To this end, efforts are being made to expand medical school intake and encourage applications from students from diverse and underprivileged backgrounds.5

Case study: Glan yr Afon GP practice, Tredegar, Blaenau Gwent

A four partner practice serving more than 6700 patients, Glan yr Afon is down to a partnership of two GPs, supported by locums and an out-of-hours service.

GP Krishan Syal celebrated his 70th birthday on 1 August, but he will not be retiring. Nor has he any hopes or plans of doing so any time soon because continuous and concerted efforts to recruit a new GP partner have failed.

Having lured his younger partner, Georgy Mathews, 41, from a salaried job in Newport six years ago, Syal says: “I’m staying on now because of him. I don’t want to let him down.”

Originally from the Punjab, Syal came to the UK for its better job prospects. Trained in general medicine, then anaesthetics, he married, had a family, and moved from a hospital job in Wolverhampton to a general practice in the Rhondda valley in 1981, and then to the Tredegar partnership with another GP (since retired) in 2006.

“It was a good move, and there was no shortage of GPs then,” he recalls. Over time the town has slid into economic decline. But Syal doesn’t look back through rose tinted glasses. “A GP’s life wasn’t easier. When I started I was on call 24 hours, seven days a week and bank holidays,” he says.

Mathews, after qualifying in southern India, also came to the UK to gain further qualifications and experience. “My aim then was to go back,” he says. But now he’s settled in Cardiff with his family and understands the reluctance and apprehension of younger GPs who do not want to commute or commit to the workload, management, and financial risks involved in taking on a partnership.

Mathews dreams of Glan yr Afon become a training practice, which would stand a better chance of attracting future partners, he believes.