Monthly Archives: January 2019

Gene tests ‘threaten core NHS principle’

Genetic testing can be really helpful. Some diseases are single gene dominant, such as Huntington’s Disease, and discovery at birth and from screening populations, could reduce this to new mutations only. The Human Gene Project has opened up multiple genetic diseases, some with many genes. The potential for increasing the health of populations is there, but a long way off. Meanwhile, the research is likely to benefit volunteer families, mainly those living near centres of excellence. So we need to be very careful that the development of the governments suggested scheme is regressive for as shorter time as possible. We should not ignore the potential to find the truth, but we need to acknowledge the risks. In addition, will all 4 jurisdictions do the same?

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Chris Smyth 29th Jan 2019: Gene tests ‘threaten core NHS principle’

Selling genetic tests to healthy people breaches a core principle of the NHS, creates a two-tier health service and risks forcing the sick to go without treatment, doctors warn.

World-leading NHS genetic services for people with cancer and rare diseases will be overwhelmed by the worried well and give unfair protection to those who can afford them, they say.

The plans, revealed by The Times, would let healthy people pay to have their genetic code sequenced and receive a personal health report based on the results.

Unlike commercial tests, which look at a limited sample of genes, the NHS plans to read every letter of a person’s DNA. Ministers hope that offering the most detailed prediction of the risks of conditions such as cancer and dementia will tempt people to volunteer their genetic data for research.

Yesterday MPs on the health select committee warned Matt Hancock, the health secretary, that the scheme could swamp GPs with queries from the worried well and lead to inequality. Mr Hancock rejected this, saying that if done carefully the plan could save lives and prevent illness by reducing demand on the NHS. “Healthy people who have their genome sequenced can find problems that they didn’t know existed. That allows for them to change behaviour, have preventative treatment or take other actions that can reduce the long-term pressure,” he said.

However, in a letter to The Times, experts including Andrew Goddard, president of the Royal College of Physicians, Jo Martin, president of the Royal College of Pathologists and Helen Firth, chairwoman of the Joint Committee on Genomics in Medicine, write: “Selling whole genome sequencing to healthy people breaches a core principle of the NHS. It will create two-tier access to services, where people who can pay are able to access services that are denied to those who cannot.”

People deemed at high risk of some conditions may be offered extra NHS screening, a protection not available to people who cannot afford the test.

There are concerns that genetic testing breaches NHS guidance on mass checks. It is also feared that unreliable information could lead to patients having needless drugs or surgery and cause psychological damage to people told they are at risk of conditions for which there is no treatment.

Other experts are cautious about the plans. James Pickett, head of research at the Alzheimer’s Society, said that DNA tests could revolutionise dementia treatment but had not reached that stage. “Everyone has a right to know about their risk if they want to, but whoever provides the test must ensure people understand the meaning and consequences of the results,” he said.

Concerns over sale of gene tests on NHS l

Sir, You report (“Gene test for sale on NHS”, Jan 26) that the NHS intends to sell whole genome sequencing to healthy adults who will receive a “personalised” test report. The UK leads the world in collaborative genomic research and in the provision of a high-quality genomics clinical service. Genomics has already transformed the lives of many and promises much more in the future.

Selling whole genome sequencing to healthy people breaches a core principle of the NHS. It will create two-tier access to services, where people who can pay are able to access services that are denied to those who cannot. Furthermore, without additional resourcing the extra demand that it will create on laboratory and clinical capacity may compromise the provision of diagnostic genome sequencing and clinical care for NHS patients for whom there is already proven benefit, such as those with rare diseases and cancer.
Helen Firth, Chairwoman, Joint Committee on Genomics in Medicine; Andrew Goddard, President, Royal College of Physicians; Jo Martin, President, Royal College of Pathologists; Bob Steele, Chairman, UK National Screening Committee; Dian Donnai, Emerita Professor of Medical Genetics, University of Manchester; William Newman, Professor of Translational Genomic Medicine, University of Manchester; Paul Pharoah, Professor of Cancer Epidemiology, University of Cambridge; Jane Hurst, President, Clinical Genetics Society; Anna Middleton, Chairwoman, Association of Genetic Nurses and Counsellors; Andrew Wilkie, Nuffield Professor of Pathology, University of Oxford; Eamonn Sheridan, Professor of Clinical Genetics, University of Leeds

Sir, The reported intention by ministers to allow the NHS to charge healthy people to map their genetic code will create a new and potentially damaging level of intimacy alongside a false sense of certainty. Although we all have experience of the dynamics of an intimate one-to-one relationship with another human being, we begin to feel very uneasy when Mark Zuckerberg tells us that privacy is an outdated social norm in his justification of the Facebook brand. And for some, when things all go wrong, they are tormented by their intimate thoughts to the point of mental breakdown.

This latest move means that otherwise healthy people will be given access to their whole personal genome from deep within their being, and supplied with a prediction of the risk of some very disabling condition: for example, you might be told that you have a 74 per cent chance of developing Alzheimer’s disease by the age of 56. Because of the power of numbers this may appear to present a certainty but it is a false one. Without professional post-test counselling and a full understanding of risk this new intimacy could be extremely destructive. We do not want the necessity of a new psychiatric diagnosis of “post-traumatic genome test disorder”.
Morton Warner
Emeritus professor of health strategy and policy, Welsh Institute of Health and Social Care

Sir, Although dementia research could benefit from the large and potentially diverse pool of data that population DNA testing would provide, we do have concerns. Genetic testing is not recommended for people who are not already suspected to be at high risk. Little is known about the impact of informing healthy people about their genetic risk of dementia, a disease that is much feared. Anyone taking such a test would need the results explained to them sensitively and with the uncertainties around the result clearly explained to them. Provision for such expert advice would need to accompany the national rollout of whole genome sequencing.
Dr James Pickett
Head of research, Alzheimer’s Society

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Robert Plomin interview – why genetic testing is the future David Aaranovitch 29th September

Gene test for sale on NHS – Healthy patients to learn risk of killer diseases – Chris Smyth in the Times 26th Jan 2019

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At last – common sense on the right to die with agreement of Dr and Family. The cost implications of prevention of genetic diseases are a barrier too high for most countries..

Societal debate on CRISPR should occur: but it won’t…… Of course there is a cost too, but that’s another matter. Lets just see if we can agree that CRISPR is desirable.

You have been warned…. No genetic secrets will remain ….

 

2018

Britain is worse off for GP cover than Malta, Romania and Estonia

Its ironic that the chiefs who have decided to advertise in Australia don’t mention the land of Aneurin Bevan and Beveridge. Yes, their plans were over ambitious, and yes we have planned our manpower woefully for the last 30 years. The blame for this lies with successive governments of all colours, and the first past the post electoral system which encourages short termism, and discourages longer term financial commitment and planning. Now we are at risk of banning doctors from the EU, and of those that are here feeling rejected and leaving, and the result of our shortage could simply be more doctors from the old commonwealth countries. When I was training, more of my trainees went to Aus than came from them.. and that trend is set to continue for a decade or so.. Its still better for the population than the US system, but it is worse than many others in the G7. It is worse for rich individuals but then they can go privately.

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On 25th January 1019 – Britain is worse off for GP cover than Malta, Romania and Estonia …

[PDF] Malta: health system review – LSE Research Online

Laura Donelly in the Telegraph 27th Jan 2019 reports: Aussie doctors urged to work for the NHS – in land of Harry Potter, Shakespeare and Manchester United

Health chiefs will attempt to recruit doctors from Down Under with a new campaign urging them to come to the land of Shakespeare, Harry Potter and Manchester United.

Australian GPs are being targeted by the new drive, in a desperate bid to plug shortages of family doctors across England.

In September 2015, then-Health Secretary, Jeremy Hunt, pledged there would be 5,000 extra GPs in England by 2020. But since then the number of full-time doctors in the workforce has fallen.

The new social media campaign will attempt to persuade doctors abroad to come to the NHS and work for “a national treasure”….

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A series of intellectually and ideologically bancrupt administrations has led us to a GP recruitment crisis.

Perverse behaviours – and perverse incentives. This is partly what drives doctors away…

The GP – his future as a permanent locum? Inadequate manpower planning gives a wonderful business opportunity to some..

An American compares the two systems: USA and UK. 

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Leadership without accountability in all 4 health services.

The rules of the 4 Health Services define games that cannot be won. The managers and the top doctors all know this, as do experienced staff at all levels. It takes a few years for the penny to drop: we cannot have Everything for everyone for ever. 

So until the “leaders” are given permission to tell us that there have to be services we cannot have, and to expound on the alternative ways to decide on how to use their limited resources best, we cannot have the “honest debate” that Mr Stevens wanted 4 years ago!

So there is another item to add to the list of what is “National” in the 4 health services. Lack of Leadership and accountability, and lies. Lemmings do seem to have a leader… Our leaders have the private parachute option..

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Partha Kar writing in “The Bottom Line” in the BMJ opines Leadership: where does accountability lie? and in the e-version “Leadership without accountability benefits no one”. (BMJ 2019;364:l248 )

In the NHS, the term “leadership” generates a huge range of emotions. Sometimes it’s ethereal and inspiring. At other times it prompts disdain or even derision. Leadership quangos abound, courses are drip fed into email inboxes, and conferences keep springing up.

Yet every analysis of the NHS’s failings tells us the same story—one of a “lack of leadership.” Why? Because we don’t have the right type of leader? Because we don’t have enough “completer-finishers”? Because “leadership” is now seen as a career opportunity? In my view, all of these have contributed to a lack of effective leadership in the NHS.

One thing the NHS should also acknowledge is that the system also needs followers. Many people currently in the NHS seem to believe that we must all be leaders. In promoting the importance and value of leadership the NHS has made being a follower seem far less attractive. You can couch it in any terms you want, but the fact remains that leadership simply isn’t for everyone.

Any leaders worth their salt are only as good as those who follow them. And following isn’t unsexy: it’s an integral part of making the whole thing work, of delivering care and delivering outcomes.

In other spheres of life, leaders are defined by the outcomes they deliver and by their accountability. In the case of football managers this is often starkly apparent. When José Mourinho was winning trophies, his style was sexy. When the victories dried up, the same man was boorish. Somehow, in the NHS, things rarely work out like that. It’s more often a case of old wine in new bottles.

In the NHS, leaders who have failed to deliver in a role are moved from one organisation to another, and organisations are endlessly restructured. But changing the name, structure, or shape of the organisation they led isn’t going to deliver outcomes. The problem may lie with the individual rather than the system.

The health service has many challenges, not least around its workforce, structures, and finances. A lack of accountability among leaders—or indeed a lack of those able to deliver beyond the boardroom—may be a significant part of its problems.

The NHS must find a balance between seeing failure as a part of leadership and knowing when to draw the line. We need to know that we shouldn’t accept failure as the norm, and we need to know when to find someone else to do the job. In tipping the balance towards allowing failure without accountability, we benefit no one.

A dishonest and covert dialogue is all that is happenning at present.. Simon Stevens says he would like to change this.

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What is National About the Health Services in the UK? I have thought of 10 areas…

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On the Brexit slipway…. There is a problem: there may be too many to save, all at once.

Above all do no harm. I wish our politicians had read this before landing us on the Brexit lifeboat slipway. Unless there is bold leadership, which will have to come from outside the current leaders, we are heading for the water. The safety chain has been removed and we are awaiting the captains order to cast off and descend… There is a problem: there may be too many to save, all at once.

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The RCN in August reported: Patients need protecting in the event of a no deal Brexit. Patient safety could be put at risk if EU nurses aren’t guaranteed settled status should the UK leave the EU without a deal.

Alex Matthews-KIng reports in the Independent Friday 19th Jan 2019: Pharmacists facing ‘massive shortages’ in common medicines across UK, experts warn

Harriet Pike in the BMJ 19th Jan reports: GP workloads are made worse by shortages of common drugs.

 

Closure of Hospital inevitable. Enormous shortage of GPs. A&E target times in Wales worse than last winter

Yes, its going to get even worse. Despite the Brexit promise to let fewer immigrants into the UK, we are going to have to reverse this for doctors. Will they be trained adequately? Will their communication skills,  and cultural awareness be enough? Will they incur more litigation? and Will they be needed more where they come from? Will they deny our own medical students places in GP? The promise of 5000 extra GPs is beyond belief, as it will take another 10 years to train enough. Those working can pick and choose, and it can be lucrative to burn yourself out. 

This is all the result of the rationing of medical school places, the power of Deaneries, and their inability to embrace on line learning. The virtual medical school is an urgent need..

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Owain Clarke for BBC News 24th January reports: A&E target times in Wales worse than last winter

And another Hospital will close: Rothbury Hospital future ‘to be decided in summer’. The delay is just window dressing for the inevitable. Its a GP Hospital, after all….

GP recruitment is getting worse too. Even in the richer and more desirable areas of the UK.

Kentonline 21st Jan 2019: GP numbers in Swale and Thanet among worst in England as NHS … and Luke May reports: GP surgeries in parts of Kent have just one doctor looking after thousands 

Worcestershire one of the worst areas for recruiting GPs

£20000 ‘golden hello’ doubles GP recruitment in under-doctored areas

Demand for Wokingham health services leaves NHS with recruitment challenges

Fancy £20000? Trainee GPs given cash windfall to work in Staffordshire

16th Jan 2019 from GPonline: GMC to double PLAB test capacity to boost recruitment of overseas …

Pulse on 10th Jan reports: No target date for recruiting 5000 extra GPs, says health secretary

‘There’s no easy fix’ warns GP as scale of doctor shortage revealed

The Lynn News: National scheme hopes to boost trainee GP numbers in West Norfolk

The Guardian: New GPs sign up to poorest areas after £20000 incentives

Some parts of England have three times as many people per GP than … (INews) . West Sussex, the second worst place to get sick, there are 2,997 people per GP. … There are areas that aren’t seeing investment in GPs, and RCGP … Hello scheme to attract GPs to areas struggling to recruit GPs, Pulse, ..

Renfrewshire medical practice left with no permanent GPs after doctor …

TheGazette.co.uk22 Jan 2019
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Interviewed, but not examined. Surely the internet is not capacle of that!

Chloe Holmwood reports in KentonLine 20th March 2018 : Islanders can now be examined by a doctor who is up to hundreds of miles away using digital technology:

Well lets hear the feedback including referral rates and litigation costs. Is the service, now nearly a year old, used for anything other than skin conditions and psychiatry, and repeat prescriptions. The idea of an abdominal or a rectal examination “on line” defeats me. It is not the first “mad idea” in primary care, but it is necessary because of the paucity of GPs.

We need so many more doctors and nurses its untrue.

 

Doctors to see groups of patients – is probably madness. The fox is waiting..

Any GP you want: so long as you’re healthy

fewer women should be allowed to train as doctors because men are ‘better value for money’… The answer is graduate entry to medical school.

Referrak thresholds are different for different doctors… computer data could help.

A colleague of mine tells the story of the city GP who was not really qualified. He survived for years, and when “exposed” his patients queued around the block to complain that he would be leaving. His technique was to refer everything to the local A&E….with a “Please see and advise” letter. He thus never made a mistake or diagnosed late.

As an example of the “split personality” of the administrators in the departments of health, please consider todays report in the Times. Chris Myth reports: Rivalry can help save lives of cancer patients. We know that performance related pay has a short term benefit and a long term negative effect. What makes a GP efficient is when he does not refer. If GPs referred everything and did not allow “time” to help sort common problems, there would be little point in having them. They are the goose that laid the golden eggs of efficiency – in the past. Will the days of the GP as symptom sorter and access door to more expensive tests be stopped? The split personality is reflected in the opposite – “non referral,” which was encouraged in 2015! Several articles in 2015/2016 in the Guardian and the BMJ offer advice that tribal rivalries are destructive. There will be many confounding factors and perverse incentives in every health system, but if we want efficiency for the population, we need GPs who can live with uncertainty, and refer appropriately. Abandoning the GP will mean the state service implodes and private care will expand rapidly. Giving incentives to refer is perverse as far as the state efficiency is concerned. Providing health to populations is different to providing it for individuals. What may be of help is ratios showing how many referrals per female aged 60-70 with say, indigestion for a few days, are made compared to the mean. Some doctors have low and some have high thresholds, and they should be aware of this.

GPs have been trained for about 10 years to do what they do. We just need more of them.

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Chris Myth reports: Rivalry can help save lives of cancer patients. 

Telling GPs that they are sending fewer patients for cancer tests than their colleagues can save lives by boosting referrals by up to 20 per cent, an NHS trial has found.

Sending letters to doctors with low rates of referral pointing out that others are doing better spurs them to improve, the study concluded. Health chiefs are considering whether to adopt the plan more widely in response to calculations that 2,500 cancers could be spotted a year earlier as a result.

Late diagnosis is thought to be one of the reasons why cancer survival in Britain is notably worse than in other rich countries. A report by Sir Mike Richards, the government’s former cancer chief, concluded last year that one explanation for late diagnosis was that GPs were sending too few patients for tests.

The study in Manchester involved sending letters to 244 GP surgeries with below-average referral rates. While the effect was limited among surgeries just below average, those in the bottom 30 per cent increased referrals by 20 per cent compared with similar surgeries not sent letters. Below-average prescribers increased referrals by 10 per cent overall.

Felicity Algate of the Behavioural Insights Team, a social-purpose company spun out of Whitehall, said that the idea came about after letters sent to GPs who prescribed large amounts of antibiotics led to the number of prescriptions falling by 3 per cent. “Just browbeating people or just giving information, that’s not effective in changing behaviour [but] social norms are a very, very powerful factor,” she said.

Ms Algate was surprised by the size of the effect, suggesting that it also involved professional competitiveness and reassurance that the surgeries were not referring too many patients. “There are conflicting messages because there is quite strong pressure not to refer too many people,” she said.

Jodie Moffat, of Cancer Research UK, said that the charity would look at the scheme in more detail, adding: “Building the evidence to understand how the NHS can improve urgent cancer referrals is really important.”

However, Helen Stokes-Lampard, of the Royal College of GPs, said that putting GP surgeries under more pressure could “cause more harm than good”.

She said that GPs were often berated for sending too many people to hospital, adding: “When some cancers are in the early stages they display similar symptoms to many much more common illnesses that must first be ruled out . . . The real problem lies with the lack of resources, including diagnostic tests in the community.”

NHS England is studying the results.

Doctor and nurse rivalries ‘undermine NHS reforms’ | Society | The Guardian 2001…

Our NHS is in serious danger – we should be scandalised – GPs are being paid not to refer cancer patients to hospital and free hearing aids are being axed. All the politicians are cowards.. This is a healthcare system under strain, but where is the debate?

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?