Monthly Archives: November 2018

In a celestial world as outlined by the old NHS, there was universal, cradle to grave cover, with no barriers to access, free at the point of delivery, and without reference to means. Funny that we have so many medical charities then. And the greatest number of these charities is in the Hospice (Palliative and Terminal care) sector. These charities are mostly run from physical buildings, and hospices, but in the poorer areas of the country they are “Hospices at Home”. The idea to help elderly at home is a good one, BUT it overlaps so much with charitable providers. The perverse incentive for Trusts and Commissioners to offload as much as possible to these charities will inevitable mean there are large post code voids in cover. NHS reality does not object to this IF it is honestly discussed. The solution is a means based insurance based system, and since most of the assets in the UK are held by the elderly this would be more progressive.

Chris Smyth reports November 22nd in the Times: Rapid response teams will help elderly at home

NHS “rapid response teams” will be on call 24 hours a day, seven days a week to help frail and elderly patients who fall or suffer infections, Theresa May will say today as she promises to use extra health service cash to keep people out of hospital.

GPs will also get to know care home residents personally in an effort to keep them well at home. Such services will get an extra £3.5 billion a year by 2024 as part of a £20 billion boost promised to the NHS in the summer

Experts welcomed the ambition but questioned whether the NHS would have the staff to provide the services, and warned that such top-down initiatives often backfired…..

…Simon Stevens, chief executive of NHS England, said that guaranteeing the money for local services would help to make the plans a reality.

“Everyone can see that to future-proof the NHS we need to radically redesign how primary and community health services work together,” he said. “For community health services this means quick response to help people who don’t need to be in hospital.”

Sally Gainsbury, of the Nuffield Trust think tank, said: “This money will simply allow GPs and community services to keep up with demand over the next five years. That’s important but it means the new money announced today is not going to lead to a significant change.”

She added that there were “serious questions about whether the NHS has the right staff in the right places to carry this out”. She warned: “We would agree the NHS needs to focus on helping people more outside hospital and getting them home more quickly. But the idea of telling every local area to do the exact same thing has often backfired in the NHS, as it is bound to be less well-suited to certain places.”

When standards cant be sustained…. raid nurses (and doctors) from non english cultures…

Short term solutions to lack of capacity in personnel has been the rule for all governments since the 1948 health service started, and has been continued by the devolved governments. Wales has a particular problem, in that if it trains more doctors and nurses then over 30% (My estimate) leave Wales after graduation. Scotland has always trained far too many for its own needs, and yet it still has problems in the islands and the remote areas…. so merely training more does not work, until the whole of the \UK has overcapacity. Even then, this encourages many doctors to take spells abroad, and some are tempted to stay. They find the new jurisdiction much more caring, less threatening, and gives them more choices and clinical freedom. NHSreality welcomes all nurses who are willing and able to come, but communication has to be good, especially when there are too few doctors, and 40% of them have the same communication problem. Perhaps we need the unqualified psychiatrist more than we realise..!

The latest headline is on Nurse recruitment. Chris Smyth in the Times on 22nd November reports: NHS relaxes English tests to tackle nursing shortage

English tests for foreign nurses are to be relaxed after regulators admitted that higher standards were causing NHS staff shortages.

The pass mark for written English is being lowered after a review concluded that good candidates were “just missing out” on being able to work in Britain.

Tougher language tests introduced in 2016 have been cited by some as a bigger factor than Brexit in a collapse in the number of EU nurses coming to work in Britain, with new arrivals down by more than 90 per cent.

Emma Broadbent, director of registration at the Nursing and Midwifery Council, said: “We absolutely recognise that good communication is essential to safer, better care and people can be assured that only those who can communicate to a high standard in English will be able to join our register. We also recognise the current workforce is under significant pressure. The change proposed would increase flexibility for highly skilled professionals coming to the UK without compromising safety.”

She plans to accept candidates who score 6.5 out of 9 in written English tests, down from 7. They must still score 7 in reading, listening and speaking and have an average score above 7. A score of 6 certifies someone as a “competent user” of English able to deploy “fairly complex language”, and a 7 denotes a “good user”who can “handle complex language well”.

Joyce Robins, of Patient Concern, said: “I don’t think dumbing-down critical language tests is a good idea. Patients and nurses need to understand each other or mistakes will be made.”

John Kell, of the Patients Association, said the reform “appears to be a small and evidence-based change, though we hope the effects will be kept under review.” Danny Mortimer, chief executive of NHS Employers, said his group believed that “these recommendations balance the need to protect the public with improved access for much needed nursing talent”.

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Thousands of patients could have been harmed by unqualified

NHS in Scotland is “not financially sustainable,” auditors warn. Do the Scots expect a bail out?

Is the Scottish Government expecting England to bail them out? Financial responsibility comes at a price, and it looks as if Scotland is not willing to pay that price – yet. Reality has not yet hit our politicians. Health has to be rationed…. Individuals can declare bankruptcy, but not state hospitals.

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In BMA news Bryan Christie on 25th October reports: NHS in Scotland is “not financially sustainable,” auditors warn (BMJ 2018;363:k4520 )

A stark warning has been issued about the future of the health service in Scotland in a critical report that says it is not financially sustainable in its current form.

Audit Scotland has performed its annual health check on the service and found a continuing decline in performance, longer waiting times for patients, major workforce challenges, and increasing difficulty among health boards to deliver services within existing budgets.1

Only one of the eight key national performance targets was met in Scotland in 2017-18 (for patients with drug and alcohol issues to be seen within three weeks), while only three of 14 NHS boards met the 62 day target for cancer referrals. And there has been a 26% rise since 2016-17 in the number of patients waiting more than 12 weeks for inpatient or day case surgery, to a total of 16 772 in 2017-18.

Total spending came to £13.1bn in 2017-18, a fall of 0.2% in real terms on the previous year, forcing NHS boards to use one-off savings or extra support from the Scottish government to break even. In the coming years projected increases in healthcare costs are expected to outstrip any additional funding for the service.

“The NHS in Scotland is not in a financially sustainable position,” said the report. “The scale of the challenges means decisive action is required, with an urgent focus on the elements critical to ensuring the NHS is fit to meet people’s needs in the future.”

The steps the report recommends include:

  • Moving away from short term firefighting to long term fundamental change

  • Ensuring effective leadership

  • Creating a more open system to encourage an honest debate about the future of the NHS

  • Carrying out detailed workforce planning, and

  • Improving governance and the scrutiny of decision making.

Caroline Gardner, auditor general for Scotland, said, “The performance of the NHS continues to decline, while demands on the service from Scotland’s ageing population are growing. The solutions lie in changing how healthcare is accessed and delivered, but progress is too slow.”

The day before Audit Scotland’s report was released the Scottish government announced an £850m initiative over the next 30 months to shorten patients’ waiting times across Scotland. It seeks to achieve the 12 week treatment time guarantee for all inpatient or day surgery patients, which was introduced in 2012 but has never been met.

But Lewis Morrison, chair of BMA Scotland, said that this was the wrong approach. “We need to adopt a more mature, wide ranging way to assess our NHS and the care it delivers. Simply piling more political pressure on the meeting of existing targets that tell us little about the overall quality of care will do nothing to put the NHS on a sustainable footing for the long term.”

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Plans for state-backed indemnity scheme for GPs in Wales

This is a piece of good news for GPs in Wales, but it should be National, not regional, and the ultimate solution is a “no fault compensation” scheme as in New Zealand. The scheme may give Wales an added attraction, which along with the inducement payments may help recruit and retain GPs.  There is a net 20% loss of graduates from Wales annually, and this may help correct, but it alone is not enough. Education is the big issue for doctors and their families, and addressing this is a longer term problem. Perhaps it will be extended to Hospital specialists as well?

Adrian O’Dowd for “onmedica” reports Friday 16th October in the BMJ: Plans for state-backed indemnity scheme for GPs in Wales

he Welsh government has announced its preferred partner to deliver the new state-backed scheme to provide clinical negligence indemnity for GPs in Wales from next year.

A medical defence body, however, has criticised the move, saying this was an untested scheme with insufficient detail and could remove GPs’ ability to choose an integrated indemnity and advice product instead.

Welsh health secretary Vaughan Gething announced yesterday the NHS Wales Shared Services Partnership’s Legal and Risk Services, who currently indemnify GPs working out of hours, is the preferred partner to operate the Future Liability Scheme from April next year.

Mr Gething, speaking in Cardiff at the Primary Heath Care Conference, organised by the Primary Care Hub and 1000 Lives Improvement in Public Health Wales, said the scheme, which would be aligned to the scheme announced in England, would ensure GPs in Wales were not disadvantaged and that GP recruitment and cross border activity would not be adversely affected by different schemes operating in the two countries.

Mr Gething said: “This new scheme will provide greater stability and certainty for GPs in Wales. It will support GP practices and primary care clusters in their delivery of sustainable and accessible health care.

“The Future Liabilities Scheme will cover the activity of all contractors who provide primary medical services. This will include clinical negligence liabilities arising from the activities of GP practice staff and other medical professionals such as salaried GPs; locum GPs; practice pharmacists; practice nurses; healthcare assistants.

“I will make a final decision on the delivery of the Future Liability Scheme in Wales following further engagement with medical defence organisations.”

Medical and Dental Defence Union of Scotland (MDDUS) chief executive Chris Kenny was sceptical, saying: “We are concerned that this untested state-backed indemnity scheme will be implemented in April 2019 when so little detail has been shared with MDDUS or GPs in Wales.

“We have been pressing the UK and Welsh governments to provide comprehensive operating and funding details of the new scheme for some time now yet little has been forthcoming.”

The existing medical defence organisation (MDO) model worked well, he argued, adding: “Writing MDOs out of a claims service is a false economy – and a threat to GPs’ professional standing.

“That’s why we expect the state-backed schemes in Wales and England to preserve these principles. If government want to offer a simple claims only service, then GPs should be able to choose the integrated MDO service at no financial disbenefit.

“We believe this is a high-risk approach which fails to protect GPs’ professional reputation, removes choice and, as independent contractors, GPs should have the option to choose an integrated indemnity and advice product as compared to the state-backed scheme.”

Dr Charlotte Jones, chair of the British Medical Association’s GPC Wales, said her organisation supported the Welsh government’s choice of preferred partner.

“The proposed scheme will address one of the biggest financial pressures on GPs and will help enable all GPs, practice teams and wider cluster healthcare professionals to work more closely together taking forward the transformation of Welsh primary care.”

Dr Peter Saul, joint-chair of Royal College of GPs Wales, said: “Indemnity is a real issue for GPs, which can affect the time they can spend in practice treating patients. The college campaigned for and supported the announcement of a state-backed indemnity scheme and it’s encouraging to see steps being taken to create a sustainable solution.”

Asbestosis report: BMA – Medical indemnity for GPs in Wales

2012 (6 years ago and it’s worse now!) : Medical negligence costs rise in Wales – NHS News

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The decline of suicide (except for the USA). No GP should avoid psychiatry training..

It is a worry to professionals who have an interest in “systems” that so much government time is spent getting advice from the USA. In mental health especially, but life expectancy as well, America does worse than most other countries. On Saturday the Economist (this week) publishes a report: Staying alive – why suicide is falling. 

It is socialised medicine, and especially universal care/cover which really addresses Mental Health, but it has to be properly funded. In the UK some 40% of what a GP sees has a psychiatric element, and yet not all GPs do psychiatry in their postgraduate training. Psychiatry is so unpopular that there have been “doctors” discovered practicing who are not trained…. This needs to change, and it is only by training all GPs in psychiatry, and with ongoing Balint support for these GPs, that psychiatry will get the professional backup it deserves.

“Around the world, suicide rates are falling as a result of urbanisation, greater freedom and some helpful policies. America is the notable exception: since 2000, its suicide rate has risen by 18%, compared with a 29% drop in the world as a whole. It could learn from the progress made elsewhere, and more lives could be saved globally with better health services, labour-market policies and curbs on booze, guns, pesticides and pills”

Jamie Ensor on Newshub 20th November 2018: Investigation into Kiwi woman’s fake psychiatry qualifications leads to 3000 doctors being inspected in the UK.

GPs on the press/media rack. The Balint approach.

Mental health still surviving on the crumbs

Lets train GPs properly in 6 week rotations. None should avoid psychiatry..

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